Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're talking about variance in length of stay, what drives it, and what teams can do today. Joining me is Dr. Kierstin Kennedy. She's the Chief Medical and Quality Officer at UAB Medicine. Dr. Kennedy, thank you so much for joining us today. I love this topic because it really is so patient-centered. And from a patient's perspective, why do you feel that reducing length of stay actually matters? How does that more consistent care change their experience in the hospital?

Dr. Kierstin Kennedy: Well, thanks for having me. This is a favorite topic of mine too, for the same reasons. I think when we think about care from the patient perspective, being in the hospital is just the right place to be when you are really sick. But it's not the right place to be for too long because there are other people around you that are sick.

So when we keep patients in the hospital longer than we necessarily need to, we're increasing their risk of infections. We are also disrupting their sleep cycle, which has a major impact on healing. And for our older patients, it increases the risk of delirium. And so, those are many patient-centered reasons why we would want to make our care in the hospital as efficient as possible.

Not to mention, patients are also coming in from normal lives, and I think we sometimes forget that. So, they have jobs, they have home responsibilities, they may have people or pets that they have to care for. And so, when we bring them into the hospital, we disrupt that. And we need to find ways to reduce the amount of time that we have them missing work or missing home or their loved ones, if at all possible.

Melanie Cole, MS: Yeah, I agree with you. And as we're talking about how standardizing parts of care helps patients get better care, not just necessarily more efficient care, where have you seen it reduce confusion or delays for patients and families as you're talking about their quality of life and their home lives and the things that they need to get back to? What have you seen as far as reducing that? Because, boy, there's a lot of moving parts.

Dr. Kierstin Kennedy: Well, I mean, we have a lot of opportunities, but we are actively working on it. One of the ways that we've tried to work on that is through our consult efficiency. We once talked to the patient and family advisory council about this idea to work on consults. And I'll never forget, one of a patient's caregiver said—you know, I can remember thinking every time they would say on rounds, "Oh, we're going to consult this team," "Oh great. That's going to add another one to two days to our hospital stay," our patients really notice that. And so, that's one of the things that we've tried to take on is, when we need to engage an additional team in consultation, how do we make that as efficient as possible, both so that patients are able to get what they need in a timely fashion, but then also so that patients don't have that anxiety of, "Well, now that we've added this additional layer to the care, what does that mean for me? How long is that going to take? How much longer does that prolong my hospitalization?"

Melanie Cole, MS: Yeah. So, that's interesting that patients notice this kind of thing, and they certainly do. Now, as we think about patients, they're not standard, they're not all the same, especially in an academic medical center. When we think of reducing that unnecessary variation, while still making sure care feels individualized and appropriate for each patient, how do you walk that fine line between them staying long enough to get the care that they need, have all the consults that they need, make sure that the treatment modalities and the follow-through on all of that is set before they're released and releasing them too soon. Back in the day, a pregnant woman, have a baby, stay in the hospital a week. Now, 24 to 48 hours, she's out. How do we walk that fine line?

Dr. Kierstin Kennedy: Well, I think that's one place where standardizing care actually helps us, because it takes out some of the guesswork and it takes out some of the variability that can be influenced by our experience. For example, if you have a physician that is less experienced, they may feel less comfortable discharging a patient and may want to hold them a little longer, but may not necessarily have fixed data for why they're doing that. On the other side, you could have a physician that is more experienced and feels way more comfortable discharging and maybe discharging too soon. But there's no objective data that we use to decide on when the patient is ready to go.

So if we can try to standardize more, it gives us an opportunity to be able to look at these pathways, for example. And once we've checked the things that we know that we need to do, and we can look at the data and it's lining up, then we can say, "Okay, this patient is ready to go home," and you reduce some of that variation that is influenced by our experiences for good or for bad.

I think the other benefit to that is that patients start to feel that consistency. So, there's less variability in the messaging, the nurses, the doctors, the RTs, everyone's messaging essentially the same thing. "Here are the steps. Here is where we want to go. And this is what needs to be done in order for you to go home." And while yes, every patient is different, I'll tell patients every body is different. A lot of the care that we deliver can be standardized to some extent. Eighty percent of it we can probably standardize. And then, we have the opportunity on the 20% to really make it personal for that patient. I also think in our messaging is where we have the opportunity to tailor it to the patient and make it personal.

Melanie Cole, MS: I am going to ask you a tough question now. How? How do you set a standard when everything is so variable and different? Give us a little ABCs to how you would begin an initiative like this, which seems insurmountable, but really isn't. And the way you're describing it, Dr. Kennedy, makes it sound very doable and yet also so important, so needed, so efficient. How? How do you get started?

Dr. Kierstin Kennedy: Listen, it's so doable. And I love this question because when I think about—historically, we've heard comparisons between healthcare and the airline industry. And people will say, "Oh, but that's so different." But if you think about it, and I only have this insight now because my husband became a pilot, but when he flies, everything is variable for that day. The wind direction, the wind speed, the temperatures, which can impact the cloud composition, and what it feels like to move at different levels. All of those things can be different when you are flying. And yet, there's still an expectation of standardization, even though every flight will be slightly different.

And I think healthcare is very similar to that. For most of the conditions that we treat, 80% of the time, we can be consistent in the way that we approach it. There is always a zebra. There's always the 20%. But I think we create waste and we create inefficiency when we build our systems around the 20% instead of building our systems around the 80%.

So, I'll give you an example, congestive heart failure. When someone comes in volume-overloaded from congestive heart failure, yes, every patient is different. Their makeup of medications will vary. Their comorbidities will be completely different from one patient to the next. Their renal function and the way that they tolerate certain diuretics will be totally different. But there are some thread in there that is the same. We're going to diurese them. We're going to check their heart function. We're going to get an echo. We are going to monitor their electrolytes, like there's some component of that care that is standard for every single patient. And I think what we need to do is focus on standardizing those pieces that we can, so that then when we have variability, it is truly necessary variability tailored to that patient as opposed to wide variability in who gets an echo, when do we order the echo, you know, when do we check renal function, when do we not. That's the guesswork that we can take out.

Melanie Cole, MS: Yeah, that makes so much sense. You've made so many good points. I mean, there's criteria for so many things. And following that criteria is paramount to that good care. And if there is a way to put that across the board in variance and length of stay, that really can increase patient satisfaction and indeed physician satisfaction, because it must make you all feel like, "Wow, I really did my best for this patient and they left feeling cared for."

Dr. Kierstin Kennedy: No, absolutely. And you're bringing up a really great point. You know, sometimes as the physician or APP, that's trying to deliver the care, sometimes it can feel like you're out there on your own. You're trying to order the things and get the things done, and it feels like no one else quite understands how urgent this is or how timely this needs to be. And I think when we start standardizing our care, when we start setting expectations for how long something should take—using the CHF example, again, if the patient has not had an echo in the last six to 12 months, we are going to get an echo and we're going to do that within the first 24 hours. And that read is super important because it's going to dictate how we organize the care during that hospitalization. So, we need that read within X amount of time. Now, everyone understands what their role is, how efficient they need to be in their role in order to make sure that what the patient receives is the most efficient care and coordinated care.

Melanie Cole, MS: This is a great conversation. Really, really a great conversation, and so important for other providers and other institutions to hear. As we wrap up, Dr. Kennedy, for health systems listening, who really want to do this kind of work, what's one mindset shift or practical lesson that's been really important in reducing successfully variation without compromising that quality, which is really the crux of this discussion?

Dr. Kierstin Kennedy: Well, I have several thoughts if that's okay, but I'll try to make them concise. I think the first thing is that people have to view standardization as a tool for reliability and not view it as something that is boxing them in or something that creates unyielding rigidity, because you can flex, remember, for the 20%. This just makes it easier to coordinate the care and more efficient for the 80%, the "textbook" clinical situations.

The other thing that I think is super important is that we have to lead thinking about patient care, that has to really be our focus when we do this. It should not be about chasing metrics necessarily, which is probably odd to hear someone who's focused on quality say. But it really should not be driven by the metrics or the numbers. It's got to be driven by what is best for the patient, what creates the best environment and the best care delivery experience for the patient. And so, the goal is we want safer, clearer care for patients. And we want it to be clear for those who are providing the care.

And then, I think the last thing that I would just emphasize for those health systems that are listening is that sustainable change is going to require ongoing feedback, iteration, and trust. You never get it right on the first time, and that's normal. So when you do it and it doesn't work perfectly, we don't throw it out of the window and say it doesn't work. We learn from it, we tweak it, we continue to reiterate and try again. And we will, if we do that, find the perfect tool or pathway or approach to deliver on our mission.

Melanie Cole, MS: Well said. And that flexibility is really just as important as you said, even if it's just the 20%, being able to ebb and flow with it. And that's so important. And thank you so much for joining us and sharing your incredible expertise and your thoughts on this very important topic. So, thank you again for joining us. And for more information, you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.