Performance improvement team creates success in patient flow, clinician buy-in

Relentless monitoring of the discharge process is the key

A process begun four years ago when the Medical University of South Carolina (MUSC) in Charleston took a hard look at pending discharges has led to a cutting-edge bed management program and a best practice designation from two national benchmarking organizations. Both the Oak Brook, IL-based University Hospital Consortium and the Washington, DC-based Health Care Advisory Board have recognized the hospital for "best practice for patient flow."

The basis for that achievement, explains Maureen McDaniel, RN, manager for bed management in the patient access services department, was a year’s worth of auditing and monitoring, an active, multidisciplinary performance improvement team, and the fostering of some healthy competition among nursing units. Key to the initiative’s success, she adds, was buy-in from the hospital’s physicians and nurse managers. "Four years ago, we were having trouble getting patients in," McDaniel recalls. "There were long delays in the emergency department (ED), and we were holding patients over in outlying hospitals, so our referral business was getting a hit." The hospital administration, meanwhile, was fielding complaints that it was taking days to get patients into the facility, she says.

Late discharges mean late admissions, notes Cindy Williams, manager of admissions and financial counseling, which put extra stress on her staff. "We are staggered, so most staff are working between 9 and 5," she adds, "but we were finding some of our clinic [patients] being admitted after 5 p.m. So every hour, we were losing [an employee], but at the same time, the volume of patients was the heaviest."

To deal with the problem, Williams says, staff were staying later — increasing overtime hours — to make sure transfers were handled, and patients admitted or preadmitted, before the regular admitting office closed at 7 p.m. After that time, she explains, the ED staff would have to get involved.

Putting the situation into context, McDaniel explains that 66% of the patients at the 568-bed hospital are unscheduled, 30% are admitted through the emergency department, and there is an occupancy rate of 88%. Sixty percent of the discharges, she adds, were happening after 3 p.m.

To address the problem, McDaniel notes, a performance improvement team was formed, with participation from nurses, administrators, physicians, housekeepers, and unit clerks. That led to the auditing and monitoring of the comings and goings of 500 patients on 10 medical/surgical units, she says, a process that was both time-consuming and labor-intensive. "We gave a log to each of the units for monitoring when the discharge order was written by the physician, when the discharge order is taken off the chart, when the patient actually left, and when the notice of discharge was actually put in the system," McDaniel adds.

Some of the problems, she says, were that physicians were not writing orders early enough in the morning, the times for doing rounds needed to be adjusted, and the nursing units were not being compliant about putting notice of pending discharges, as well as notice of the actual discharges, into the system.

"There was a four- or five-hour lag time between when the patient left and when they notified us," McDaniel says. "Their feeling was, Why let bed control know we have a bed open? They’ll just put another patient in it.’"

"The team knew," she says, "that we needed to build a relationship and communication with the charge nurses and unit clerks."

As the performance improvement team continued to monitor the discharge process — and let the nursing staff know they were being watched — the situation started to improve, McDaniel notes. "I would follow through at the end of each day, go to the charge nurses, audit the discharges, make note of the discrepancies found, and send them to the nurse managers, who started using [the results] as a tool for performance evaluation, she adds. "We knew we couldn’t just say, Hey, guys, you’ve got to do this.’ The nurse managers had to have buy-in, their directors had to have buy-in, and when the physicians came in with buy-in, that really helped."

The physicians on the performance improvement team assisted by piloting the discharge monitoring process on certain service units, she says, with a focus on improving the situation by initiating more timely discharges.

The effort developed into a competition between nursing units, McDaniel says, with the bed control office sending nurse managers a daily list of discrepancies between the time the discharge order was written, the time the patient left, and the time the bed control office was notified.

"We would take a med/surg unit and see how many pending discharges were sent down, compared to how many patients went home that day," she notes. "If there were eight discharges, did eight pendings come down?" (See graphs.)

Receiving early information on pending discharges, McDaniel says, allowed bed control staff to take a proactive look at what the bed availability would be all day, and notify the ED, the recovery room, and the outlying clinics as to that status.

As the monitoring process continued, the performance improvement team decided to recognize the unit most compliant for the week, and then later, the month, she says. "When we decided to do it monthly, we would give a reward — tickets for free frozen yogurt to the entire staff of that unit — put up a big congratulations banner, and e-mail all the [hospital] directors."

To get credit, the unit nurses and clerks had to give notice of pending discharge and then follow up with the notice of discharge, she explains, with the notice given well in advance, preferably just after the physician writes the order. "The most frustrating thing for bed control is when four or five discharges get sent down at once," McDaniel adds. "You know a bus didn’t come and pick everybody up." Over time, she says, there has been a shift in discharge times, so that 46% of patients — rather than 60% — leave after 3 p.m. "It’s a slight shift, but enough so there are not as many patients waiting."

From the admitting office perspective, Williams notes, understanding early in the day what the discharge activity will be has enabled her staff to get patients preregistered and admitted closer to 3 p.m. Overtime no longer is an issue, she says. "Staff come in and work their shifts. If a patient doesn’t arrive by 5 p.m., [the admission] just requires activation, because the person is already pre-admitted."

As an additional benefit, McDaniel says, "there is so much more communication between the bed control office and the charge nurses."

Day starts with bed meeting’

To keep that communication ongoing and active, she says, McDaniel in the past year has instituted bed meetings in three different locations. At 8:30 a.m., McDaniel explains, she or one of the nurses on the bed control staff, goes to a meeting at the pediatrics hospital that includes case managers, the charge nurses of each unit, and social workers. "Bed control brings the elective admissions list to the table, and [the other participants] bring a list of patients they think are going home."

"We make bed assignments," she adds, "based on the bed availability at that time, for scheduled admissions and any transfers from the intensive care unit [ICU]." Because she knew nurses would be reluctant to have a meeting scheduled during their busy morning time, McDaniel notes, she promised to keep it short and sweet. "We just do what we need to do, and we keep it to 15 minutes," she says. As an added incentive, she sends a monthly report card to nurse managers, letting them know the attendance record of the charge nurses.

A similar meeting is then held in the lounge of the med/surg unit, and at 9 a.m., the process takes place in the ICU lounge, she says. "We talk to them about any patients coming to them off the operating room schedule and any who need to come out of the units."

By the time she gets back to her office at about 9:15 a.m., McDaniel says she has a pretty good idea of what the day will look like. "What these meetings have achieved over a year’s time is that everybody starts the day knowing what the hospital is about," she adds. "It makes them so much more global, and they’re enjoying that. They don’t have that silo’ feeling."

(Editor’s note: Maureen McDaniel can be reached at