Cleveland Clinic Abu Dhabi
At Cleveland Clinic Abu Dhabi, accurately measuring the length of stay (LOS) and discharge ratios for individual hospitalists has proven to be a significant challenge. The current method of attributing hospital inpatient days to the discharging physician does not provide a precise assessment of each physician’s impact on patient flow.1
Additionally, there was no clear metric in place to track physician-related avoidable days—a crucial factor in reducing LOS and improving discharge efficiency.2,3 Physician-related avoidable days refer to the days when a patient’s discharge could have been expedited or managed more efficiently by the attending physician, thus reducing unnecessary length of stay.
To address these challenges, there was a need for a more accurate way to measure individual physician performance, specifically focusing on timely discharges, and establish a metric to encourage hospitalists to reduce avoidable delays and improve overall discharge practices.4
Solution: Building the Initiative and Implementation of the Study
To implement the study, 44 hospitalist physicians participated, with data collected over three months from January to March 2025, with plans to extend it throughout the year. During this period, performance metrics such as discharge ratios, shifts worked, and the LOS ratio were tracked to provide clearer insights into physician performance and identify opportunities to improve discharge efficiency.
Additionally, the healthcare insurance companies follow the ICD-10 coding system for documentation and CPT codes for billing purposes, similarly to those in the U.S. This standardization ensures consistency in medical coding and billing practices across providers and insurers, streamlining the financial aspects of patient care and further supporting the use of these codes to measure the following performance metrics.2
- Discharge ratio: This metric is calculated by dividing the total number of discharge note CPT codes by the total number of progress note CPT codes within the specific time period.
- LOS ratio: The LOS ratio is defined as the total number of progress note CPT codes divided by the total number of discharge note CPT codes.
- CPT codes used: CPT codes 99231, 99232, and 99233 are used for progress notes, representing the daily hospitalist visits and the associated care provided. CPT codes 99238 and 99239 are used for discharge notes, representing the final discharge evaluation and preparation for each patient.2
By analyzing these ratios, we aimed to gain a better understanding of physician performance in managing patient discharges and LOS, to identify potential improvements in discharge practices.1,4
Outcomes and Impact
We assessed key metrics to evaluate the impact of the intervention:
- The average discharge per shift was 1.09.
- The average number of shifts worked was 29.2.
- The average LOS per patient was 6.38 days.
- The average discharge ratio was 17.41%.
These results provided insight into hospitalist performance and served as a baseline for further improvements.
Limitations
Charge tracking inconsistency: This method tracks charges dropped by physicians, and if there is no consistency in dropping charges, it may affect the accuracy of the results.
External variables: There may be variables, such as patient types or floor assignments, that can affect results. However, these variations tend to become less significant over extended periods of time, such as quarterly or yearly.1,3
Week-to-week variability: Variability in discharge ratios can occur from week to week. However, over an extended period, such as quarterly or yearly, these fluctuations tend to be balanced and provide a more accurate reflection of physician performance.3
Future Directions
This study continues in 2025, with plans to extend it across a longer period. The data gathered will help further refine hospitalist performance metrics and guide future improvements. Additionally, the initiative’s success has laid the groundwork for exploring ways to further optimize physician workflows and reduce physician-related avoidable days.1,2
Dr. Khalil
Dr. Khalil is a consultant of hospital medicine at the Cleveland Clinic Abu Dhabi, with over 15 years of experience. He specializes in optimizing patient flow, reducing length of stay, and driving quality improvement initiatives.
References
1. Rachoin JS, et al. The impact of hospitalists on length of stay and costs: systematic review and meta-analysis. Am J Manag Care. 2012;18(1):e23-30.
2. Rothman RD, et al. The relationship between the follow-up to discharge ratio and length of stay. Am J Manag Care. 2020;26(9):396-399. doi: 10.37765/ajmc.2020.88490.
3. Kirubarajan A, et al. Morning discharges and patient length of stay in inpatient general internal medicine. J Hosp Med. 2021;16(6):333-338. doi: 10.12788/jhm.3605.
4. Vinh KP, et al. The effect of hospitalists on average length of stay. J Healthc Manag. 2019;64(3):169-184. doi: 10.1097/JHM-D-18-00042.