Quality improvement and cost savings after implementation of the Leapfrog intensive care unit physician staffing standard at a community teaching hospital.

BACKGROUND: Prior studies have shown that implementation of the Leapfrog intensive care unit physician staffing standard of dedicated intensivists providing 24-hr intensive care unit coverage reduces length of stay and in-hospital mortality. A theoretical model of the cost-effectiveness of intensive care unit physician staffing patterns has also been published, but no study has examined the actual cost vs. cost savings of such a program. OBJECTIVE: To determine whether improved outcomes in specific quality measures would result in an overall cost savings in patient care DESIGN: Retrospective, 1 yr before-after cohort study SETTING: A 15-bed mixed medical-surgical community intensive care unit PATIENTS: A total of 2,181 patients: 1,113 patients preimplementation and 1,068 patients postimplementation. INTERVENTION: Leapfrog intensive care unit physician staffing standard MEASUREMENTS: Intensive care unit and hospital length of stay, rates for ventilator-associated pneumonia and central venous access device infection, and cost of care. RESULTS: Following institution of the intensive care unit physician staffing, the mean intensive care unit length of stay decreased significantly from 3.5±8.9 days to 2.7±4.7 days, (p<.002). The frequency of ventilator-associated pneumonia fell from 8.1% to 1.3% (p<.0002) after intervention. Ventilator-associated pneumonia rate per 100 ventilator days decreased from 1.03 to 0.38 (p<.0002). After intervention, the frequency of the central venous access device infection events fell from 9.4% to 1.1% (p<.0002). Central venous access device infection rate per 1000 line days decreased from 8.49 to 1.69. The net savings for the hospital were $744,001. The 1-yr institutional return on investment from intensive care unit physician staffing was 105%. CONCLUSIONS: Implementation of the Leapfrog intensive care unit physician staffing standard significantly reduced intensive care unit length of stay and lowered the prevalence of ventilator-associated pneumonia and central venous access device infection. A cost analysis yielded a 1-yr institutional return on investment of 105%. Our study confirms that implementation of the Leapfrog intensive care unit physician staffing model in the community hospital setting improves quality measures and is economically feasible.

Addressing roadblocks to hospital-physician alignment.

In Lefton's June column, he outlined the need for meaningful healthcare reform and presented 14 reform strategies. This month, he examines two of these 14 strategies - both of which relate to hospital-physician alignment.

Coinsurance discounts: one possible solution to illogical pricing.

Illogical pricing has placed hospitals at a competitive disadvantage with nonhospital providers for outpatient services. For some hospitals, discounting coinsurance may improve that scenario.

What's it worth?

Patients without effective coverage frequently must pay charges for medical services that are higher than the hospital's contracted rates. A national survey of hospitals shows great variation in how charges are set and accommodations made for patients with low income. The government is taking a more active role in examining charging practices. Hospitals can take several steps to help stave off government intervention.

Developing organizational charity-care policies and procedures.

A lack of standards in healthcare organizations often makes it difficult to consistently define and report charity care. Accurately documenting services provided to patients who are unwilling or unable to pay can be difficult for many organizations. Temple East, Inc., Philadelphia, Pennsylvania, established several policies in an attempt to clarify its charity-care provisions. Among the organization's guiding principles were that all unreimbursed costs of caring for patients who are either uninsured or enrolled in a Medicaid program and all bad debt directly attributable to services to low-income or uninsured patients should be included as charity care. The organization also determined that contractual allowances and disallowances for payers other than government payers should not be included as charity care. Determining clear, unambiguous definitions for several terms related to charity care also helped the organization better track and document its charity-care services--a task that will become increasingly important for hospitals in the future.