Christine White, MD, MAT, led a project at Cincinnati Children’s Hospital Medical Center (CCHMC) to improve discharge efficiency. The project significantly decreased length of stay without increasing readmission rates, earning the Children’s Hospital Association Pediatric Quality Award in 2013. Dr. White is faculty on IHI’s Hospital Flow Professional Development Program. In this IHI interview, she explains how using QI methods can help improve hospital flow.
Some organizations try to improve flow by fixing bottlenecks in the emergency department (ED) and the operating room (OR). What does that approach miss?
Bottlenecks in the ED and OR impede flow in those specific areas, but inefficient discharges impact overall hospital flow and capacity. Delays in discharge can lead to delayed admissions from the ED, delayed transfers from the ICUs, and subsequently delayed or canceled surgeries. Thus, even if bottlenecks are improved within the ED and OR, overall flow and capacity may not improve if the discharge process is inefficient.
How did you use quality improvement (QI) to optimize discharge efficiency?
We used the Model for Improvement
to guide us in solving the issue of inefficient discharges. We defined what we were trying to accomplish through the development of our outcome measure, phrased as a SMART aim
. Then, we examined the key drivers of our aim, which guided our ideas for interventions. We then used Plan-Do-Study-Act
(PDSA) cycles and generated a run chart
with our data displayed over time to analyze whether or not our changes made a difference. For example, medication delays were one of our top reasons why patients did not leave the hospital within two hours of reaching their medical discharge goals. To address this, we tested delivery of filled prescriptions to the patient rooms, which led to a decrease in medication delays due to our pediatric patients’ parents not picking up their medications. This intervention, along with many others, helped to increase the percentage of patients who left within two hours of meeting medical discharge goals.
What results have you seen as a result of focusing on discharges to improve flow?
The percentage of patients who are discharged within two hours of meeting medical discharge goals has increased from 42 percent to 80 percent, results that have now been sustained for more than three years. We have also been able to spread this process to 80 percent of the acute care units at our hospital. By standardizing discharge goals and implementing high-reliability interventions, we have improved discharge timeliness and increased bed occupancy rates, without increasing readmission rates.
People who are less familiar with QI can be skeptical about its potential. Do you need a lot of QI training to use QI to improve discharge efficiency?
Understanding the terminology and different quality improvement methodologies is helpful, but I think in reality the core concepts of defining a specific goal, displaying the results over time, and making sure interventions link back to the overall goal are good starting blocks. Successful quality improvement projects are team efforts, which afford people with less QI training great opportunities to serve as team members on QI projects.
In a provocative post last year, IHI Senior Fellow Maureen Bisognano described inefficient flow as "disrespectful" to patients. How would you describe optimal flow from the perspective of patients and families?
As a parent, I’ve had the experience of being discharged from the hospital with my child. Transitions home after an acute hospitalization are stressful. It is very difficult to absorb all the information on the day of discharge, as oftentimes the planning seems to be crammed into the last day. Spreading out the tasks that need to be completed before discharge helps decrease the stress for everyone on the actual day of discharge. The ability to accurately tell families what time they will actually leave the hospitals allows families to coordinate their parts of the transition home such as transportation, child care for siblings, home health care visits, medication deliveries, and work.
Why do you think flow is so important to patient care?
Optimizing flow in the hospital allows patients to receive “the right care, in the right setting, at the right time
.” I think this simple phrase emphasizes what is so critical about hospital flow. I have experienced long, recurring hospital stays with a family member, and being able to receive care in the right unit (with nurses, patient care assistants, and other staff who specialize in a particular diagnosis) helps relieve some of the incredible stress that comes from being in the hospital.