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How Mayo's stroke care pathway improves bed capacity—and why the process works for more than just your stroke patients

January 15, 2019

    It's no secret that the strain on hospital beds will persist as our aging population requires increasingly complex care. Reengineering patient flow can help hospitals meet this demand by ensuring patients are treated in the right care setting at the right time. Mayo Clinic adopted a risk-stratified approach to address this issue, and in doing so, it cut stroke care costs by 10%.

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    Mayo's time-driven, activity-based costing (TDABC) model stratifies stroke patients according to severity—a successful model that's not just replicable across hospitals, but also across specialties.

    4 easy steps to improve efficiency and cut costs

    We've distilled Mayo's process into four steps that you can use, regardless of the unit or patient population you're targeting:

    1. Map existing care pathways using TDABC. Mayo first developed process maps of various stroke care pathways and used TDABC to assign each step of the pathway a comparable cost-per-time value. Historically, all stroke patients were sent to the intensive care unit (ICU); Mayo also maintained a neuroscience progressive care unit (NPCU) that could receive stroke patients after the ICU. By developing these process maps, the team found that a stay in the NPCU cost an average of $500 less per day than in an ICU.

    2. Identify alternative, lower-cost care settings. By analyzing historical stroke data with these process maps, Mayo determined the characteristics of low-acuity patients who could safely bypass the ICU and go straight to the NPCU, saving the ICU beds for patients with more complex needs.

    3. Use or create a system to stratify patients. To determine which patients could be safely sent directly from the ED to the NPCU, Mayo stratified patients according to the NIH Stroke Scale (NIHSS), which assesses a stroke patient's condition using a range from 0 for normal to 42 for severe. Ultimately, the group recommended that high-risk patients (those with a score of 18 or higher) be sent to the ICU, while low-risk patients (those with a score of 14 or lower) would be suitable candidates for the NPCU.

      In replicating Mayo's model in your own organization, it's helpful to start with specialties that have a well-regarded severity scale for ease of implementation.

    4. Maintain flexibility when reengineering patient flow. The new care pathway guideline was introduced into care team workflow with physician judgment playing a significant role in deciding where patients should be treated, especially for those who fall between the low- and high-risk categories. Mayo met Joint Accreditation requirements by leveraging a "specialized hybrid level of nursing care," and the group still receives the same level of Medicare reimbursement for administering tissue plasminogen activator (TPA), regardless of where the patient is treated.

      When reengineering a new pathway, keep quality and reimbursement information transparent to gain physician buy-in.

    While the above process has greatly benefited Mayo's stroke program, these steps can help hospitals offer care that is increasingly targeted toward specific patient complexity. In this case, leveraging a progressive care unit doesn't just lower utilization of high-cost ICU beds; it also increases the homogeneity of stable patients seen in a regular ward. Ultimately, Mayo's success indicates that using a TDABC model doesn't—and shouldn't—stop at stroke care.


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