Even though delayed inpatient discharges (i.e., discharges that are late in the day; discharges that move past the expected discharge day or estimated length of stay) lead the list of hospital operational problems, most hospitals approach resolving the situation in the same old ways – a lot of time spent on process improvement that isn’t tied to desired outcomes. How many time have you recently been frustrated by discharge related problems?
Services delays and boarding backups in the Emergency Department and Operating Rooms
Late afternoon discharges that drive headaches across the hospital, from staffing issues to customer anger and physician stress
The high cost of extended Lengths of Stay, extra staffing and coordination of the turmoil
Throughput leaders usually understand that the old ways they have repeatedly used to achieve desired discharge outcomes at best create incremental results that are not sustainable. The fundamental reasons for changing your approach to timely discharges are as follows:
Current, mandated regulations require achievement of outcomes (HCAHPS) and tie outcomes to reimbursement, and
Traditional Performance Improvement techniques like Lean and Six Sigma are not delivering necessary results
Performance Improvement projects that follow the same old DAMAIC methodology each time one is “implemented” create a situation that fits Einstein’s definition of insanity and is like pushing a boulder up a hill.
Insanity: doing the same thing over and over again and expecting different results.
-- Albert Einstein
So, why can’t hospitals discharge inpatients earlier in the day? The simple answer is that discharge activity needs to begin immediately when the patient is admitted and behavior that drives delays should not be permitted: orders don’t get written on time so treatments aren’t delivered in a timely way, ancillary therapies are not completed on schedule, patients aren’t educated until the day of discharge and education is fragmented by discipline, authorizations for home prescriptions and DME and not anticipated early enough during the stay be ready at discharge, final results reporting hasn’t been documented, final clearances, authorizations and scheduled transportation doesn’t begin until the morning of discharge.
Activities that delay discharges are symptoms of bigger problems, in that there are often no stated desired outcomes, few goals or objectives, no priorities or mandates for discharging patients. Care delivery priorities are clear and often well communicated in diagnosis or disease based standing orders, clinical workflows or protocols and parameters. Care management or care coordination often becomes the lowest priority, discharging gets delayed until the end of the day. The day of discharge becomes the wreck that results from a journey that was doomed from the start. Remember, a timely discharge starts with a completed admission that keeps the discharge on track from day one. This journey from door to floor and door to door requires ongoing communication and planning in every department that touches the patient.
Why Focus on and Change Behavior? Achieving timely discharges depends more on behavior, staff accountability and commitment, than on structural or process changes. Behavioral changes are required at every level that impacts the discharge, but critical for hospital medicine, nursing and clinical ancillaries and care management or care coordination. Changing the critical few behaviors for the positions that have the greatest impact on outcomes is easier and more effective than process improvement that is not linked to achieving outcomes.
Physician behavior is critical to improving patient discharges and physician behavior for timely discharges needs to focus on those critical behaviors that impact the discharge. If physicians, i.e., hospitalists and specialists are not interested improving results then do not begin this journey. The critical discharge behaviors for physicians establishing and communicating an Expected Discharge Date upon admission and leading the multidisciplinary care team concurrently through care delivery and care management activities. Leading the team means getting the team functioning as a high performing team focused on outcomes. Critical physician behaviors for priority and timely discharges include
Review current day’s assignment list and determine patients’ with an expected discharge for the current day (date) and ensure Patient’s Medical Plan of Care is managed to current and next day expected discharge date
Begin rounding on patients who have discharges scheduled for today and Identify barriers to today’s discharges that are placement, specialist consult, diagnostic testing, pharmacy, nursing or ancillary treatment related – expedite removal of barriers
Review current day’s assignment list and determine patients’ with an expected next day discharge
Determine any special patient needs for discharge tomorrow
For patients who are having additional testing or a procedure completed check to make certain the test or procedure is ordered, scheduled, pending results reporting and or specialists consult notified
Identify pending (next day) placement issues and expedite with care coordination or case management
Identify pending (next day) issues with specialists and expedite with specialists, Nursing and or care management or care coordination
Determine and conduct appropriate patient rounding for next day discharge bedside or geographic
Determine and expedite immediate actions required to foster next day discharge
The benefits of timely discharges are real for physicians and include satisfied patients and families, higher reimbursement, higher quality outcomes, reduced discharge generated interruptions, less end-of-day stress and greater staff satisfaction. Leadership must focus on these benefits and provide timely consequences for achieving targets i.e., recognize and reward physicians for improving discharge times.
Inpatient nurse behavior plays a critical role as well. Inpatient nurses are often overloaded with six or more patients with countless clinical priorities. Patient discharges get a lower priority than critical clinical tasks because nurses prioritize clinical care and sicker patients, over administrative tasks and well patients. Patient discharges generate a lot of work, not to mention the impending patient admission that comes fast on the heels of a discharge. The result is that patient discharge activity sometimes falls to the bottom of their “must do” list.
Changing nurse behavior also requires reinforcing behavior that does meet targets and appealing to the benefits of a better planned and executed patient discharge. Critical nursing discharge behavior includes but is not limited to
Prepare the nursing team for multidisciplinary rounds
Attend and participate in rounds in a fully informed way
Expedite any role appropriate actions from rounds
Follow up with ancillaries and specialist consults about discharge priorities and related issues
Communicate discharge actions and timing with patient and family
Enter patient discharge into electronic medical record within 15 minutes of patient leaving unit
Timely patient discharges that conclude quickly, with fewer delays can greatly reduce the daily stress and aggravation -- fewer phone calls, order expediting and listening to family complaints. When nursing adjusts their behavior to anticipate timely discharges and coordinate closely with the care team and family, they need to be recognized for improving service, satisfaction and financial discharge outcomes.
Behavior changes are also important for care managers and care coordinators who often need to step up their part in coordinating and completing the discharge. Rather than focusing solely on patient authorizations and placement, the case manager can provide guidance on inpatient and outpatient transitions. Patients with particular diseases or particular populations often have consistent continuum of care needs; case manager need to identify and communicate these to the multidisciplinary team. As an integral member of the multidisciplinary team care management can provide awareness of the wider range of patient needs.
The care teams also play a critical role when the hospital experiences a full capacity alert, when there are not enough inpatient beds available to support the ED and OR admissions. Leadership needs a Capacity Alert program for monitoring and managing inpatient capacity. This goes beyond a simple “fire alarm” to providing clear expectations for roles, scripts, tools and goals for each team and leader. A capacity alert system works continuously to anticipate overcrowded hospital conditions and implement contingency plans. This same system can provide ongoing monitoring and recognition to units and care teams.
Improving discharge times requires team and individual behavior change. Behavior change is only effective when it is supported and rewarded over a period of time. This requires leadership to provide the resources (financial and human; tools, techniques and systems) and effective policies and procedures for the teams who are changing their behaviors to increase timely discharges.
Behavior is a function of its prompts and anchors – and a function of the work environment in which it occurs so leadership needs to provide daily feedback and recognize the teams who are improving and achieving desired outcomes. Effective behavior change is outcome focused and rewards the teams who achieve results to encourage other teams to make similar changes. Unlike structural changes that focus on improving the process for a single delay or task, a behavioral approach identifies the critical few behaviors for improving the outcomes for an entire episode from admission to discharge. It is effective because it provides an integrated team with the resources and accountability to achieve improved results that only come with improved behaviors.
Your hospital can reduce LOS, reduce boarding time in the Emergency Department and Operating Rooms, decrease discharge delays, reduce capacity alerts and improve satisfaction by implementing a behavior based approach to timely discharges.