How can we improve the patient experience? Have a smooth and timely discharge. We’ve all experienced the discharge process in a Hospital. If not ourselves (lucky you!) then a loved one. The anticipation of going home fades into the realization that hours have gone by and nothing has happened. It’s the last time the Hospital can make an impression and many times it’s not good.
SBTI has worked in Healthcare for over 10 years and have helped Hospitals improve many of their internal processes. The results have been better patient and financial outcomes. Small rural hospitals and large urban hospital systems share many of the same problems. A common one is the time it takes to discharge a patient after the Physician writes the order. Patients usually want out and Hospitals have an incentive to get them out as long as patient safety isn’t compromised.
There are many potential benefits to improving the discharge process. Improving the flow and bed turnover would increase Hospital capacity, ultimately reducing the Length of Stay. Many teams felt that re-admissions could be reduced with a quality discharge. Continuity of care would improve and so would patient satisfaction.
So why do so many Hospitals handle the process so poorly?
Early on, we interviewed Hospital staff and found that the staff didn’t have time to devote to a quality discharge process. The Nurses feel rushed at discharge and many felt that patient education was lacking. There is little communication and a feeling that discharge is not as important as the urgency that comes with the treatment and diagnostics. This triage approach to patient care results in less focus on discharge.
We’ve found a few key ways to reduce the time it takes for patients to safely head for home in a smooth, timely way. Here are seven ways that you can make the discharging of your patient experience a good one.
- Focus on discharges that you can control
We helped each Hospital define discharge. Most of the time we landed on “From Doctors orders being received to the patient being transported to the vehicle”. These definitions provided lots of opportunities for improving discharges. However, early on we focused on the ones staff can control. We often try to improve all parts of the process. One hospital had an informal goal of two hours for discharging a patient. They rarely hit it. When we looked at the data collected for a year there was a great deal of variability. We discovered times that ranged from less than 30 minutes to over 16 days! The few that had excessive times pushed the average up. Such instances were due to patient acuity changing, shortages of staff, errors in recording, among other potential reasons. Although they represented a lot of time, they were outliers that we would tackle after we developed a better process and standardized the discharge process. We targeted discharge times less than 5 hours. This represented over 80% of the discharges and over half of the total discharge time.
- Avoid batch discharge orders by Physicians
Healthcare professionals are aware of improving efficiencies. Many Hospitals had Physicians “batching” their discharge orders after they had rounded on all of their patients. Although it saved the Physician from having to record the order after each patient, it created a backlog. For some hospitals a technology solution such as carrying an iPad solved the problem. Not all Hospitals have the IT budget. In these cases, we worked on submitting a smaller number of orders more frequently. One Hospital hired Advanced Practice Providers (APP) to work with the Hospitalists to the efficiency of ordering discharges. In all cases we brought the providers into the team and worked with them to find ways to eliminate or greatly reduce the batching of orders.
- Have a short huddle in the morning standup meeting with cross-functional staff
This was key. Most of the improvement came from simply communicating with the main functions that are involved in the process. Each morning the floor would have Physical Therapy, Pharmacy, Social Worker and Nurse Manager meet and review the discharges for the day. The team discussed the patients who were ready and a list of what was needed for discharge. The first time the team met, the Physical Therapist commented “No problem, I’m happy to use this meeting to set my schedule. It’s no problem at all”. The “Aha!” moment for us was that we simply needed to ask. All the functions were happy to adjust their schedule to help with a smooth and timely discharge.
- Put up a simple visual board
A simple white board can be put up at the morning discharge huddle. It’s a simple and powerful tool. It can contain information about patients who are ready to be discharged with a list of necessary tasks. It acts as a prioritization tool and for cross functional communication. Questions can be noted during the different shifts and any needs around discharge can be addressed. Its presence alone provides a visual reminder about the need for focus on patient discharge
- Create standard work for the process
Standard work is one of the most effective ways a Hospital can improve their processes and workflows. It’s a fundamental step and documents the best practices for any procedure or process. There are lots of ways to discharge a patient. Each Nurse will do what they think is efficient and effective. But there should one way that is standardized and represents the best current practice. It means that the staff has to work together and invest some time to develop a consensus approach, document it and use it. Improvements will come, but only after everyone is consistently doing it the same way.
- Develop a Discharge Nurse role specialist
We usually don’t like to throw resources at a problem. When we looked at the amount of value that reducing discharge times over a year could yield, we developed a role. Having a focused resource helped, but there were other benefits to the position. The nursing staff wanted opportunities to grow and learn. The discharge role required clinical experience, communication skills and interaction with other functions that would be ideal for more advanced leadership positions.
- Have Nurse Manager review monthly data
The last step is a commitment to review the results each month. Any changes are identified. If the times are increasing, an action to analyze and fix the issue is assigned. Improvements can be added to the standard work. We like Leader Standard Work as a way to drive accountability for both the discharge process and the Nurse Manager. It serves as a tool to document the review, record improvements and assign resources to problem solve in areas holding back improvement.
The discharge times improved in all of the Hospitals we worked with. There were also benefits that resulted from the process improvement. Other areas picked up visual boards as a way to coordinate staff huddles. They also identified what their key metrics were and posted them on the board to keep them in sight. Some of the key leaders began to use Leader Standard Work as they saw how it could help them help their teams. The success of the projects led to confidence in using the tools in the improvement activities. Success drives more success.