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A Medical Director’s Perspective

Internally Marketing a Case Management Initiative –
Engaging Physicians in Efforts to Reduce Hospital Length of Stay
By Karl Bushman, MD, FACP

In the summer of 2006, St. Clair Hospital (St. Clair), a 329-bed community hospital in the south hills of Pittsburgh, PA, embarked on a concerted
effort to reduce inpatient length of stay (LOS). Many forces combined to raise LOS to a high degree of importance. A large percentage of
St. Clair’s payors use a case rate, so a short LOS is more profitable. A busy emergency room produced 70% of the hospital admissions
(excluding newborns), and a major expansion of its physical plant was underway. The existing hospital already operated at high occupancy,
and an anticipated increase in admissions sparked a multifaceted effort to “stretch the skin” of the hospital to allow more patients to receive
care within the same space. According to an external source, reducing LOS in a 300-bed hospital by 0.5 days would effectively increase the
capacity of the hospital by 25 beds.

Key to the success of this LOS initiative was to engage physicians.
Effectively, this called for marketing this initiative to an internal audience
– a series of initiatives and communications designed to influence them
to certain actions. This article will provide an overview of how this
successful initiative was communicated, and from these examples will
discuss marketing concepts that are more broadly applicable to
engaging internal personnel in other case management initiatives.
Though the information and concepts communicated as part of
this initiative are likely common knowledge for most case managers, it
is critical to realize in such communication that the audience – in this
case physicians – does not necessarily share a case manager’s
job-specific knowledge nor frame of reference. Therefore, information
and concepts that can be assumed to be common knowledge amongst
case management professionals may likely not be possessed by others.
Common concepts and methods of assessing or evaluating an issue are
likely very different as well.
UNDERSTAND THE AUDIENCE
After a careful evaluation of the current staffing of the
department of case management and social work (CM/SW), case
management leadership at St. Clair decided to realign the nurse
case manager to social worker ratio. In addition, case management
developed a new part-time role for a physician advisor for case
management (PACM). This role brought the perspective of a
practicing physician to the case management team – in effect
producing a greater understanding of the “audience” or “market”
that the new initiative was seeking to influence.
One key insight was to explore a practicing physician’s motivation
to engage in the initiative and to put forth effort to reduce LOS.
Practicing physicians worry about many considerations in patient care,
and LOS occupies a comparatively low priority on that list. The factors
that motivate most physicians to reduce LOS are very different from
the motivations of the hospital or case managers. Though short LOS is
financially beneficial to the hospital, it usually does not help the
physician and can even lead to decreased billings. For most physicians,
the benefit of having fewer inpatients and less work the following day is
sufficient to encourage timely discharges. If hospital administrators
approach physicians on long LOS cases in a nagging or accusatory
manner, the message is immediately disregarded. Collaborative and
data-based techniques stand more chance of success. With each
contact the message needs to stress avoiding unnecessary extension
of LOS, not sending patients home or sending them to facilities when
their medical problems require continued hospitalization.
DEVELOP DATA SUPPORT
Case management leadership at St. Clair undertook a new data
extraction program that reported physician-specific LOS examined
from multiple angles: in comparison to peers, trended over 12 months,
and LOS compared to geometric mean length of stay (GMLOS, the
national average for Medicare patients with the same diagnosis).
These reports helped the PACM and director of CM/SW identify
individual physicians to invite for personal interviews. These meetings
included sharing of data, asking the physician about specific challenges
to the individual and group LOS, and an appeal to improve LOS.
Individual and group-specific data sheets went to the physicians by
mail with an explanatory cover letter. This effort aimed to improve LOS
by sharing comparative data with physicians, who overall do not like to
be outliers. This technique successfully informed the medical staff of
the hospital goal of lowering LOS and indicated who needed to
improve. Some physicians responded very positively to this simple
sharing of data, and made major changes in practice patterns to
improve LOS. Others, however, refused to engage in any efforts to lower
LOS. Most members of the medical staff made modest improvements
and the hospital’s LOS began to trend down.
DEVELOP A CLEAR MESSAGE – PRACTICES TO LOWER LOS
During this period the PACM met weekly in a Case Review and
Utilization Management committee (CRUM rounds) with the CM/SW
department and director to discuss individual cases regarding patients
who currently had long LOS. Most had legitimate medical need, but in
a few cases the PACM went to the attending physician to intervene and
recommend discharge or a clarification of plans.

continued on page 14
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Internally Marketing a Case Management Initiative (continued from page 13)

Practice patterns of recalcitrant physicians were discussed at these and through different media. Distribution of the Best Practices included
meetings and were compared with those of physicians with shorter mailing and emailing, and posting on inpatient units and in the medical
LOS. The collective experience of all the case managers with members staff lounge. Poster-sized versions were hung in the public relations
of the medical staff allowed a distillation of patterns that delay discharge poster holders at the entrance from the physician parking lot and
and development of countermeasures to elsewhere. A flurry of attention to the same
avoid such delays. The PACM articulated message made sure the whole medical
these techniques to minimize PRINCIPLES FOR INTERNALLY staff knew about the best practices.
unnecessary LOS and grouped them into
seven best practices to reduce LOS. Once
MARKETING AN INITIATIVE Use Unexpected Placement
this message had been developed, the to Gain Attention
content received approval from the case Messages that are placed in
managers, their director, the president of 1. Understand the Audience unexpected places often catch our
the medical staff, and the chief medical attention. Once these practices became
officer before dissemination. well known as a hospital recommended
2. Develop Data Support standard, they found new use as
COMMUNICATION individual reminders. Half sheets
Keep it Brief 3. Develop a Clear Message (4 ¼ x 11) with each of the best practices
Most individuals are bombarded printed on goldenrod paper serve the
with thousands of advertising messages case managers as they work on the
each day, and in the hospital this is
4. Communication – Keep it Brief hospital units. Nurses at St. Clair use
increasingly true as hospital staff see similar sheets in pink on the charts to
countless messages throughout the 5. Use Multiple Media as communicate with doctors. When a
facility each day. The result, combined Appropriate to Increase Frequency potential problem arises with a patient,
with busy schedules, is that hospital staff the case manager or PACM puts a
members – and physicians – have short goldenrod reminder with underlining or
6. Use Unexpected Placement
attention spans for posted messages, and additional notes on the chart to suggest
a message must be noticeable to break to Gain Attention that the attending “Call the Cavalry” or
through the constant flood of media. “Let My People Go.” These sheets are
The seven best practices were used only to catch the attention of those
written as brief messages with interesting, memorable headlines. Each viewing them, and are removed prior to final record filing. Making
best practice fit easily on an 8 ½ x 11 sheet of paper with bullet points suggestions based on an established standard reduces the sense of
and liberal blank space to increase readability. The public relations “singling out” and the need for defensiveness on the part of physicians.
department formatted each practice in a colorful and professional
graphic matching the branding format now used in all hospital-wide CONCLUSION
communication and advertising. The labeling included the footer This endeavor is a small part of St. Clair’s efforts to decrease its
title of “Micro Case Management Education” as a play on the idea of LOS, which to date have been successful. In fiscal year (FY) 2005, LOS
“Micro Continuing Medical Education.” The name of the PACM was 4.86 days. This decreased in succeeding years: In FY 2006 LOS
undersigned the message, to establish that the message came to the decreased to 4.71, in FY 2007 to 4.50, in FY 2008 to 4.46, and year to
doctors from a peer. date in fiscal 2009 it is 4.33 days.
The Best Practices were rolled out sequentially in easily digestible As an internal marketing initiative, the project’s success is
pieces – this kept the message alive and changing without demonstrated by the level to which the seven best practices have
overwhelming the audience. A new best practice was released every become recognized by the medical staff, and recognized as a hospital
two to four weeks. Each sheet had the titles of the previous and future accepted standard. The seven best practices have become well known
best practices as teasers, promoting familiarity through repetition and among the medical staff, if not universally applied.
a slight sense of mystery and anticipation. Karl Bushman, MD, FACP, has been a practicing general internist with
Use Multiple Media to Increase Frequency Mt. Lebanon Internal Medicine since 1993. He is a former president of
Because of the number of messages competing for attention in the the medical staff and a member of the board at St. Clair Hospital, a
hospital setting, it is important to ensure that each member of the targeted 329-bed independent community hospital. He has been Physician
audience is exposed to the message multiple times in different settings Advisor for Case Management at St. Clair Hospital since 2006.

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Best Practices of Physicians with Short Length of Stay
1. Call the Cavalry – Allow others to help you help your patient achieve
a rapid recovery. Patients might have many medical problems and other
needs that require attention from a variety of specialists or hospital
personnel. If they all start at once, the patient will be ready to go home
sooner. The primary care physician need not relinquish overall
management when others join the care team of the patient.
• If you know you will need certain tests, ask the emergency department
to order them and you may have results when you first see the patient.
• If one or more specialists are needed, get them involved before the
condition becomes dire.
• If you see a social need or anticipate placement, get the social worker
and case manager involved early to coordinate home care services or
skilled nursing beds.
2. Care for the Whole Patient – Many patients have multiple medical
problems that all need attention in the hospital. Identify and address all the
problems simultaneously so the whole workup will be done at once. If each
consecutive problem takes a few days, the patient may stay long enough to
develop still more problems.
• Order physical therapy early to help the patient ambulate to avoid
discharge delays from deconditioning and help identify if they need a
higher level of care.
• Manage chronic problems like diabetes and anticoagulation actively
while other problems predominate, so the hospitalization does not
need to extend longer to get those back in shape.
• Use hospital protocols to avoid complications like thromboembolism, falls,
and infections to allow your patient to return home safely and promptly.
3. Pull the Tubes – The length of hospital stays can depend upon
intensive therapies with medical devices such as surgical drains, chest
tubes, and nephrostomy tubes. Endotracheal tubes, foley catheters, and
central lines can cause dangerous infections if left in too long. Use them
while the patient needs them, but remove them as soon as it can be done
safely. Assess which need to be continued at home and make plans for
home services.
• Be aware of all tubes and devices, and remove them when appropriate.
• Transfer patients off monitored beds when the monitor is not needed,
to allow new patients into those beds.
• Alert case managers and social workers early about potential homecare
needs such as oxygen, tube feeds, wound vacs, or IV therapies.
4. Weekend Warriors – If your patient might be ready for a discharge
over the weekend and someone else is covering your service, do not let
your absence prevent an appropriate discharge.
• Inform your patient and family of the likely discharge by your
covering physician.
• Inform your covering physician of the likely discharge and what could
trigger or delay it.
• Help out by outlining discharge instructions, orders, medication
reconciliation, prescriptions, and follow-up on the chart before you leave.
• If you are the weekend rounder, discharge the patients who do not
need to be in the hospital.
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5. Involve the Patient and Family – Unrealistic or mistaken family
expectations scuttle many discharge plans. If surprised and unprepared,
patients often request “just one more day” to make their own preparations.
Talk to patients and family members often and let them know two to three
days in advance of expected discharge. Sharing your discharge criteria in
advance also helps them see when the hospitalization could appropriately
end. Avoid open ended plans and comments like “you will be here for as
long as you are feeling sick,” or “don’t go home from the hospital until I get
back from my long weekend.” Use statements such as:
• “When your mother can eat and walk and is cleared by the cardiologist,
then she can go home.”
• “Call me this afternoon with your family’s decision on code status.”
• “You could go home as early as tomorrow if everything goes as planned,
but we’ll assess your condition each day and decide what is best for you.”
• “I am writing your discharge orders now, which will take effect this
afternoon when the stress test results come back, if they are negative.”
6. Prepare the Launching Pad – Occasionally administrative matters
delay discharges of medically stable patients. Predict early how long the
patient needs to be in the hospital. Outpatient services or facility transfers
take time to prepare. Case managers and social workers can perform
much of the paper work for you and prevent delays if they know a day or
more in advance what will be needed. If a treatment or transfer turns out
not to be required, cancel it.
• Order a six minute walk test within 48 hours prior to discharge to justify
home oxygen therapy.
• Have a PICC line placed if IV antibiotics will continue.
• SNF transfers work best with a day or two for family evaluation of
facilities and facility evaluation of the patient.
• Round early in the day on discharges and write detailed orders
including medications, transportation and services to avoid receiving
calls for clarification.
7. Let My People Go – Know what workup needs to be done in the acute
care hospital and which can be done in the outpatient setting. Discharge
patients who are well enough to go home and let them get follow-up tests
as outpatients. Finish long therapies in a skilled nursing facility (SNF) once
the plan is in place.
• Complete long courses of antibiotics in a SNF once the patient and
plan are stable.
• Transfer your patient to a SNF if all they need is some physical therapy
to get back on their feet before going home.
• Order outpatient colonoscopies, MRI’s and stress tests if the acute
medical problem is past, particularly when a weekend delays the test.
• Arrange office follow-up to review test results.