BACKGROUND: Prolonged hospital stays beyond medical necessity pose avoidable risks and costs. Reducing length of stay (LOS) without compromising patient outcomes is a national priority for hospitals. The authors aimed to systematically and safely improve LOS and LOS index (LOSI) at an urban academic safety-net hospital. METHODS: The research team conducted a multifaceted quality improvement initiative in a 550-bed hospital, focusing on improving LOSI and reducing LOS. Interventions included institutional investment in an LOS reduction program, development of rigorous internal LOS data analytics, and multiple Diagnosis Related Group (DRG)-focused LOS reduction initiatives (specifically, sepsis, obstetric, and psychiatric DRGs). Initial interventions occurred in mid-2019, with subsequent iterative improvement through 2023. Statistical analyses assessed pre- and postintervention outcomes. RESULTS: Mean LOSI significantly improved postintervention from 1.15 to 1.02 (-0.13, p <
0.0002), with sustained performance for more than three years. The average LOS demonstrated a non-statistically significant but clinically relevant improvement from 6.24 to 5.91 days (-0.33 days, p = 0.45). Excluding outlier long-LOS encounters, the LOS demonstrated a statistically significant improvement in the postintervention slope change (-0.02 per month, p = 0.04), indicating a delayed improvement to LOS postintervention. There were no adverse effects on readmissions or mortality. CONCLUSION: A multifaceted approach to LOS and LOSI improvement in a safety-net hospital yielded clinically significant and sustained results, showcasing the value of integrated strategies and organizational commitment.