Mass General Brigham Makes Progress in Improving Patient Care Progression

Nov 26, 2024

10 minute read

Mass General Brigham’s work to improve Patient Care Progression – our systemwide initiative to reduce inpatient length of stay – is advancing across Medicine, Cardiology and Neurology at our academic medical centers, where teams are beginning to leverage data and increased collaboration across care teams to create efficient pathways to home or post-acute care.

Patient Care Progression launched earlier this year to improve the timeliness of care delivery and transitions out of the hospital for our patients, enhancing quality of care and expanding access.

“Shorter length of stay positively impacts quality of care both for the patients who leave the hospital sooner – as they experience fewer care delays and reduce their exposure to the risks of hospitalization such as delirium and infections – and for the patients who more rapidly gain access to hospital beds,” said Kyan Safavi, MD, MBA, senior medical director of Clinical Integration and Operations for Mass General Brigham, who leads the system’s Patient Care Progression initiative along with Niki Keefe, RN, MSN, MBA, vice president of Operations. “For example, patients who get faster access to beds because the hospital’s length of stay is shorter will spend less time boarding in the emergency department. This is important for quality of care as national studies have shown that long boarding times are associated with higher adverse events and mortality.”

Two multi-disciplinary teams with dedicated areas of focus — Clinical Progression and Care Transitions & Post-Acute Access — are leading the Patient Care Progression initiative. Colleagues from across Mass General Brigham are collaborating on best practices and new ideas within each of the 15 workstreams that these teams encompass.

The Clinical Progression workstreams bring together leaders from physician departments, nursing, physical therapy, procedural and perioperative services, and imaging. Foundational to their work is the evaluation of curated data that clinical teams have begun using to help identify improvement opportunities. Leaders in General Medicine, Cardiology and Neurology are shaping this effort, piloting data-informed approaches at our academic medical centers (AMCs) that hold promise as best practices that could be applied across services and hospitals systemwide.

“We’re using data to help identify the barriers that are preventing medically ready patients from progressing to home or post-acute care and then supporting our teams as we pursue solutions to eliminate those barriers,” said Chris Roy, MD, medical director of Brigham and Women’s Hospital’s (BWH) Hospitalist Service and member of the Patient Care Progression Clinical Services workstream.

Big step forward for our patients

Led by Roy and his team, BWH hospitalists have begun regularly reviewing data that is designed to measure performance relative to patient length of stay, including “discharge rate.” A validated metric that has been implemented successfully in other health systems, discharge rate divides the total number of discharges in a day or week by the total census cared for by an individual clinician or a hospital unit/team during the same period. The higher the rate, the more success a clinician or team is having at progressing patients through to discharge.

This metric is part of a compilation of data or “dashboard” that includes other measures that provide important context, including the readmission rate within seven days.

“Many clinicians have never had the opportunity to see their own data as it relates to hospital discharge. Sharing this information is a basic and important step,” Safavi said. “This data can be used to gain insights into opportunities to progress the care of patients – either opportunities that an individual clinician or team can take action on or systemic barriers that require multidisciplinary fixes.”

Each week, BWH Medicine leaders and their teams review their discharge data from the week prior. “We’re able to see which teams have lower discharge rates and do our best to provide the support and resources they need to address any operational issues that might be standing in their way,” Roy said. That may mean prioritizing imaging orders, procedural needs or consults, or working to overcome other clinical barriers that are delaying care progression.

Success in reducing length of stay will come as a result of multiple care teams working together to optimally and efficiently progress patients through their care. The more experience we get and the better we understand what works and what doesn’t in a particular setting, we can share the lessons we’ve learned across the system.

Chris Roy, MD
Medical Director, Hospitalist Service
Brigham and Women's Hospital

While still early in its implementation, data shows the effectiveness of being proactive in identifying complex patient cases early and connecting with appropriate teams, including Case Management, upon admission rather than waiting until a patient is ready to be discharged, Roy said.

At Massachusetts General Hospital (MGH), Amber Moore, MD, MPH, director of Inpatient Medicine, recently launched a four-month pilot on an MGH unit that will incorporate the use of discharge data under the leadership of a unit medical director, a new role modeled after a position in place on BWH units. “This leader will partner with the nursing director and Case Management to escalate delays in care and work on specific issues to help move patients through the hospital efficiently,” Moore said.

Working on service in recent weeks, Moore has begun to share discharge data with her teams, emphasizing how the metrics tie directly back to the meaningful ways that improving care progression benefits patients. She highlighted specific patient stories to demonstrate the impact of mobilizing teams and resources to create access.

“We were able to bring in a patient from an outside hospital with a rare magnesium wasting disorder who really needed specialty care,” Moore said. “It allowed us to bring up a 90-year-old patient experiencing delirium, which wasn’t being helped by a noisy ED environment.”

The Clinical Services workstream team, including Moore, Roy and colleagues across MGB, meet twice a month to share their progress and exchange ideas.

“We know that success in reducing length of stay will come as a result of multiple care teams working together to optimally and efficiently progress patients through their care,” Roy said. “The more experience we get and the better we understand what works and what doesn’t in a particular setting, we can share the lessons we’ve learned across the system.”

Breaking down discharge barriers

Our AMC Cardiology and Neurology teams also have launched concerted efforts to identify barriers to discharge for their patients and work collaboratively to address them.

“We wanted to understand what was underlying the long length of stay and tease apart how we could attack it from multiple angles,” said Brad Molyneaux, MD, PhD, chief of Neurocritical Care and director of Inpatient Neurology at BWH. “For us, the message has been it’s not one thing, it’s 50 different things that are preventing patients from progressing through the system as rapidly as we want them to.”

BWH Neurology has been able to develop and deploy solutions that have helped substantially reduce length of stay. They identified delays in tracheostomy and PEG (feeding tube) placement, a procedure many patients require prior to discharge, and established a new workflow in collaboration with colleagues in Surgery and Anesthesia that has reduced the median time from consult to procedure by nearly two full days.

Noticing the impact that providing inpatient radiation therapy for some glioblastoma patients had on length of stay, leaders questioned whether there was a viable alternative approach. “Keeping patients in the hospital to receive this treatment is not the standard of care across the country,” Molyneaux said. Hospital leadership and multiple teams, including Case Management, worked together to eliminate this practice by transitioning patients home with a treatment plan and services or to a nursing home or rehabilitation facility to receive continued care.

MGH Neurology has improved patient progression through the adoption of weekly Complex Patient Rounds, a forum that brings together attendings, residents, nurse directors and Case Management leaders to address barriers to discharge for challenging cases. These discussions led to a new joint protocol, developed with BWH, to facilitate discharges to rehabilitation facilities for patients with nasogastric (NG) tubes. They also enabled improved collaboration with the Mass General Brigham Patient Transfer and Access Center to increase the repatriation of patients to their referring hospitals when appropriate.

In addition, daily Interdisciplinary Rounds have strengthened collaboration among MGH Neurology team members, allowing for real-time problem-solving or escalation to hospital leaders. “These efforts have streamlined ED and hospital transfer triage, while improving care delivery, optimizing discharge planning and reducing delays in transitions of care for complex cases,” said Marcelo Matiello, MD, vice-chair of Clinical Affairs for MGH Neurology.

Danita Sanborn, MD MMSC, associate chief of Cardiology at MGH, and Sanjay Divakaran, MD MPH, associate chief and clinical director of Cardiovascular Medicine at BWH, have pursued a number of efforts within their departments aimed at improving patient care progression. Within BWH Cardiology, multidisciplinary cardiovascular medicine teams are finding more opportunities to deliver appropriate care in outpatient settings. “This has not only improved patient progression, but has also led to an improved experience for our patients, which is most important,” Divakaran said.

Teams also are working more effectively with system partners, including Spaulding Rehabilitation and Mass General Brigham Home Hospital, to alleviate capacity pressures. These and other successful interventions are a promising start but the focused work to enable further progress continues.

“We’ve done a lot,” Molyneaux said, “but I’m excited about what’s ahead as we come together as a whole system to affect change for our patients.”