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LOS management is analogous to a sports team.

Recently there has been a lot of posting, blogging, and articles on length of stay (LOS) and Medicare spending per beneficiary (MSPB). These are, in the opinion of many, related metrics, yet somewhat different. One does not replace the other, and either may examine similar data, but from different points of view. Both are designed to reduce cost and increase efficiency without sacrificing quality. When it comes to hospitals and healthcare systems, LOS issues are variable, and usually specific to each institution, with minimal comparison to national standards, and that’s OK.

MSPB takes a more global, overarching perspective, with individual, state, and national comparisons, longer intervals of time associated with a particular hospital admission, and several different claim types associated with the period of time examined.

Revenue cycle, among many areas, centers on:

  • Direct costs – related to the cost of the delivery of care; and
  • Indirect costs – fixed costs, such as dietary, personnel, housekeeping, overhead, etc.

Both LOS and MSPB take each of these into account, in varying degrees. The rest of this article will be spent on LOS, discussing the process of identifying areas of concern, data gathering, and solving issues. For further clarification, the definition of “process” is a series of events leading to a desired outcome. Each topic under review will be different, but the process across the investigation must be the same in order to ensure the validity of the results.

When getting started, there are some basic questions to be answered, at the beginning:

  • What are you trying to accomplish?
  • Why?
  • What have you tried before?
  • What are your goals?
  • What are your indicators of success?

It is not just a matter of saying “this is our problem, so find a solution and be successful” without a consistent, reproducible process.

Keep in mind that LOS is an important indicator of the efficiency of hospital management. Reduction in the number of inpatient days results in decreased risk of infection and medication side effects, improvement in the quality of treatment, and increased hospital profit, with more efficient bed management. 

Since the process of LOS management will include teams as one component, keep in mind that there is a very close analogy to sports teams that will be mentioned. Even if you are not a sports fan, you are more than likely familiar with the concept.

Here are the steps for management to take, from leadership to team deployment:

  • Determine the issue to be investigated:
    • Once the issue is identified, who will manage it?
    • Realize there are three groups in this endeavor:
      • Leadership
      • Management
      • Teams
    • Determine your goal and your end point:
      • This is, in essence, a gap analysis: you know where you are, but where do you want to be?
    • Gather your data:
      • No matter what the issue is to be researched, you must have benchmark data to start, and for comparison.
      • Then, establish a dashboard.
      • Gathering of data must be consistent, without variation: for example, every day at the same time, depending on the issue.
        • Facilitate areas to be addressed.
      • Identify areas of obstacles, work-arounds, and bottlenecks.
    • Work towards your goal(s):
      • Establish your teams (see definition of “team” below).
      • Empower your teams.
        • Give them what they need to accomplish the goals.
        • Reward based on outcomes, not tasks clicked off a list.
      • Make sure that what is achieved matches your indicators of success.


This all may seem somewhat simple, as far as the anatomy of LOS management, but here are some overarching principles to keep in mind.

First of all, the definition of a team, according to Wikipedia, is “a group of individuals (human or non-human) working together to achieve their goal. Teams normally have members with complementary skills and generate synergy through a coordinated effort, which allows each member to maximize their strengths and minimize their weaknesses.”

When looking at the three groups involved in such an endeavor, remember this:

  • Leadership is like a coach in a sports game; they are not in the trenches, and they don’t manage nor play the game. They have a plan and give their teams direction and motivation to help them to reach their goals as they empower them.
  • Management removes the roadblocks, the workarounds, and the bottlenecks, and directs by planning, organizing, staffing, and controlling throughput utilizing human, financial, and material resources, but they don’t coach. They must ensure effective communication.
  • Teams, when empowered, will do the work, moving toward achieving the desired results – and the level of accountability belongs with them, and not the upper levels.

The reality is that the anatomy of managing LOS comes down to process, teams, and leadership principles. Finishing this article with a quote from a man who understands these three principles, Chesler “Sully” Sullenberger, one of the heroes from the challenged commercial flight that landed on the Hudson River:

“When it comes to teamwork, there are lessons to be learned from the cockpit.

In air travel, when the captain first meets the crew, after making introductions, they align team goals and open channels of communication with everyone; they make it psychologically safe for even the most junior flight attendant to approach a senior captain about a potential safety issue and know that they will be heard.

We create among the team members a shared responsibility for the outcome of the flight, that it’s not only their right to speak up if they need to, it’s their responsibility to.  

It’s not about who’s right, but what’s right.”

This is team empowerment, the essential ingredient to the success of any initiative.


John Zelem, MD, FACS

John Zelem, MD, is principal owner and chief executive officer of Streamline Solutions Consulting, Inc. providing technology-enabled, expert physician advisor services. A board-certified general surgeon with more than 26 years of clinical experience, Dr. Zelem managed quality assessment and improvement as a former executive medical director in the past. He developed expertise in compliance, contracts and regulations, utilization review, case management, client relations, physician advisor programs, and physician education. Dr. Zelem is a member of the RACmonitor editorial board.

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