Systemwide Work Begins to Improve Patient Care Progression

Our new Patient Care Progression initiative is aimed at reducing length of stay and ensuring safe, timely, and seamless transitions to home or post-acute care. It’s a major step in our work to improve healthcare capacity and boost access to care.

Mass General Brigham has launched our new Patient Care Progression initiative to reduce the length of stay for patients at our acute care hospitals and ensure their safe, timely and seamless transitions to home or post-acute care. Guided by two multidisciplinary teams of clinical and operational leaders in collaboration with clinicians across Mass General Brigham, this coordinated, systemwide effort will develop and implement solutions that will create much-needed capacity and provide patients increased access to our system’s exceptional care.

“Everyone who has worked on reducing patient length of stay has learned that there is no silver bullet, no one change in practice that will solve every problem. It takes the coordinated effort of multiple care teams working in unison along every step of the inpatient journey,” said Kyan Safavi, MD, MBA, medical director of Clinical Integration for Mass General Brigham. Dr. Safavi is leading Patient Care Progression for the system with Vice President of Operations Niki Keefe, RN, MSN, MBA. “We are taking a holistic, integrated approach that leverages the resources of our system, proven effective interventions already in place, and the best new ideas as a springboard for action systemwide,” he said.

Work began this past spring with the formation of two teams with specific areas of focus: 

• Clinical Progression Team led by Mallika Mendu, MD, MBA, Mass General Brigham’s interim chief Population Health officer and vice president of Clinical Operations and Care Continuum at Brigham and Women’s Hospital
• Care Transitions & Post-Acute Access Team led by Kim Barry, RN, MS, FACHE, vice president of Enterprise Care Continuum

Each team is comprised of separate workstreams — eight under Clinical Progression, six under Care Transitions & Post-Acute Access – that involve key contributors to the work needed to be done to safely and efficiently advance patients through their hospitalization and facilitate their transition home or to continued care. Members of our Business Operations, Data Analytics and Digital teams will provide critical support that will inform strategy and help develop digital tools, including optimizing the capabilities of Epic, to operationalize proposed interventions.

“The launch of our comprehensive, multidisciplinary approach to managing patient progression across the continuum of care is an essential step forward for our system as we navigate a dynamic and busy healthcare environment. Beginning this fall, every department, from clinical care teams to administrative and support services, will play crucial roles in improving patient flow and enhancing outcomes,” Keefe said. “Our willingness to collaborate, adapt, and innovate represents the absolute best of who we are as a system.”

With the goal of eliminating persistent barriers that prevent the clinical progression of care and timely transitions to post-acute settings for medically ready patients, the Patient Care Progression initiative will help free up beds systemwide, enabling improved access for our sickest patients and reducing wait times and the number of boarders in our emergency departments.

“The leaders of the workstreams are all subject matter experts who have been working for many years in their respective areas of focus. They’re extremely plugged into our frontline operation and any intervention we pursue will be shaped by clinician feedback and grounded in the experience of what it’s like to deliver care at the bedside,” Dr. Safavi said.

Moving patients along their care pathway

The Clinical Progression workstreams bring together the services responsible for the clinical progression of patients and ensuring patients are medically ready for discharge. This includes leaders from physician departments, nursing, physical therapy, procedural and perioperative services, imaging, and more. Foundational to their work will be the evaluation of curated data that clinical teams can use to help identify best practices and opportunities for improvement. Leaders in General Medicine, Cardiology and Neurology are shaping this effort.

“We are not optimally progressing patients, and we need to understand opportunities for improvement by systematically reviewing data to identify consistent factors contributing to delays and developing plans to address them proactively,” Dr. Mendu said.

Workstreams began meeting over the summer, sharing best practices, learning from one another, and exploring improvement opportunities. All workstreams have identified one or more intervention that they will implement in the coming year. “We have truly begun to operate as a system and so the ability to scale best practice is much easier now than it has ever been before,” Dr. Mendu said.

Led by Barry, the system’s first vice president of Enterprise Care Continuum, the Care Transitions & Post-Acute Access Team will expedite the progression of medically ready patients from our acute care hospitals to the next level of care that they require. Drawing on the expertise of our system’s case managers and social workers and forging closer connections and collaboration among internal partners, including Spaulding Rehabilitation, Behavioral Mental Health, Population Health, Home Care, Home Hospital and EMS/Transport Services, the team will work together to reduce delays that impact medically ready patients awaiting discharge.

“We want to take a proactive approach to discharge planning that begins at admission and continues as a patient progresses in a timely, appropriate and safe way through the hospital,” Barry said.

The Care Transitions & Post-Acute Access Team also is committed to strengthening partnerships with post-acute facilities outside our system to develop a reliable care continuum network. “We need to build bridges to best serve our patients,” Barry said, “and keep them moving along a high-quality trajectory.”