CMO Message: July 2023

July 10, 2023

Our fourth edition of Medical Staff News is here! Thank you for your feedback to date and keep it coming. If you have suggestions for future content in the newsletter, email And always feel free to reach out to me directly at:

This month’s Chief Medical Officer message includes information on three very important topics: 

1) Communication and Feedback: Please plan to attend the Joint Medical Staff Annual Business Meeting Sept. 19 at Indian Summer Golf and Country Club. There will be important updates and discussion and voting on bylaws changes that are designed to ease the way of our providers at both facilities and across the division by standardizing some things where appropriate. We want to hear your voice! 

2) What to watch: Length of Stay (LOS): Geometric Mean Length of Stay Observed to Expected (GMLOS O:E) for June increased to 1.69 (while PCH decreased further to 1.09) and observed Average Length of Stay/ALOS increased overall to 5.73 (St. Peter increased to 6.23 days but PCH decreased to 3.91 days). Data below is from both ministries: 



So… what’s the big deal/BLUF here? 

  • There are multiple metrics we follow and multiple ways to look at LOS that all vary slightly (average LOS, financial LOS, LOS by discharge disposition, LOS by floor/diagnosis, financial LOS, etc.); all are important because they reflect how efficiently we use our limited resources to care for our patients. All are higher than expected for us (overall, as South Puget Sound), and higher compared to other similar sized facilities in our System and we are generally increasing … 

  • Admissions that stay for extra days translate to additional resource consumption (nursing and other support and ancillary staff, time, occupied beds), which limits our ability to admit new patients and get them the care they need (resulting in boarding in our Emergency Centers). 
  • Admissions that stay longer require additional nursing that translates into agency/contract utilization, which comes at a higher cost. 

  • Note the patient days and opportunity days in the snapshot above, with the smaller numbers in the bottom right being the values for June. There were 3,873 opportunity days for the month of June (calculated comparison of observed vs. expected). 

3) Quality Matters: St. Peter Hospital just completed our unannounced full accreditation survey by The Joint Commission (TJC) from June 20-23. As with any TJC survey we expect some findings but received NO condition-level findings based on the final report, which I consider a successful survey! Thank you for your support. 

Findings to note that pertain to our Medical Staffs included: 

  1. Failure to ensure documentation signed within 24hrs. Medical Record was signed by Physician Assistant but not co-signed by physician within 24 hours according to bylaws. 

  1. Widespread practice variability in some high acuity areas. Potential opportunities to standardize some portions of practice to increase quality of care. 

  1. OPPE/FPPE/Late career practitioner policy: Recommend strengthening program with specialty specific indicators and metrics (as decided by specialty leaders) to monitor the quality of care we provide. Recommend conversations to develop a policy that provides objective measures for monitoring physicians and APCs across the spectrum of our careers, including late career providers. 

Based on the findings that we did receive, we will be completing action plans for submission by end of August to allow for review, revisions, and sign offs by Sept. 1. 

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