Hospital discharge process can be more efficient

Nursing satisfaction rises, turnover drops

While hospital discharge planners make certain each patient's discharge and transition in care are handled with quality of care and safety in mind, it's the job of hospital operations chiefs to make certain the entire process runs smoothly and efficiently.

A poorly run discharge process might result in high nursing dissatisfaction and turnover, bed census swings between high vacancies and overcrowding, and wasteful resource spending.

For instance, when nurses feel their staff-to-patient ratio is too high, they are unhappy and will not stay long at their jobs, says Michael Bundy, MBA, vice president of operations support at Wellmont Health System in Kingsport, TN.

At another Tennessee hospital, Bundy had overseen a discharge process restructuring that resulted in a major change in nursing turnover rates.

"We went from 100 vacancies and 70 contract nurses to 12 vacancies and no contract labor," Bundy says. "We were saving hundreds of thousands of dollars."

The 544-bed hospital also saw a decrease in its length of stay (LOS) from an average of 5.2 days with a case mix acuity level of 1.6 to an average LOS of 4.4 days with a case mix acuity level of 1.7, Bundy says.

"So, the hospital had a higher acuity level with a shorter length of stay and still maintained all beds full," he adds.

The hospital's volume has remained high, above 90% of beds occupied, despite the economy having impacted demand through surgery postponements, Bundy notes.

"We are seeing a decline in volume, but we're still above 90%," he says.

Before making changes in discharge operations, the hospital's discharge process was caught in a cycle of inefficiency; the hospital had too many patients waiting for inpatient beds, so the nurse-to-patient ratio was kept high. The high ratio led to nursing dissatisfaction, high turnover, and workflow problems.

For instance, nurses would keep well patients in beds because these patients didn't take as much work and would ease the pressure caused by high nurse-patient ratios.

"Or the nurses would discharge patients in the evening, so they didn't have to do another admission on their shift," Bundy says. "So, they're holding those patients in bed, but I have to manage the whole hospital, and the emergency room is backing up."

Since there was a strong demand for more beds, nurses were given more patients, which led to their feeling overwhelmed, and the cycle continued.

The solution was to reach an agreement with nurses, Bundy notes.

Bundy agreed not to give them a higher ratio of patients than the nurses thought would impact quality of care. But in exchange, the nurses would make all of their discharges early in the afternoon, so that when the emergency department began needing beds, there would be enough available.

"So now we've reduced risk, and it's much less stressful," Bundy says. "It worked extremely well, and we kept the ratio down."

This was the chief reason the nursing turnover rate dropped dramatically, and it's led to other positive outcomes, he says.

A better discharge process also improves patient safety, Bundy says.

"Timely discharges are the answer to patient safety," he says. "The longer a patient is in the hospital, the more likely there will be a medical error or a nosocomial infection or fall."

Patients and physicians respond to the improved process by frequenting the hospitals that handle patient flow better.

"When you improve the discharge process, customer service goes up, and then the demand for the beds goes up, so you've created new demand," Bundy explains.

While this can put more pressure on a hospital and its discharge process, it's a better pressure since the revised discharge process eliminates waste.

"You get all of the wasted days out and continually improve the cycle and remove barriers that prevent nursing staff from getting patients out," Bundy says.

Creating a more efficient discharge process begins with understanding what drives the hospital's bed demand, Bundy notes.

For instance, in the hospital that is emergency department (ED)-driven, it might make sense to have an early afternoon discharge time, because the emergency department starts to pick up patients who need inpatient beds in the afternoon, he explains.

But if a hospital picks up more inpatients from surgeries and is a surgical suite-driven facility, then the discharge timeline is very different. The hospital might then need to make certain beds are available by 11 a.m., Bundy says.

And even this varies according to which types of surgeries are most commonly performed.

"You need to know the bed demand down to the type of procedure that day," Bundy says. "You could need beds at 9 a.m., or for some surgeries, you might not need beds until noon."

It's also essential to collect data, develop metrics, and hold people accountable for inefficiency and discharge bottlenecks.

One important metric is the time the patient is admitted, measured from when the physician wrote the order to the time the patient is accepted on the floor, Bundy says.

"That's the holy grail of the discharge process," he says.

So each month someone should be analyzing demand for beds by assessing the average time patients are admitted and how many minutes lapsed before the patient was in a hospital bed, he adds.

"You have to make sure you have beds available, and you have to make sure the discharge process works," Bundy says.

For example, these are some metrics that could be measured:

• What is the average discharge time?

• What percentage of patients need a bed at 11 a.m.?

• What percentage of patients can be transferred to a bed at 11 a.m.?

• How long are admitted patients being held in the emergency department?

• How long are post-surgery patients being held in the post-anesthesia care (PAC) unit?

• How many times were surgeries postponed because the PAC unit was full?

• Where is there the greatest demand for resources?

• How well is the hospital meeting the resource demand?

• How many transfers could the hospital accept in a month?

• What is the turnaround time for X-rays?

"You put everything on an Excel spreadsheet, so it doesn't take anyone with special training to see the numbers day by day," Bundy says.

Even when a hospital makes these discharge process changes, it will continue to be necessary to make adjustments and improvements, he says.

"In tertiary care, the discharge process is never complete," Bundy says. "You can always find inefficiency."


For more information, contact:

• Michael Bundy, MBA, Vice President, Operations Support, Wellmont Health System, 1905 American Way, Kingsport, TN 37660. Telephone: (423) 230-8200. E-mail: