Rae Woods (00:09):
From Advisory Board, we are bringing you Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. My name is Rachel Woods. You can call me Rae. We've said it before on this podcast. Hospital volumes are back, and that means that managing the acute care operating model, things like throughput, patient flow, length of stay is again top of mind for healthcare leaders, if it ever even left. Improving hospital capacity is not a new problem, and yet there hasn't been an industry-wide consensus on how healthcare leaders can best hone their acute care operating model. I know these things are hard, but today I want to dig deeper into why capacity and length of stay remain persistently difficult problems to solve.

(00:59):
This week I invited Advisory Board's Isis Monteiro. She spent the last eight months talking to 45 healthcare leaders across nine countries. In fact, Isis and her team identified, and I'm not kidding here, 124 individual root causes of high acute length of stay. Don't worry, we're not going to give you a to-do list 124 items long. In fact, we're going to shift your attention away from the never-ending to-do list and towards addressing the structural barriers that keep hospitals from reaching their full potential. Isis, welcome back to Radio Advisory.

Isis Monteiro (01:35):
Thank you so much. I'm happy to be here.

Rae Woods (01:38):
I feel like you have been on tour, Isis. Has it felt like that to you?

Isis Monteiro (01:44):
Yeah, I'd say so.

Rae Woods (01:45):
Not only have you been on tour, you have been on a global tour. Maybe it's not you Eras Tour or your Renaissance Tour, but you've been going on a tour trying to understand acute care operating models. Definitely not the same as Beyonce or Taylor.

Isis Monteiro (02:01):
Not quite that.

Rae Woods (02:02):
But in all seriousness, you have been out there really trying to learn about different approaches to operational challenges, throughput, length of stay, capacity, these tried and true hospital-based issues, and you've identified a lot of problems that contribute to ultimately pretty high length of stay. Okay, so we know what's going wrong. Do we have any idea of what's going right? Did you come across any big solutions that we should just name from the outset?

Isis Monteiro (02:33):
Yeah, so actually one of the biggest takeaways from this research is that systems are really not leaving a lot of easy wins on the table. We actually did a survey where we found that there's an average of 14 patient flow improvement initiatives that are happening concurrently across a single organization. So it's really not for lack of trying or a shortage of ideas for how to improve length of stay. To give you some examples here, we heard things like creating discharge lounges for patients that are medically fit for discharge and are awaiting transportation back home or to their next site of care or doing asynchronous discharge rounds so that patients are still being evaluated by their entire care team. But that's not happening simultaneously. So even implementing command centers, and even that, while it does help to improve visibility, which is increasingly critical, is not a silver bullet solution. So that's the point here is that there's no one single tactic that's going to be the end-all be-all for the capacity challenges that systems are facing today.

Rae Woods (03:34):
I had a feeling you were going to tell me there's no silver bullet. I did not think you were going to tell me that the average organization has 14 different initiatives going on at the same time. I'm going to risk asking a ultra-simple question here.

Isis Monteiro (03:49):
Go for it.

Rae Woods (03:50):
Just that there are no easy fixes, but just humor me. If the problem at the end of the day is capacity, why isn't it the right answer to just add more beds?

Isis Monteiro (04:03):
Expanding your bed supply is not necessarily going to unlock additional capacity if you don't have the workforce to staff those beds. And while the outlook has improved, staffing is still insufficient to meet patient demand or to be able to capitalize on the volumes that are returning. And this might not be true for everyone. Maybe the right answer in some contexts is to build or buy. But while that may help to alleviate capacity challenges in the short term, that's not going to be the answer to achieving long-term sustainability.

Rae Woods (04:34):
And I guess comes back to the idea of why there are so many different initiatives happening at once. Because even if you add more beds, that doesn't solve the entire problem because you need to worry about staff, you need to worry about the right nurses, the right level of those nurses, and so on and so forth. I can't help but still think about all of the different tactics that hospital leaders are running at to solve this problem. And it sounds like they're not actually making that much of an impact. Why aren't these tactics making a dent in addressing length of stay?

Isis Monteiro (05:11):
To echo the point that you actually just made, when you're doing so much simultaneously, it's really hard to coordinate across all of these efforts or to identify what's working within pockets of the organization to be able to scale that out across the enterprise. So that's one challenge, just how difficult it is to scale out these capacity building solutions. The other challenge is a, when in doubt admit, or when in doubt don't discharge culture that keeps patients in beds for longer than they need to be. And the third is a limited influence over factors outside of the traditional remit of the hospital. So things like a shortage of beds and staff in post-acute or long-term care or even patients unmet non-clinical needs that might end up driving downstream utilization.

Rae Woods (06:00):
This is interesting to me. You found 124 problems, but what we're not going to offer is 124 solutions or 124 tactics. In fact, those three things that you just mentioned, these are entrenched systemic barriers that make it really difficult for hospitals to make an impact on length of stay. So let's take them one by one. And I'm really glad you started with scale. It sounds like we're at the spaghetti at the wall phase trying to improve hospital capacity, trying to improve length of stay. And it's a big problem if we can find something that's working, but we can't actually scale that across the health system or across multiple hospitals. How do we overcome that challenge?

Isis Monteiro (06:40):
So I actually have an example of what good looks like from an organization in Australia, Gold Coast Hospital and Health Systems. So a little bit of context here, especially if you're not in Australia and you're wondering, okay, how is this relevant to me? I think that Gold Coast is really a microcosm of the demographic challenges that a lot of our members including in the US are facing. So Gold Coast population exploded over the last decade, and that's been fueled in part by new retirees that are migrating to the area, which means that their overall population is also aging. And we did the math because that's what we do, and we figured out that if Gold Coast was going to try to increase its bed supply to OECD average, which is 5.04 beds for a thousand people, to serve their geography with its population growth they were going to need to build the equivalents of eight more midsize hospitals by 2040 or add almost 5,000 beds.

Rae Woods (07:34):
Oh my goodness. But they weren't going to do that.

Isis Monteiro (07:36):
Yeah. They weren't going to do that. That's just not sustainable or feasible. So in the face of all of these pressures over the course of five years, they gradually built out this foundation for a system-wide capacity management approach. And this evolved creating a centralized coordination hub with the command center and later pulling in critical partners like the ambulance service to optimize patient flow decisions. And this laid the groundwork for the stuff that they did in 2023, which is to create their patient flow steering committee. And this patient flow steering committee is their centralized capacity improvement function, which they've housed under their strategy, transformation, and major capital division. This committee is responsible for identifying where the most impactful opportunities for improvement are, coming up with the solutions, testing them and socializing those solutions across other clinical areas.

Rae Woods (08:31):
Hold on a second. You've said a couple of things that have perked my interest. You said decade, you said five years ago. And then you said they set up this centralized improvement team that's totally dedicated to testing, coordinating, scaling the actual problem we're trying to solve here in 2023. How long ago did Gold Coast do this?

Isis Monteiro (08:53):
Yeah. So this is an effort that's been, to your point, like a decade in the making, and I think it illustrates just how difficult it is to resolve the structural challenge of scaling out solutions.

Rae Woods (09:06):
It also is the benefit of looking globally for solutions.

Isis Monteiro (09:10):
Yeah.

Rae Woods (09:11):
What you said is that what was happening in Australia in 2016 is what's happening in America today. So US health systems can actually learn quite a bit by looking at challenges abroad. In this case, looking at Australia.

Isis Monteiro (09:24):
Yeah, actually, and thank you so much for making this point because I cannot miss the opportunity to get on my soapbox about this. As someone that's worked more closely with international organizations and [inaudible 00:09:34] a really big advocate for systems looking to other jurisdictions and learning from their peers abroad, right? Because I think systems have more in common in terms of the challenges that they're facing and the solutions that they're looking to than it might seem on the surface. And while you might not be able to copy and paste exactly what somebody in another country is doing, there are certainly approaches or behaviors that are worth adopting or at least considering in a local context.

Rae Woods (10:00):
We love soapboxes on Radio Advisory. So I'm actually going to ask you to stay on your soapbox for a minute longer. What are the key lessons that US health care leaders should take away from this particular example with Gold Coast?

Isis Monteiro (10:13):
So I think the two things that I highlight here is the way that Gold Coast has married strategy and operations. So I mentioned that they house this patient flow committee within their strategy transformation and major capital division. And this is really important because this is what allows the team to tap into and leverage resources like data analytics, IT support, project management expertise, and a whole network of clinical experts that are typically safeguarded for transformational projects. And this to me, really illustrate what it looks like to elevate capacity building from being a clinician's side-of-desk work to a transformational objective with institutional resources behind it.

Rae Woods (10:57):
Wow, I love that. And that is the only way that you're going to take pilot projects, things that are done in a handful of places and actually scale them across a hospital and across an entire health system, an entire ecosystem.

Isis Monteiro (11:10):
Absolutely.

Rae Woods (11:11):
That was only one of the structural challenges that you mentioned. Tell me about this other one. You called it the bias of defaulting to acute care. What does that mean?

Isis Monteiro (11:25):
Yeah, so it's a culture problem among providers where the default is to admit patients and that's contributing to systemic issues when it comes to managing length of stay.

Rae Woods (11:35):
When did this bias come up? Is this a new problem?

Isis Monteiro (11:40):
I think that it became something that we really had to lean into during COVID in order to protect our patients, but it's something that we now need to start to reconsider as we're experiencing more of these capacity pressures more acutely.

Rae Woods (11:54):
And I'll say, I've heard this in my travels, the when in doubt admit tendency that folks have that to your point, I think comes from COVID, the fact that we had this acute, really complex, really scary moment just in the last five years. But there are other trends that added to it. I'm sure the workforce crisis, the fact that we don't have the same level of education and expertise spread evenly across, particularly our nursing workforce, can lead us to default to this acute care bias, as you've said. But let me put my cynic hat on for a minute. At the same time, we're also talking about how hospitals need to balance the fact that they've got this aging population, this population that's older, that's sicker. I've also shared that we're dealing with a sicker younger population. So I just want to push, is it really the right answer to shift away from our default to admit culture that's risen over the last five years?

Isis Monteiro (12:53):
Yeah, I'm really glad that you raised this point because we're not talking about abandoning patients, right? We're talking about delivering care in the most appropriate setting and safeguarding acute level resources for acute level patients. And that requires us to think of the acute setting as only one part of and not the entirety of the care continuum. [inaudible 00:13:14] might default to treating or keeping patients in the hospital when ideally the default should be whatever the most appropriate care setting is, even if it's not in the hospital.

Rae Woods (13:25):
Okay. So you've won me over. This is definitely a problem, but it is a problem rooted in culture. How do you actually change the mind of providers who've been operating in this model for the last several years?

Isis Monteiro (13:40):
Yeah, this is not easy and it's something that takes time to do well, because doing this well requires you to address the underlying challenges that prevent clinicians from adopting new models of care. So in some instances that might be clearing up any confusion about who can be treated in alternative care settings or addressing their fears about patients not receiving the right level of care in the alternative setting. So I do have an example from another international organization. So Pennine Acute Hospital Trust is a health system that's based in the UK. They had an urgent care facility, but they still had patients who could have been safely treated there still presenting to the ED, and inappropriate ED presentations is something that a lot of systems are struggling with and something that our research suggests is actually going to get worse with time.

(14:31):
And Pennine realized that part of the reason why their urgent care was being underutilized is because it was hard for clinicians and patients to know or to keep track of all of the conditions that could be safely treated in their urgent care center. And so patients kept showing up to the ED, and clinicians kept admitting from the ED instead of referring patients to the urgent care center, which was the more appropriate setting.

Rae Woods (14:55):
I can see the problem. How did they actually solve it?

Isis Monteiro (14:58):
Yeah. So what they actually did was create a short list of exclusion criteria for urgent care, right? So instead of people having to remember a laundry list of conditions that can be treated in urgent care, clinicians and patients now know that the default is urgent care unless they meet one of five exclusion criteria. So this really flips the decision from should this patient go to urgent care to why shouldn't they? And now because you had more and more kinds of patients that we're presenting to urgent care, have to expand and adjust the staffing. And one of the changes that they made was to actually install a senior decision maker to manage this wider range of patients.

Rae Woods (15:40):
And I'm sure to also help staff get more comfortable with this new model, which is as an important feature in culture change.

Isis Monteiro (15:49):
And so that point, they also have a rotating member of the acute medical console team that's there every day to provide additional specialist support and additional guidance.

Rae Woods (17:06):
At the beginning of this conversation, Isis, you outlined three systemic barriers for managing length of stay, the difficulty in scaling successful initiatives, we covered that, and the pervasiveness of this acute care bias, which we just talked about. The last one is post-acute capacity shortages. And I'm going to admit this last one seems a lot harder for health systems to address because they just don't have control over what happens in post-acute, at least in most cases. Again, I'm going to ask, is there a simple answer here that we are overlooking? Does this mean that hospitals should be owning and operating post-acute care facilities?

Isis Monteiro (17:46):
So I'm going to copy out my answer by saying there may be some exceptions to this just to cover my grounds here. But most of the time the answer is going to be no. Beyond the financial burden of owning and operating a SNF, which for a lot of systems already makes this a complete non-starter, you're also facing a slew of regulatory barriers, staffing challenges, and a lack of expertise about how to run and to operate the SNF.

Rae Woods (18:13):
So then we really saved the most difficult problem for last. I mean, what are health systems to do here? What approaches are you seeing in the market to manage the post-acute throughput problem?

Isis Monteiro (18:24):
Yeah, so there's been some experimentation here from SNF at-home models, which are still very much in their infancy and face the same kinds of regulatory and reimbursement challenges as acute care at-home models to partnering with or buying hotels for patients who are medically fit for discharge or awaiting transfers.

Rae Woods (18:45):
Oh, wow.

Isis Monteiro (18:46):
But I really think that the biggest and most scalable opportunity for health systems is in bridging expertise and staffing gaps across their post-acute partner sites.

Rae Woods (18:56):
Tell me more about that.

Isis Monteiro (18:58):
So something that we're seeing more and more organizations do is deploy their own team of nurses and geriatricians and sometimes other specialists to go to SNFs or to residential aged care facilities to deliver in-person acute-level care to patients in order to prevent emergency department utilization or readmissions. In Australia, of course, I have to lean on my international examples here, but these are called Geriatric Flying Squads, but you can almost think of these as an adaptation of something like the Community Paramedicine Program.

Rae Woods (19:31):
Or it's like they're doing rounds, they're just doing rounds out on the road.

Isis Monteiro (19:36):
Exactly. Yeah.

Rae Woods (19:37):
Geriatric Flying Squad is a much cooler name than just setting rounds. I'm a little bit surprised that you haven't brought up the role of technology. If I think about the first two systemic challenges, culture is not one that is easily solved by tech. Neither is scale. But this last one is a little bit more about workforce. Why aren't we running to tech, to AI, pick your buzzword here to help health systems make headway either on this [inaudible 00:20:10] or just on length of stay in general?

Isis Monteiro (20:12):
I'm glad that you brought this up and I figured that this question around AI and tech would be coming, but what we found is that organizations are really using AI to do things that they were already doing, but perhaps a bit more efficiently, like using AI to improve admission or bed placement decisions, for instance. So it's still bed air traffic control, it's just AI-enabled bed air traffic control.

Rae Woods (20:36):
So it sounds like more of the tactics that we're saying are not bad tactics, they're still useful, they're just not going to solve these systemic problems. Those are the ones that can be replaced with technology, but you also have to deal with these entrenched systemic issues if you really want to make a move, make a change on length of stay.

Isis Monteiro (20:56):
Yes. To your point about workforce and technology, and specifically in this point around how do we partner more effectively with our post-acute care partners, we actually came across a really interesting story from Canada this time from Quebec hospital called Jewish General Hospital. They're using virtual reality to provide remote specialist support to caregivers and long-term care site.

Rae Woods (21:17):
Whoa.

Isis Monteiro (21:18):
The staff at the long-term care facilities that are wearing these VR goggles, which are feeding real-time audiovisual information to nurses that are sitting in the hospital and nurses can help assess the patient's condition and help the caregivers make better decisions about the patient's treatments.

Rae Woods (21:36):
Great example of technology making an existing solution better. This is like a souped up consult.

Isis Monteiro (21:42):
Mm-hmm.

Rae Woods (21:43):
Isis, we've covered a lot of ground, but I have to imagine you have a lot more that you could offer to our listeners to help them with length of stay, with capacity with their hospital operations. Where do you want our listeners to start?

Isis Monteiro (21:57):
So we do actually have a landing page for provider operations, and within that landing page, it's going to be all of the resources that the advisory report has published over the past couple of years, not just from this research cycle, but in the recent past as well that are still going to be relevant for health system leaders today.

Rae Woods (22:15):
We'll add those links to the show notes. Isis, thank you so much for coming on Radio Advisory.

Isis Monteiro (22:22):
Thank you so much for having me, Rae.

Rae Woods (22:30):
Look, this was a conversation totally focused on operations, and maybe you're thinking this isn't the coolest, sexiest story in healthcare, but I want to remind you of an episode that Abby did a couple of months ago. It's actually one of my favorite episodes we've ever done, and it's all about the new mandate for health system growth. And one of the things I learned from that episode is how important it is to focus on these fundamentals, to focus on the operations. We can't afford to get these things wrong. So remember, as always, we're here to help.

(23:32):
New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by me, Rae Woods, as well as Abby Burns, Chloe Bakst, and Atticus Raasch. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. Special thanks to Paul Trigonoplos. We'll see you next week.