Can you imagine the chaos that would ensue if airlines required all flights to depart by 11:00 AM? It’s hard to envision the frantic rush of activities that would need to happen in the morning hours to accomplish this goal: the passengers processed, bags checked and loaded, mechanical systems checked, fuel tanks filled, tires inflated, and so forth. Such a requirement would cripple the air travel system. And yet, this is a fairly good analogy for how the patient discharge process is designed to occur in hospitals today.
While most hospitals have a “discharge planning” function, it commonly plays a financial role, matching treatment stays to insurer requirements. The discharge process is usually not well planned, but is a disorganized, inefficient sequence of events with little rhyme or reason, often marred by delays and frustration for patients, their families and providers. And rather than working from a schedule, the staff is advised to follow the general principle: aim for morning discharges.
According to Carol Haraden, PhD, Vice President at the IHI, “the majority of hospitals want to get all discharges out in the morning, but not one that I know of has come close to achieving this goal, despite many innovative attempts." In truth, explains Haraden, operating under the pretext of across-the-board morning discharges is counterproductive, “a phony rule” that further creates bottlenecks in care delivery and strains overburdened clinicians: “The ‘all out in the AM’ approach stresses the system at one of the busiest times of the day by creating an artificial bolus of work,” says Haraden. “It’s busy for nurses, pharmacists, labs, radiology, nutrition — all the folks who need to be involved in the discharge."
Haraden and colleague Roger Resar, MD, Senior IHI Fellow, are innovation leaders of IHI’s work in improving “patient flow” that is addressing the unwieldy discharge process within the larger context of how patients move through the entire stay in the hospital. Working with more than 50 hospitals participating in IHI’s IMPACT network, Haraden and Resar’s team has been evaluating the factors that influence timely and efficient flow of patients through the hospital.
Seeking new perspectives on the problem, the team studied organizations and businesses outside of health care that rely on the timely delivery of a product. It became clear that managing patient flow in a hospital is about balancing the hospital’s “input” (admissions) and ”output” (discharges). Haraden refers to this balance as “creating throughput.”
The troubling bottlenecks in admissions to hospitals — ambulance diversions, “parking” patients in hallways or in scarce ICU beds awaiting transfer to a floor — are often caused by gridlock at the back end of the process: the discharge. New patients can’t be admitted until beds open up, and beds don’t open up until all the necessary transition steps are completed by a myriad of disparate departments. Often, there are patients ready for discharge, but single pieces are missing — an order isn’t written, the pharmacy hasn’t delivered the meds, or the patient education isn’t done.
Haraden and Resar’s team began exploring strategies for more efficiently managing the transition process. (She prefers the term “transition” to the term “discharge." “We don’t just ‘let patients go,’” she says, “but rather transfer them to the next stage in the care continuum.") It turns out that in most acute care hospitals, patients come in throughout the day in rather predictable patterns. This might be, for instance, one or two admissions at 11 AM, two more at 1 PM, at 2 PM and again at 4 PM. The trick, according to Resar, is to “match discharges to the admission pattern, with enough slack to clean the room and get it ready for the next patient.” That’s how the concept of the ”discharge appointment” was born. IMPACT teams began testing the concept of scheduling the discharge: assigning patients to a day and time for the transition to occur.
Participants are using various methods to implement the process. One hospital enters new patients’ names on a large white board. The care team is asked to enter onto the board the discharge date and time, based on established standards and practices. Each day the care team reaffirms the discharge date. If the patient is a ”go” for the estimated day, they get the green light. If things start to slow down for any reason, the team asks: “What must be done today to meet the scheduled transition day?” There are two categories of problems that can hold up a transition: medical and logistical. Both must be aggressively managed.
The key innovation lies in the added level of detail: the scheduling of a specific time of discharge on the appointed day. Ideally, if a patient is going home, this decision rests with him or her and the family: they are asked to choose the most convenient time for them from among several standard options on the unit: noon, 1 PM and 4 PM, for example.
With the date and time established, the care team works backwards to orchestrate the discharge process, bringing all necessary forces to bear to meet the target. The person orchestrating the discharge develops the correct "receipe” for that particular patient. This requires knowing how long each discipline will need to complete their work on the discharge day — the physician, the physical therapist, the nutritionist, the pharmacist, and so on. So if the patient wants to leave at 2:00 PM and the recipe for her discharge adds up to two hours, the appointments with the disciplines must begin at 12:00 PM.
Long term, Resar says, “our goal is that 80 percent of patients throughout the hospitals participating in the Flow initiative will have a scheduled discharge and that 80 percent of those are actually orchestrated and kept.” The 20 percent margin reflects acknowledgement that there will always be complex cases with unexpected developments. But, especially because a patient care unit tends to see a handful of diagnoses, Haraden says, by observing and documenting discharges over time and being disciplined in “sticking with the recipe,” a unit can achieve encouraging results.
Treating the patient discharge as a service that can be predicted, scheduled and thoughtfully orchestrated is certainly a new approach to inpatient care delivery. But the inefficiencies in the current system are so widespread that bold changes are required. And sometimes, the best solutions come from the most obvious places; just take a look at your local airport.