CMO Message: May 2023

April 27, 2023 Angela Maki

The second edition of South Puget Sound Medical Staff News is here. The newsletter will be sent the first week of every month. Communication is a high priority for me. I am here to listen and receive feedback. 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 & Feedback
  2. What to Watch: Length of Stay
  3. Quality Matters

1) Communication and Feedback:

I am looking forward to meeting with Medical Directors at the CMO Monthly Forum on May 4. This meeting will serve as an opportunity to meet with other leaders to discuss and share information. We will occasionally have other members of our executive team drop in with information and hear your feedback. In person is preferred, but there is a Teams option. If you have topics you want to be sure we cover, please let your Medical Director know!

2) What to Watch - Length of Stay (LOS):

Geometric Mean Length of Stay Observed to Expected (GMLOS O:E) for March increased overall from 1.43 to 1.57 (St. Peter from 1.48 to 1.65 while PCH decreased slightly from 1.32 to 1.28) and observed Average Length of Stay (Obs ALOS) increased to 6.07 days (from 5.58 in Feb) due to a significant increase to 6.4 days at St. Peter alone.

How can we help? Admitting physicians and APCs can help decrease Length of Stay (LOS) by:

  1. Minimizing social admissions
  2. Beginning discharge discussions with patients and staff as early as possible in the hospital stay (even on admission). It’s okay to be wrong but focusing on disposition (when to expect discharge and to where) helps patients and teams prepare and plan for consults, transportation, coordination early. Put a goal date on the bedside whiteboard to create a positive goal for patients!
  3. Placing discharge orders for known discharges early (goal by 10 a.m.) and notifying patient, family, and care team of anticipated discharge (nurse, case manager, etc.).
  • Did you know? Our care teams participate in MDR (multidisciplinary discharge rounds) Mon.-Fri. at 11 a.m. to discuss discharges for the day. These are timed according to the hospitalist teams and focus on discharges today, tomorrow and up to 72 hours out.
  1. The discharge ward is up and running on most days. This ward takes patients who are discharging today and may be waiting for a last dose of antibiotics, teaching, transportation, etc. to facilitate timely discharge and free up a bed on the ward for a patient waiting for a bed.

3) Quality Matters:

We remain in the window for The Joint Commission (TJC) survey. Trend to watch – wrong site procedures. Universal Protocol is covered in Policies 86100-PCS-092 (PSPH) and 86100-PCS-146 (PCH) and defines a process to verify correct patient, procedure, and site/level. Great time to brush up on these policies and remember:

  1. The entire team (including, when possible, the patient) should participate
  2. TJC will want to be sure that ALL parties cease ALL activities during the time-out/pause
  3. Confirm patient identification, correct site and laterality/level, and the procedure to be done
  4. Repeat time out, re-confirm laterality in two-step surgeries and when patient is repositioned, or equipment may shift (for level confirmation)
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