Failure to synchronize admissions and discharges commonly results when discharges are not managed efficiently. Creating a more consistent and predictable discharge schedule can help improve flow. Traditionally, hospitals have attempted to "batch" discharges by establishing a set time for all patients to be discharged; however, this approach has been largely unsuccessful. Scheduling the discharge creates a continuous flow process, spreading discharge times throughout the day. This approach streamlines the process, better addresses the needs of patients and families, and helps coordinate the placement of patients who are admitted and transferred with discharges that occur throughout the day.
Changes for Improvement
Provide a Process for Scheduling the Discharge
Provide a process for scheduling the date and time that patients will be discharged one day in advance or on the day of discharge. In some units, particularly surgical units, the discharge can often be planned a day ahead of time. Although for some patients the date and time of discharge cannot be planned a day in advance, the hospital should still be able to coordinate the discharge. In most cases, orchestration of the discharge is left to chance, creating a chaotic situation. Having a planned discharge time helps everyone involved orchestrate their activities toward a common goal. Reaching the goal will most likely require centralized planning and scheduling.
To test this change, hospitals should start with a prearranged set of appointment times. Patients can then be placed in defined appointment "slots," based on unit resources, admission history, and discharge history, with input from nursing and other affected disciplines. Ideally, morning appointments should be used for patients identified for discharge the next day. Saving appointments later in the day for patients identified on the day of discharge allows for the time needed to orchestrate the discharge.
- Record data about the ability of the system to comply with the schedule and document reasons for noncompliance to identify bottlenecks and processes needing improvement.
Orchestrate the Discharge
A set series of tasks must occur prior to discharging a patient. These tasks include examination and sign-off by appropriate providers and patient education. For each patient, the time of discharge and the tasks that need to be performed will be provided one day ahead of time. This allows for everyone involved in the discharge to self-organize on the day of discharge to get the work done within the window necessary to meet the scheduled discharge time.
- Place a whiteboard by the patient’s bed with the scheduled discharge time to remind all parties of the goal.
- Communicate the discharge schedule with hospital disciplines through the use of white board on the unit, an extranet, or a dedicated phone line.
Synchronize Admissions and Transfers to the Discharge Schedule
Once a discharge schedule is in place, internal transfers of patients — for example, from an ICU to a patient care unit — can be synchronized to that schedule. Individual units can begin scheduling and orchestrating the movement of their patients at the local level. This synchronization allows local, unit-level control and system-wide optimization to occur simultaneously.
Communication and planning across units is important to create a process for placing admissions and transfers into beds made available by patients discharged out of the hospital. Many hospitals use bed huddles to coordinate this planning. Bed boards placed in a central location (or made available electronically) are a communication tool that helps to link admissions and transfers to anticipated discharges.
- Place a whiteboard by the patient’s bed with the scheduled discharge time, in order to remind all parties of the goal.
- Hold daily (or more frequent) bed huddles to coordinate planning across units/departments for linking admissions and transfers to planned discharges out of the hospital.
- Use a consistent method to communicate bed availability and distribute beds throughout the day, such as a designated person ("bed czar"), a manual bed board, or an electronic or web-based tool.