By the Healthcare Financial Management Association, October 2008
About 17.6 percent of hospitalized patients in the United States are readmitted within 30 days of their discharge. Some of these readmissions are unavoidable—but the majority (13.3 percent) could be prevented, according to a June 2007 report by the Medicare Payment Advisory Commission (MedPAC). Many readmissions are caused by process failures: For instance, patients frequently return to the hospital simply because they do not fully understand their diagnosis and follow-up needs or because of clumsy handoffs between inpatient and outpatient caregivers. (Greenwald J.L., et al., “The Hospital Discharge: A Review of a High Risk Care Transition with Highlights of a Reengineered Discharge Process,” Journal of Patient Safety, February 2007, pp. 97-106).
Solving these hand-off problems can be difficult given the silo-based nature of the current healthcare system. But nurse leaders around the country are showing that you can improve the discharge planning process and reduce readmissions. Here are three how-to stories.
Case Study 1: Moms, Babies Out by 1 p.m. at Barnes-Jewish
More than 80 percent of mothers and their new babies leave Barnes-Jewish Hospital by 1 p.m. on their discharge day, thanks to a complete overhaul of the discharge process.
“Preparation for discharge time starts when the patient arrives to the postpartum floor,” says Donna Hecke, MSN, RN, CPNP, performance improvement engineer in the Women and Infants division of the 1,100-bed St. Louis hospital. “It’s a totally different way of thinking about a hospitalization for the patient.” Hecke was manager of the 60-bed postpartum maternity unit in November 2006, when the discharge process was reengineered as one of many process improvement projects throughout the hospital.
“When you look at traditional modes of discharge, usually it’s, ‘You’re going to go home tomorrow. I guess we better start working on this list of 50 things,’” says Hecke. “We could never get everything done and have a standard discharge time.”
Correcting Hold Ups
While that challenge pertains to most units, it is particularly daunting when there are two patients (mother and baby) admitted to two services lines (pediatrics and OB) that must coordinate the discharge.
Getting patients discharged on time was important to keep patients flowing through the system. “If postpartum is not prepared to take another patient, that backs up labor and delivery,” says Hecke. In turn, that backs up the hospital’s pregnancy assessment center (similar to an ED for maternity patients).
The discharge process was reworked during a four-day rapid improvement event in November 2006. A 15-member team, including 10 nurses, redesigned discharge activities, tested a new process, and trained staff members to make it the new way of providing patient care.
“Before then, the percentage of patients being discharged on time was zero. It was evident to all that we had an opportunity for success right before us,” says Hecke. Unless complications dictate otherwise, mothers who have vaginal deliveries stay in the postpartum unit for two days and those who deliver by Caesarean section stay for four days. To make this happen, the team focused on understanding all the activities needed to get mother and baby out the door—from performing circumcisions and taking baby photos to offering breastfeeding support and arranging for transportation.
Because physician support was essential, the hospital included physicians on the redesign team. As a result, physicians offered to change their own workflow to make early discharges possible. For example, obstetricians and pediatricians agreed to organize their rounds so the first patients they see are mothers and babies scheduled for discharge that day.
Transportation was another frequent barrier to timely discharges, so nurses began informing patients and family members about the 11 a.m. discharge time and discussing their transportation plans shortly after they arrived in the postpartum unit.
Visual Tracking Tool
The new discharge process involves a “discharge board” that serves as a visual tracking tool to quickly see which discharge-related activities have been completed and which still remain to be done (see the picture on page 9). The board is a grid in which patient room numbers are listed in the columns across the top. Each test, procedure, and activity required before discharge is listed in the first column on the left. When a task for a specific mother and baby is completed (for example, a lactation consult), a magnet is placed in the corresponding box.
Keys to Improvement
Hecke, who is completing Lean/Six Sigma black-belt training in process improvement, offers several keys to success for improving the discharge process.
Communication. Make sure all caregivers—as well as the patient and family members—know about the discharge time. Posting a reminder of the discharge time in each patient’s room can keep this top of mind.
Physician discharge orders. Physicians should write an order with “intent to discharge next day,” listing any contingency that might prevent discharge from occurring. On the day of discharge, the order should be written at least two hours before the established discharge time.
Discharge board. This visual tool is most successful if it is located in a high-traffic area convenient for all caregivers. The board should be flexible so that, if a procedure is not required for a specific patient, all caregivers can easily see that activity is not holding up progress on other required tasks.
Data collection and analysis. Analyze discharge times before the process is redesigned to provide baseline data.
When the new process is implemented, record the time of discharge for every patient; if a patient is discharged after the target time, the reason for delay should also be recorded. Track trends on a weekly or monthly basis, identify barriers to hitting the discharge time, and adjust the process to eliminate the delays.
Donna Hecke, MSN, RN, CPNP, was interviewed for this article. Hecke is performance improvement engineer at Barnes-Jewish Hospital in St. Louis, Mo. ([email protected]).