Overview

As the final step in the hospital experience, the discharge process is likely to be well remembered by the patient. Even if everything else went satisfactorily, a slow, frustrating discharge process can result in low patient satisfaction.

The discharge process is a critical bottleneck for efficient patient flow. Slow or unpredictable discharge translates into a reduction in effective bed capacity and admission process delays. In fact, the discharge process and scheduling in-patient surgery rank as the two biggest factors impacting wait times for in-patient beds.

Implementing the required changes for more efficient patient discharge can be greatly enhanced with the application of Lean Flow principles, as well as with a supporting Change Management Framework.

Typical Emergency Department–Scenario

Symptoms

Achievable Results

Discharge by Appointment: Freeing Up In-Patient Bed Capacity

By Andrew Wilson MD, Chief of Emergency Medicine, William Beaumont Hospital, Royal Oak, MI

Background

Hospitals recognize that moving discharge times toward the earlier hours of the day can pay large dividends in patient flow throughout the hospital. The patient who leaves a medical-surgical bed allows transfer of a patient out of the intensive care unit (ICU), which allows the operating room (OR) to place the complex case in the ICU.

Arguably, the discharge process begins the day of admission, and a robust care management program can set expectations for discharge with the patient and family at the time of admission. Even with care management, however, there are at least two general approaches to the actual hour-by-hour timing of discharges.

The first approach is to attempt to move the time of discharge for all patients to an earlier time in the day. This approach has met with mixed results and can generate considerable frustration for patient and staff. It can also require a disproportionate investment in time with staff attempting to move immovable patients, while patients requiring minimal assistance to be discharged languish.

Recommended–Discharge by Appointment

The second approach focuses on establishing a realistic time for discharge for each patient–an appointment for discharge. All relevant services and the family are aware of this appointment and efforts are focused on making the appointment. If the patient is scheduled for a 9:00 a.m. discharge, then physical therapy would make every effort to slot that patient for an early appointment and give the patient with a discharge appointment of 11:00 a.m. a later session. A similar practice is followed in other areas such as imaging and the lab. (Note that if the directive is to discharge all patients earlier, ancillary departments do not know where the greatest dividends for effort invested are to be had.)

In order to make the discharge appointment concept work, there are several critical success factors:

• Hospital staff, typically the Care Managers, must routinely identify those patients who are the best candidates for early discharge.

  With all the pieces in place, it is possible to achieve significant improvement in the balance between bed supply and demand during peak periods.

  
  

  Typical Case Summary

  Situation

  • Large teaching hospital
  • Admissions peak significantly earlier in the day than discharges, creating a mid-day bed crunch
  • Backups in the Operating Room, Catheter Lab, Emergency Room, and ICU

  Solution

  • Create a sufficient number of discharges early enough in the day so that demand can be accommodated

  Results

  • Improved balance between bed supply and demand during peak demand hours
  • Reduced queuing times in other critical areas 

   

   

   
• The patient's family must be in the loop and committed to make the appointment. Transportation is usually the biggest issue here.
• Unit nursing staff must know the overall discharge schedule for the unit and have a commitment to make it happen.
• Ancillary departments must have implemented the kinds of scheduling practices previously mentioned.
• Rounds must be performed on a schedule that supports discharge appointments. This can be accomplished through a variety of strategies, including discharge mini-rounds and physician extenders.