Critical Path Network

Six Sigma projects add efficiency to discharge process

Hospital system improves patient throughput

Six Sigma projects at Sharp HealthCare hospitals have dramatically shortened the time that elapses between the time that discharge orders are written and the time the patient leaves the acute care setting.

The Six Sigma team at Sharp Chula Vista (CA) Medical Center shortened the time it takes for patients to be transferred to skilled nursing facilities after the discharge orders are written from a median of four hours to a median of 3.3 hours. Projects at Sharp Grossmont Hospital and Sharp Memorial Hospital shortened the median time between discharge orders and actual discharge from 2.2 hours to a median of about 1.5 hours.

The teams determined that using the median was a better measure than using averages because there are always outliers that unduly influence the average, says Patricia Atkins, MS, RN, CNS, director of Lean Six Sigma and a certified ASQ Six Sigma Black Belt.

"The case managers were involved in all phases of the projects because they are involved with the patients from admission through the discharge process," Atkins adds.

Sharp HealthCare's case management department includes RN case managers and care coordinators, who are clinicians but who are not RNs. For instance, some are foreign-trained physicians who are not licensed to practice in this country; others are licensed vocational nurses.

Case managers are unit-based with an average caseload of one to 25 cases. Their primary responsibilities are utilization review and discharge planning.

The health system has a centralized Lean Six Sigma department that works on projects with the staff at each of the system's four acute care hospitals.

Identifying projects

The hospitals identify potential projects proactively by reviewing performance indicators for key health care processes and reactively by reviewing customer complaints and quality variance reports in problem areas.

Each hospital submits proposed projects and the executive steering committee sets priorities for the health care system. Each Lean Six Sigma project is developed and carried out by a multidisciplinary team. The projects typically take four to six months, and often longer if they are complex, Atkins says.

The Lean Six Sigma projects at the different hospitals had similar high-level processes and goals but the strategies and tools were tailored to conform to the systems and structures at each individual hospital, she adds.

"We ran our projects concurrently with separate teams at each hospital and a project manager [that] collaborate to share the best practices we discover along the way with the teams at all the hospitals. This approach works best because there are different cultures and systems within the different entities," Atkins reports.

Before beginning the discharge project at Sharp Chula Vista, the case management department went through the Team Resources Management (TRM) training to improve their teamwork skills.

The TRM program includes training on work distribution, conflict resolution, hand-off strategies, and communication improvement strategies, such as checking to make sure a message was received.

"The program was offered throughout Sharp HealthCare to give the staff the tools they need to be effective in working with each other. The participants learned what their expectations are as a team member, within the hospital as a whole, and on the unit level. This training on working as a team creates a foundation to make it easier to change long-standing processes," Atkins says.

When the staff at Chula Vista Medical Center reviewed discharge times, they determined that they had the most opportunity to affect the discharges to skilled nursing facilities, says Cheri Graham-Clark, RN, MSN, PHN, director of quality improvement and care management/patient safety officer.

The majority of patients are discharged to the 100-bed skilled nursing facility located on the hospital campus or one of six other facilities within 10 miles of the hospital in locations that are most convenient to the patients' families.

Smoothing discharge to SNFs

The Chula Vista Six Sigma team started by looking at the time that elapsed from when the physician issued the discharge order until the patient actually left acute care.

"When we started the project, it was taking approximately 10 hours from the time the discharge orders were issued until the patient was transferred to a skilled nursing facility. Our goal was to get the time down to four hours," Graham-Clark says.

The team reviewed patient records to find out the roadblocks to a speedy discharge and drilled down to determine what could be done to increase efficiency and decrease the delays.

"Many of the reasons for the delays were around standard work flow and teamwork issues. There was not a standard process for handling skilled nursing facility discharge forms, limited knowledge of what facilities could take what kind of patients, and gaps in communication between the case managers and other providers," says Jason Broad, MBA, certified Six Sigma Black Belt.

The team determined that the case managers were spending a lot of time providing information to skilled nursing facilities that wasn't necessary for the facility to make a decision as to whether it could provide appropriate care for a patient.

The hospital invited all of the key stakeholders in the skilled nursing referral process to a meeting to brainstorm on what information case managers should provide when they refer patients. Participants included the hospital case managers, and case managers from the Sharp skilled nursing facility and from others in the immediate area.

At the time, each of the skilled nursing facilities had different requirements for information they needed in order to decide if a patient was appropriate.

The Six Sigma team members worked with the skilled nursing facility to create standard expectations so that case managers could provide the same information for each referral. By doing so, the team was able to reduce the information that the case managers were sending by 30%, Broad says.

This step saved the case managers 10-15 minutes or longer for each patient referred to a skilled nursing facility.

The team determined that case managers were spending a lot of time contacting facilities that could not provide services to a particular patient. The case managers on the team came up with a list of the types of patients who were difficult to place, such as those who needed wound vacs or ventilation equipment.

The team created a list of skilled nursing facilities throughout the county, contacted them, and found out which kinds of patients they could accept.

"This helped to narrow down the choices for patients and families and eliminated telephone calls to facilities that were not appropriate for a particular patient," Broad says.

The team tackled improving efficiency in the case managers' work stations using a Lean Six Sigma approach called "the 5S," a five-step methodology for improving the flow and organization in the workplace. The steps are: sort, straighten, shine, standardize, and sustain.

"The purpose of the 5S is to make the environment efficient so that workers have everything they need where they need it and when they need it and there is no wasted time looking for things," Atkins says.

The team looked at the design and placement of the workspace, the computer access, the efficiency of the work process, and the flow of information between the physicians, nurses, and the case managers.

At the time of the project, the case managers' work stations were located in a corner, where people had to seek them out.

"They were not in the natural flow of the physicians and nursing providers. Simply relocating the workstations so the case managers were visible and available to the physicians was a key to improving communication," Atkins says.

Observing workflow

By observing the workflow on the unit, the team determined that the case managers were spending a lot of time walking out of their work area to the other end of the unit to the fax machine. Moving the fax machines to a more convenient location and, in one case, purchasing an additional fax machine for the unit saved time for the case managers.

When the Lean Six Sigma teams at Sharp Grossmont Hospital and Sharp Memorial Hospital looked at improving discharge times for routine discharge, they determined that the delays were occurring because the staff were often being reactive to the physician's discharge orders, rather than taking a proactive approach to discharges that were going to occur in the future.

"The treatment team wasn't systematically talking today about tomorrow's discharges. They were waiting until the physician actually wrote the orders. We wanted to develop a systematic way of keeping the team aware that a patient is probably going to go home the next day so they can be prepared," Atkins says.

Solutions to the project included creating an icon placed on the spine of the chart, notifying staff that a patient is likely to be discharged the next day, a discharge checklist inserted into the communication forms on each unit, and a standardized computerized screen for home care education.

"With this project, it was difficult to come up with a meaningful figure to measure because there are so many outliers whose discharge takes longer than average for so many reasons," Atkins says.

The team decided to measure median time from discharge order to the time the patient was out the door. The median dropped from 2.2 hours to 1.5 hours.

"It is really hard to change a median, so even though it seems like a small improvement, it is statistically significant," Atkins adds.

Instead of documenting probable discharges in the chart and raising the possibility that an insurance company could issue a denial, the team created an icon that anyone on the treatment team can place on the spine of the patient's chart if the patient is likely to be discharged the next day.

The icon is a sticker of a car, in keeping with the theme of the project: "Way to Go."

The car icon calls the treatment team's attention to the fact that the patient is expected to be discharged and alerts them to make sure that all the patient's discharge needs are met.

"This is not like an actual discharge order but it encourages the team to start talking to the family, arranging transportation, setting up home health care or durable medical equipment deliveries, and taking care of other discharge needs," Atkins says.

The team created a discharge checklist to insert into each unit's communication form.

Since each department in both hospitals uses a different type of form to communicate between staff and has different information needs, the Lean Six Sigma team decided not to create a new form, Atkins says.

Instead, they took whatever communication form each department used and inserted the items that need to be double-checked before discharge, such as durable medical equipment, home health services, transportation, and patient education.

Before the Lean Six Sigma initiative, the case managers, nurses, and physical therapists documented home care instructions on a different screen. The team created a centralized documentation screen so everyone on the team could communicate potential barriers to discharge and proactively work together to address those barriers.

(Editor's note: For more information, contact Patricia Atkins, e-mail: