Reducing CEA and EVAR Length of Stay By Shernaz Dossabhoy

By: Shernaz Dossabhoy, MD, MBA
Team Members: Jocelyn Morta, NP, Carolyn King, RN; Lauran Miklosey, RN; Thelma Flores, RN; Tara Lahiji-Neary, MBA, Sudip Nag (ad-hoc PFP)
Team Sponsors: Ronald L. Dalman, MD and Sridhar Seshadri 

As healthcare providers, one of our main goals is to provide quality care for our patients while minimizing their hospital stay. Length of stay (LOS) after a surgical procedure is a significant indicator of the quality of care provided. Shorter LOS has been associated with improved patient satisfaction and decreased healthcare costs. However, in April 2022, we were alerted to a change in our typical LOS metrics. Between Jan 1 and Dec 31, 2021, our institution experienced increased LOS rates for two types of vascular surgery procedures: asymptomatic carotid endarterectomy (CEA) and endovascular aortic aneurysm repair (EVAR).

We next began a several month-long deep dive into our data to better define and understand the problem. Our analysis showed that 67% of SHC patients who underwent asymptomatic CEA had a postoperative LOS >1 day, while 36% of patients undergoing EVAR had a postoperative LOS >2 days. These rates were above the regional and national benchmarks set by the Vascular Quality Initiative (VQI) and had increased from prior years at SHC. As a team, we recognized the need to address this problem and focused on reducing LOS for these two procedures to meet our quality standards.

One of the strengths of our team was our strong cohesiveness, which fostered an environment of open communication and idea sharing. Our group consisted of a resident, APP, nursing educator, patient care manager, and case manager, providing a diverse set of perspectives. We spent a significant amount of time analyzing the data from the past two years and reviewing the system breakdowns before implementing interventions.

During our analysis, we discovered a breakdown in the system that contributed to the increased LOS rates. We targeted these gaps and implemented interventions to improve discharge planning moving forward. However, what surprised us was that the data analysis for our most recent patients showed that our “problem” may have slowly fixed itself. Nevertheless, we continued to implement interventions to sustain this positive change.

Our weekly Friday team meetings kept us accountable, and each team member took the initiative to research and implement interventions after the team had discussed them. Below are some examples of the changes to the discharge planning process that our team implemented:

  • Including an expected discharge time and date in the surgery scheduling letter that is mailed to patients ahead of surgery (similar to a “discharge appointment”)
  • Instituting a discharge screening tool the morning of surgery and documenting the results in the patient’s Epic chart, allows all providers to see if there are potential barriers to discharge before surgery starts.
  • Educating all key patient stakeholders including nurses, physicians, APPs, case managers, and PT on expected discharge procedures and length of stay.

Through these interventions, we were able to reduce the LOS  for CEA and EVAR. Accordingly, the percent of patients with LOS >1 day for CEA decreased from 50% to 43%, and LOS >2 days for EVAR decreased from 26% to 0%. 

In conclusion, our project aimed to reduce LOS for elective CEA and EVAR patients at our institution. We recognized the need to address this problem and worked together as a team to analyze the data, identify system breakdowns, and implement interventions to improve the discharge process for our patients and providers. Our efforts paid off, and we were able to sustain a positive change. As healthcare providers, it is important to monitor both our patient outcomes and existing systems and workflows to identify areas for future improvement.

Stanford School of Medicine
Stanford Healthcare
Stanford Children’s Hospital

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Alice R. Georgitso, MPH, joins the SMCI Advisory Committee as our first Patient Partner. Alice has served as a Patient Partner with the Stanford Health Care (SHC) Patient & Family Partner Program for over 4 years and was appointed Chairperson of the Adult Congenital Heart Program Patient & Family Advisory Council in January 2020. She assisted in developing the Stanford Adult Congenital Heart Program’s Peer-to-Peer Program and serves as a Mentor to ACHD patients pre-and-post-organ transplantation. Alice has presented Stanford Health Care’s C-I-CARE framework for structuring best practice communications and developing relationship-based care approaches with patients and colleagues to 500+ Stanford Medicine Directors, Managers and Clinical Staff.

Alice is a Patient Relations Manager at Stanford Health Care. Within her role, she provides a channel for problem resolution to promote the highest quality of care and service excellence. Alice has also worked as an Unrelated Donor Search Coordinator with the Blood & Marrow Transplant at Stanford Health Care to coordinate allogeneic hematopoietic stem cell transplants through collaborative planning and partnership with the National Marrow Donor Program and SHC clinicians. Prior to her work with SHC, she was the Community Service Foundation Director at San Mateo County Medical Association where she partnered with local stakeholders and clinicians to expand county-wide community health programs to diverse populations. She has also delivered invaluable community health services through her work with the American Heart Association.

Alice earned her Bachelor of Arts in Sociology and Biology at Saint Bonaventure University in Olean, NY and her Master of Public Health from SUNY Buffalo in Buffalo, NY. Alice is a member of The Beryl Institute and Adult Congenital Heart Association professional associations, Donor Network West partner advocating for organ, eye, tissue, and blood donation, and remains an active volunteer with SHC. Alice continues to promote patient-and-family-centered care in both hospital and community settings to support precision health and improve the healthcare experience for patients, families, and clinicians.

John Shook learned about lean management while working for Toyota for 11 years in Japan and the U.S., helping it transfer production, engineering, and management systems from Japan to NUMMI and other operations around the world. While at Toyota's headquarters, he became the company's first American kacho (manager) in Japan. In the U.S., Shook joined Toyota’s North American engineering, research and development center in Ann Arbor, Michigan as general manager of administration and planning. His last position with Toyota was as senior American manager with the Toyota Supplier Support Center in Lexington, Kentucky, assisting North American companies adopt the Toyota Production System. Shook co-authored Learning to See, the book that introduced the world to value-stream mapping. He also co-authored Kaizen Express, a bi-lingual manual of the essential concepts and tools of the Toyota Production System. With Managing to Learn, Shook revealed the deeper workings of the A3 management process that is at the heart of Toyota’s management and leadership.
Shook is an industrial anthropologist with a master’s degree from the University of Hawaii, a bachelor’s degree from the University of Tennessee, and is a graduate of the Japan-America Institute of Management Science. At the University of Michigan, he was director of the Japan Technological Management Program and faculty member of the Department of Industrial and Operations Engineering.
Shook is the author of numerous articles, including "How to Change a Culture: Lessons from NUMMI"; Sloan Management Review, January 2010, which won Sloan’s Richard Beckhard Memorial Prize for outstanding article in the field of organizational development.

The Stanford Medicine Center for Improvement benefits from the diversity of its members and the richness of the experiences that they bring. Although the program continues to evolve from when it first launched in October 2019, we continue to reach out to improvers across Stanford Medicine in the School of Medicine, Stanford Health Care, Stanford Children’s Health, Stanford ValleyCare, UHA and PCHA. We welcome everyone from every discipline and recognize that we are stronger together as we value the contributions of every member of our teams.

Dr. Paul Maggio is the Chief Quality Officer of Stanford Health Care. Prior to being appointed the SHC CQO, he was Vice Chair of Surgery for Clinical Affairs, Associate Chief Medical Officer of Operational Effectiveness, and Associate Director of the Adult Intensive Care Unit. He trained in General Surgery at Brown University and obtained advanced training in Adult Surgical Critical Care and Trauma at the University of Michigan. He holds a Masters of Business Administration from the University of Michigan and is triple board certified in General Surgery, Critical Care, and Medical Informatics. In addition to being a clinician and surgeon, Dr. Maggio participates in the National Committee on Healthcare Engineering for the American College of Surgeons, and his research interests are focused on the delivery of high-value care.

Dr. Maggio received the SHC Board of Hospital Director’s Denise O’Leary Award for Clinical Excellence in 2013

Micah Duchesne joined Stanford Medicine in 2020 as a Principal Consultant project managing the deployment and operations of the Hospital Incident Command System (HICS) for COVID-19. He is now the Administrative Director of Performance Improvement at Stanford Health Care where he leads annual operations planning, improvement consulting, and capability development. Micah is also a Fellow at the Stanford Medicine Center for Improvement.

Before joining Stanford, Micah was an independent consultant for his company Silicon Valley Strategy Group, which partnered with Novartis and the Perelman School of Medicine at the University of Pennsylvania to commercialize cellular therapies. He led a team of clinicians from Europe, Japan, and Australia in designing a global logistics model and quality management system for Kymriah, the world's first approved CAR-T therapy, and helped create an international advisory board aimed at improving global capacity.

Prior to independent consulting, Micah was the Director of Performance Improvement at Kaiser's Santa Clara Medical Center, and he previously held improvement roles of increasing complexity within other health systems. Micah has both a Bachelor of Science in Accounting and Master of Health Services Administration from Mississippi College. He also holds certifications as a Lean Six Sigma Master Black Belt and Project Management Professional.

As a professional, Micah enjoys organizing complex stakeholder ecosystems, clarifying ambiguous goals, aligning visions, and driving high-stakes change. As a human, Micah just enjoys breaking a sweat. While he's not at work, he's at his very own gym in San Jose, CrossFit Moxie. You can find him there coaching olympic weightlifting or working out with his wife. He has a daughter in elementary school and two gym dogs.