Pilot project to improve discharge process

Team outlined discharge responsibilities

As part of Memorial Health System's adoption of the Toyota Lean Processes, the case management department at Saddleback Memorial Hospital in Laguna Hills, CA, has standardized work flow for discharging patients and is piloting the process on one unit. The pilot project is a result of the case management's department patient flow lean initiatives to move patients more efficiently through the continuum.

Louise Della Bella, RN, MN, CNS, NEA-BC, executive director for care management, discharge planning, and social services says, "It's too early to have any firm statistics, but it appears to be working well. When everyone knows what piece is their responsibility, it supports efficiency and reduces waste in the process." The team is performing regular audits to gauge their progress and to identify how close they are to the goal of achieving earlier discharges after the discharge order is written. "When we achieve our benchmarks on the pilot unit, we'll replicate the process throughout the other inpatient care areas," she says.

At Saddleback Memorial, discharge planners are primarily responsible for coordinating discharges to post-acute facilities, and care managers are responsible for clinical care review/best practices, utilization review, and other types of discharge coordination including setting up home health and other services. Before the process improvement project, there was confusion as to the role of the nurse, the care manager, and the discharge planner in the process, which resulted in discharge delays, duplication of work, and unnecessary telephone calls, Della Bella says.

When the hospital's patient flow project began, a multidisciplinary team analyzed the work involved in discharging patients and looked at what each discipline did to get patients ready for discharge. The manager of case management and the manager for the unit on which the project was piloted were the lead people on the multidisciplinary team. Representatives from case management, nursing, physical therapy, and other disciplines involved in patient care were on the team. The team started meeting in early 2010 and continues to hold regular meetings.

The team members looked at all the steps in the discharge process to identify duplications and tasks that were unnecessary. They determined that because no particular discipline was assigned certain tasks, some things were being duplicated and sometimes things fell through the cracks because no one was in charge. For example, if a discharge was pending a physical therapy evaluation, there wasn't a clinician specifically assigned to alert the physical therapy team. Sometimes the nurse called physical therapy, and other times it was the case manager or discharge planner. Sometimes more than one clinician would call physical therapy to ask for the assessment.

"We looked at what every member of the team was doing to get patients ready for discharge, how the work done by every member of the team complements the work of others, where there is duplication, and where there is inefficiency. Taking this information, each discipline developed its own standardized work process which was presented to the senior leadership," Della Bella says.

The pilot project uses an electronic board that tracks the progress of all patients on the unit from the time the patient is admitted to the unit until discharge. Anyone on the team can see at a glance how close the patient is to being ready for discharge and what needs to be done before discharge, rather than having to go through the patient chart or access the electronic medical record. When a discharge order is written, it is flagged on the electronic board, and the targeted time for discharge is identified.

The team analyzed all discharges to all destinations and came up with an average length of time it took from the time the discharge orders were written until the patients were out the door. Team members looked at how soon the discharges needed to take place to improve patient flow and came up with a targeted discharge goal of an hour and 45 minutes after the doctor writes the discharge order. "When the discharge order is flagged on the board, everyone on the team has the same targeted time to get their part completed. It saves a lot of nudging. Each team member knows what he or she needs to do and that they need to make it a priority to meet the discharge goal," Della Bella says.

For example, case managers know the time frame in which they need to review the discharge plan and make sure everything is ready for the patient to leave the hospital. If the patient needs a physical therapy evaluation for discharge, the board alerts the physical therapy department that the evaluation needs to have a high priority, which eliminates the need for the nurse or case manager to call, Della Bella says.

The new process eliminated a lot of last-minute telephone calls between the disciplines because, when the discharge order is flagged, everyone on the team knows they have to concentrate on guiding discharge for that patient.

"Everyone knows the time we need to get the patient out. If the patient needs an ambulance, we know what time to arrange it. It's created a much greater efficiency," she says.