Trinity Health Of New England’s CEO wanted to focus on reducing LOS given its impact on patient safety, patient satisfaction, and the organization’s bottom line. To build momentum and establish LOS as an executive-level priority, the organization’s regional CMO arranged a dedicated meeting with the executive teams of the five hospitals, which included facility presidents, CMOs, CNOs, and CFOs. Trinity also invited care management and post-acute leaders to ensure a broad perspective and create cross-continuum alignment around LOS reduction.

The open forum allowed leaders to have a candid discussion on institutional performance and agree on LOS reduction as a near-term strategic priority. The meeting was divided into three parts to look at LOS through multiple lenses (data, workflow, and strategy) which helped build buy-in. In the meeting, the group:

1. Sized Trinity’s LOS reduction opportunity: To start, leaders shared Trinity’s observation and LOS data1 compared to national benchmarks (by facility, service line, and sub-service line). Trinity leaders were then able to identify the greatest addressable opportunities to improve efficiency.

2. Provided new perspectives: Advisory Board shared best practices on LOS reduction. Facility leaders then debated the applicability of new tactics in the context of their facilities’ workflow, and shared internal best practices from their own experiences.

3. Created momentum and cemented buy-in: Trinity leaders established LOS reduction as a priority for the organization—and set a shared expectation that all attendees commit to achieving top-percentile performance in the weeks ahead.

Regional CMO established leadership over LOS

LOS is impacted by many departments and members of the care team, making accountability for LOS reduction a challenge. Trinity Health Of New England’s leaders decided that one clinical executive should be held accountable for the LOS reduction initiative to ensure clear ownership. Trinity placed LOS under the purview of the Chief Medical Officer—sending a powerful message that LOS reduction was an organizational priority that everyone, especially the physician enterprise, could significantly inflect.

Regional and facility leaders work hand-in-hand

Rather than just issuing a mandate for system-wide LOS reduction, Trinity’s regional CMO and his team created a playbook to support facility CMOs. While the playbook provided a standard path, facility CMOs were empowered to customize their own action plans based on their individual institutions.

The regional CMO then met weekly with facility CMOs to monitor progress on playbook implementation, offer support on challenges, and address questions that arose. Facility progress was then reported at the division-wide monthly CMO council as a standing agenda item to ensure accountability and dedicate time for peer-to-peer discussion and problem solving.

Trinity’s LOS reduction playbook
Outlined below is an overview of the components of Trinity’s standardized LOS reduction playbook.

1. Understand drivers of excess days by unit and facility.
   Facility CMOs leverage standardized Achieving Clinical Excellence (ACE) boards on each unit to identify which units have the greatest opportunity for improvement, and to pinpoint barriers to discharge (such as insurance delays, excess consults, facility delays, test delays, etc.).
2. Prioritize the top three units driving excess days at each facility.
   Each CMO is required to identify the top three units driving excess days at their facility and propose strategies for improvement. The regional CMO holds each facility CMO accountable for progress on their proposed countermeasures.
3. Execute standard LOS reduction tactics across all units.
   Facility CMOs then assess interprofessional round (IPR) effectiveness, improve management of patients with LOS greater than seven days and complex case review, and engage physicians with the greatest opportunity to reduce excess days.
4. Develop LOS protocols for each service line.
   Facility CMOs work with individual service lines to develop LOS protocols—a critical step to reduce delays for observation patients. For instance, the cardiology service line developed protocols for chest pain and syncope observation patients.

To achieve and sustain their LOS reduction goals, Trinity Health Of New England leveraged their existing process improvement structure, Lean, and data analytic capabilities.

Lean management tools drive progress

The Trinity Health Leadership System—a Lean strategy that instituted daily tier huddles—helped structure information sharing from frontline staff to executives. This included LOS and observation data and barriers such as consult delays, insurance authorization barriers, and test delays. The facility CMO could then effectively report progress, barriers, and countermeasures for LOS O/E (observed versus expected LOS) in weekly meetings with the regional CMO.

Additionally, the Lean team implemented a strategy A3, a Lean management tool, to track progress of the LOS initiative across all facilities. The strategy A3 is customized with action plans, timelines, and ownership of LOS projects and objectives. The tool was updated on a weekly basis and shared with facility CMOs and department chairs—ensuring alignment across the region.

Data dashboard monitors playbook execution

Separately, the Chief of Data and Analytics developed a real-time dashboard to monitor LOS O/E across the region. The dashboard allowed leaders to drill down by fiscal year, facility, and area of interest (such as unit, service line, diagnosis, or attending physician on record). This level of detail helped the regional and facility CMOs develop and adapt their LOS strategy.

Trinity Health Of New England instilled frontline accountability for continued progress on LOS reduction and provided forums for two-way dialogue. Trinity instituted the following interprofessional communication forums:

• Triad model interprofessional rounds (IPRs): Trinity’s IPRs include a facility-level nurse leader, physician leader, and care manager. This group leads IPRs every day, on every unit, and includes other members (such as social work or pharmacy) when necessary. Trinity implemented standard work for IPRs on all units throughout the region—including, covering a patient’s current clinical condition, pending consults/tests, and next steps in safe transition of care.

• Weekly utilization review meetings: Trinity learned that, for executive councils to be effective and drive change in real time, utilization management meetings must occur weekly, not monthly. Utilization review meetings have become one of the key forums to bring together physician, nursing, and care management leaders to quickly uncover, discuss, and address LOS O/E barriers, among other topics.

• LOS O/E standing agenda item at executive councils: Trinity includes directors of care management at monthly CMO and CNO councils. During these executive councils, LOS O/E is a standing agenda item where facility CMOs and directors of care management report progress, best practices, barriers, and countermeasures for their organization’s LOS reduction effort. If LOS O/E is above 1, executives come to the meeting with proposed solutions to bring it down.