Timely patient discharges improves service, satisfies patients
Hospitals everywhere struggle to make discharge a smooth and efficient process. This private, 120-bed surgical-focused hospital in the United Kingdom with a nine-bed Level 3 intensive care unit was no exception. Several times a week, patients who had early morning surgeries could not be assigned to their regular patient room because the patient there had not been discharged yet. Post-surgical patients either had to be held in recovery, creating a bottleneck there, or admitted to another patient room, only to be moved later in the day, necessitating two room cleanings, and excessive patient transportation.
The hospital’s goal was to discharge patients by 10 a.m.; however, this policy came as a surprise not only to patients, but to staff members as well. Only 10% of discharges were completed by 10 a.m. And even though their discharges were “late,” patients said they felt rushed. From the post-surgical patient to the discharged patient, the process had created a cascade of patient and staff dissatisfaction.
Initially, staff members believed that physicians were the bottleneck, that they were not providing documentation in time, were not discharging in time. However, a closer look revealed where the problem really lay: there was no real process for timely discharge, but rather a hodge-podge of well-intentioned workarounds. Here, then, was something the staff could do something about.
The nursing staff had been focusing first on the morning’s new surgical patients, and only later— when it was already too late—on patients to be discharged. The staff would have to find a way to handle both types of patients concurrently, efficiently, every time.
Under the guidance of a Lean practitioner, staff members analyzed what was working, and also where the discharge process was breaking down. They fixed the problems they discovered.
Under the guidance of a Lean practitioner from Nashville-based Healthcare Performance Partners (HPP), the hospital assembled a broadly diverse team, including top leaders and frontline staff members, and physician representation, who spent one week untangling the discharge process. The team discovered ways to define priorities, and use standardized procedures and checklists.
The new procedure dedicated resources to patient discharge first thing in the morning, at 8 am. One or more nurses would be in charge of discharge only, leaving the admitting duties to the other nurses. Admitting nurses prioritized their duties, focusing on delivering care one by one.
As part of the admitting process, patients were notified that on discharge day, they would be released by 10 a.m. Communicating this expectation consistently gave patients and families a chance to plan accordingly.
Patients began to be evaluated for potential discharge the following day. The afternoon shift on the prior day ran a checklist for patient readiness, which included checks for medications ready, transport available, testing complete or scheduled, and so forth. On the morning of discharge, the morning nurse ran a checklist to find any last-minute changes or adjustments, physician requests and so forth. The team also improved communications about discharge with the supporting departments such as pharmacy, porters and radiology.
The team’s experiments implementing a discharge-focused nurse were immediately successful. Within days, over 80% of discharges were accomplished by 10 a.m., (up from 10%). The initiative quickly spread to the other units, where similar results have been reported.
The quality of the discharge is better. More information is reliably passed among the care team, and to the patient and family. The result is that, although the patients now leave much earlier, subsequent satisfaction surveys confirm that they no longer feel “rushed out the door.
The upstream effect is also being felt. Patients coming out of surgery now almost always go directly to the appropriate room on the appropriate floor. HPP has previously calculated the cost of this type of redundant work at $1,000 per instance. Based on that calculation and utilizing the conservative estimate of three times per week equals an annualized savings of $156,000.
The early discharge results are reported each day in the management meeting. Because delayed discharges are now so few in number, the team can immediately analyze each instance to root cause and solve it, using Lean problem-solving techniques.