From the 2019 HVPAA National Conference
Dr. Rupesh Prasad (Advocate Aurora Health)
Background
Ours is a mid-size teaching safety-net downtown hospital, catering to under-served population. Discharge after breakfast (previously Discharge Before Noon) is an important initiative for the medical center targeting efficiency and throughput, as well as communication within the multidisciplinary patient care team as the hospital continues to operate at near or full capacity.
Objective
Many times during the week the emergency department is holding admitted patients due to the decreased bed availability. By increasing the number of patients discharged before noon, both the emergency department throughput time, and the inpatient length of stay would decrease, and patients would be happier with a more efficient discharge process.
Methods
After executive sponsorship and approval of the project from nursing and physician leadership, a multi-disciplinary work-group was formed including representation from hospitalists, IM teaching service, nursing leadership, front line nurses and unit secretaries, case management, social work and pharmacy. Physician leadership from both the hospitalist and teaching service was important in terms of determining readiness for discharge, and the timing of the discharge order. Case management and social work play an important role in removing barriers and ensuring safe placement. Pharmacy was necessary due to the ongoing bedside medication delivery program and its impact. Finally, front line nurses, nurse aides and secretaries were integral members of the project team due to the impact on their workflow.
During the kick-off meeting, the team focused on reviewing the A3 process and process mapping current workflow. An area of opportunity that was considered to have an impact on the discharge time was the structure of the discharge rounds or OFT (Outcome facilitation Team) rounds. OFTs provide the opportunity for clinicians and the rest of the patient care team to review the discharge plan and identify barriers that would delay the discharge. In our current process the OFTs were running long and did not include the necessary information that was needed for an efficient discharge. The new OFT format would include updated guidelines for the information reported, a better location for the rounds and a white board as communication tool.
Results
While we did not meet our target of 30 % discharges after breakfast, our pilot did result in increase in OFT attendance by physicians and nurses. We received positive feedback on the updated format that resulted in improved communication among the patient care team members. The OFTs are also shorter resulting in higher clinician and nurse satisfaction. In the months following the pilot, the discharge after breakfast percentage has been fluctuating and there is some variability by physicians in meeting the secondary target of of 55 % for discharge orders by 9 a.m.
Conclusions
The team continues to work on identifying opportunities for impacting discharge order and time. Further review is ongoing on best practices by team members who achieve higher discharge after breakfast percentage.
Clinical Implications
The project aimed to streamline the process of patient discharge, while also focusing on communication and flow of relevant patient information among the various disciplines involved in patient care. This is important due to significant impact on patient safety and outcomes, and role in throughput and patient flow. As health systems are pressed to cater to increasing numbers of patients, it is imperative that we have a well-defined process in place to improve efficiency and efficacy of patient care.
