Running a hospital is more than operating a very expensive hotel with an intensive-care unit in place of a presidential suite. Yet on weekends, that's all most hospitals are-hotel rooms at $1,000 a day.
At that rate, why not stay at the Ritz?
Because the guests are too sick, obviously, to be anyplace but the hospital. So why aren't they being treated on those weekend days as aggressively as they are during the week? asked Bruce Curson, chief operating officer of East Jefferson General Hospital in Metairie, La., just outside of New Orleans.
"How do you tell a rehab patient you don't do physical therapy on Sunday?" he asked.
Or: "You present yourself for chest pain on a Friday evening. `Well,' the doctor says, `we'll put you in a nice room and monitor you over the weekend,"' Curson said. The patient will be catheterized on Monday and discharged on Wednesday.
But typically, even if the patient arrived at the hospital on Monday, he or she would still be discharged on Wednesday. In complicated cases like cardiac, Curson said, the bill including the weekend will be $32,000, the one for the weekday stay will be $16,000.
That just won't do any longer, Curson said. To maximize the value of a hospital stay, the patient must be aggressively treated seven days a week, mornings through evenings, and on holidays.
Curson and the hospital's quality management committee have launched a holy crusade to turn East Jefferson into that seven-day-a-week hospital. They are trying to speed up the time it takes to reach the decision point of surgery or discharge by aggressively moving forward on a clinical path.
Curson said it's about "redistributing resources. It's an alternative to slash-and-burn downsizing just to make profits."
Using reams of utilization information churned out by his information system, he and the quality management team have devised a plan to drastically reduce waiting time for patients admitted on Fridays, Saturdays and Sundays.
They have instructed hospital departments to perform diagnostic tests and some therapeutic procedures "within an eight-hour window regardless of day or time," according to guidelines.
They have also tried to make the program budget-neutral. That can mean staffing up to meet the need or putting employees on flex time. It can add costs in the short term, but in the long term it saves the hospital and payer bundles.
Physicians, resistant at first, are being won over. "The medical staff really likes this a lot," said Jerry Satterlee, M.D., chairman and medical director of radiology. "They're under a lot of pressure from the HMOs to keep their length of stay down."
East Jefferson's direct costs per adjusted patient day total $977, about average for a big hospital in the New Orleans market. Of that, Curson figures, $619 is just maintenance-the costs of running the hospital without doing any diagnostic or therapeutic procedures on the patient's behalf.
For that $619 in overhead, nothing is gained unless the patient is being treated. Under fee-for-service reimbursement, those costs would be incorporated into the bill and presumably paid by the insurer.
But Curson is looking at his hospital as a cost center, not a revenue center. Each extra day the patient lies in a bed is more than likely cost not covered by extra revenues. Capitation and Medicare prospective payment have put the onus on the hospital to make patients well in a hurry and move them out to a more appropriate level of care.
At this point East Jefferson is doing just 2% of its business on a pure hospital capitation basis, mostly for Medicare patients, but it expects that percentage to rise quickly.
Bill Cammarata, the hospital's director of quality and utilization management, noted: "If you're in any contract with a managed-care company, and the patient has been (in the hospital) extra days without moving to a lower level of care, they will deny those days. We're not going to get paid for those two days at a per-diem rate. The hospital is at risk for that."
It's penny-wise and pound-foolish, Curson believes, to leave patients in the hospital extra days just because certain departments aren't staffed on weekends. To do the diagnostics is not very expensive, all things considered. The hospital's direct cost on weekends for an echocardiogram is $40; for a magnetic resonance imaging, $152. "Not to do this on Sunday is going to cost the hospital and patient almost $1,000" in hoteling costs, Curson said.
The program at East Jefferson doesn't cover outpatient care or scheduled surgeries. Focus groups revealed that patients would prefer to take time off work rather than make appointments for care on weekends. It also doesn't apply to nights, when patients prefer to sleep.
So the absolute number of patients affected by the seven-day hospital is relatively small. Mostly it touches those admitted on Friday who have had unscheduled adverse events, or people who are inpatients longer than five days: rehabilitation or skilled-nursing patients.
But for those patients, weekend availability of physical therapy or other clinical services can make a huge difference in length of stay and, consequently, their bill.
In the first quarter of this year, before the new model had been set up, patients admitted on Saturday and Sunday under DRG 112 (angioplasty) spent an average of 1.9 days in the hospital between admission and the therapeutic procedure. Typically they didn't get their angioplasty until the second or third day.
The average patient admitted on weekdays got a procedure in less than a day. Of the 13 patients admitted on Thursdays, all were treated in less than a day.
On the recovery side, those patients who got their procedures on Monday through Friday were discharged after 1.8 days. But those treated on Saturdays (there were no Sunday procedures) were not discharged until they'd stayed 3.5 days.
(It's important to note that these are elective cases, where the patient can be monitored for two days. In emergencies the procedure would have been done right away.)
At East Jefferson those extra two days are classified as "possibly avoidable patient days." A computer program assigns a code to 97 different reasons why a patient stayed a day longer than he or she should have.
Cammarata keeps an eye on the computer program that calculates possibly avoidable days. "When we started it, it was 386 days in a month," he said. By August it was down to 208 days.
Of those, some 60 extra days were spent in the hospital because patients were not being discharged to nursing homes on weekends. "We had the social services director meet with nursing home directors and arrange to transfer patients on weekend days," he said. "Now, those days are negligible, two or three a month."
Typically in hospitals, about half the extra avoidable days are attributable to the hospital not moving things forward. The rest can be laid at the feet of physicians, the payer, family members or the patient.
The seven-day team analyzed what clinical services weren't being performed on weekends and why. In many cases-outpatient rehabilitation, physical therapy, utilization management-weekend service was established for the first time.
It's not easy to get a hospital to turn on a dime for an undertaking like this. It wouldn't be possible to ride herd on the 60-odd departments in the building without a sophisticated electronic data repository.
Curson, a computer wonk, likes to think of data as "opportunity," and he used his data repository to generate reports of how many orders requested on Friday were not carried out until Monday.
It's one thing to get clinical departments pumping on all cylinders on weekends; it's another to get the medical staff to come along for the ride.
Initially, doctors were skeptical. "The medical staff says, `You don't have anybody in CAT scan,'*" Curson recalled.
They can't say that anymore. Now the hospital treats the medical staff as the customer. When a doctor orders a report, no ancillary department can respond, "No, we're not open."
To turn the doctors around, the quality management team worked with the nursing council to enlist the nurses as change agents. The nurses are there to remind the doctors that if they make an order, the hospital guarantees to accomplish it within eight hours.
According to Cammarata, there were "no obstacles at all for identifying department issues, in radiology, operating room, etc." The obstacles were raised by medical staff, who wanted clear definitions of what an avoidable day is.
"When we say the patient is no longer meeting acute-care criteria, they want that defined," Cammarata said. "Initially it had some bad connotations. Once they figured out what it was, they all agreed."
Certain departments were harder to persuade than others, Satterlee said.
"The cardiologists have been very reluctant, at first," he said. "For example, an echocardiogram, if that wasn't ordered (to be done immediately) and the request came in Friday night, they wouldn't do it until Monday morning.
"It was a physician manpower issue," radiologist Satterlee continued. "They already had one person on call on the weekend to cover admits and emergencies. To do echocardiograms they would have to add another doctor on call on the weekends."
This issue was brought up every month at the medical staff's quality management committee. Eventually the hospital's need became so apparent that the physician group changed its scheduling.
Peer pressure has played a major role in bringing the physicians around. And they had to see a benefit to themselves.
That's where hard data proved persuasive. All physicians want to polish up their efficiency profiles with the managed-care payers. This system shows them an easy way to do it.
Physicians will receive individual letters showing how many avoidable days are attributable to them. A copy goes to the hospital's utilization review director.
Satterlee predicted the whole hospital and medical staff will soon be on the bandwagon. "Does it force everyone to be more efficient? I think the answer is, it does."