Children's hospital's improved DP process yields tangible benefits
LOS is down, census is up, satisfaction is up
As hospital systems nationwide struggle with more medically and economically challenging patient populations, they might look to discharge planning improvements as a way to better handle the situation.
One medical center, for instance, discovered through a pilot program that improving the discharge planning process could free more patient beds, reduce length of stay, improve patient and family satisfaction, and make work flow more efficient for nursing staff.
The Children's National Medical Center of Washington, DC, has reaped striking benefits since improving its discharge process and planning several years ago.
"Looking at our 2009 surgical care unit, our pilot unit, our cases now are up 44% percent; our length of stay is down by 17%, and their case-mix index still is up 20% over fiscal year 2006," says Mary Daymont, RN, MSN, CCM, CPUR, director of clinical resource management at Children's National Medical Center. Daymont recently spoke about planning the predictable discharge at the 2nd Annual Conference on Streamlining Discharge Planning, held May 19-20, 2009, in Orlando, FL.
The organization decided to streamline the discharge process in 2006, completing the pilot in November 2007, Daymont says.
As a result of its discharge planning improvements, the hospital has gained six beds by decreasing its length of stay by 1.3 days, and the case volume has increased by 44%, Daymont says.
"The pilot program actually ended within the first six months, because we had immediate positive outcomes," Daymont says.
For example, one of the goals was to increase the percentage of discharges that take place before 3 p.m. The baseline for the surgical care unit was 30% of discharges occurring before 3 p.m., she explains.
After the pilot program ended, the discharges occurring before 3 p.m. increased to 50%, Daymont says.
The medical center's focus on improving discharge planning came about partly because of staff dissatisfaction with the way the afternoons were chaotic and stressful.
"Our discharges were all in the late afternoon and into the evening, and the admission times were scattered around the same time-frame," says Kathleen Rigney-Radford, RN, MSN, CCM, manager of case management at Children's National Medical Center.
"I identified two different pilot units and looked at data for what were the discharge times for those units," Rigney-Radford says.
When she showed the units' nurses the findings that discharges were primarily in the afternoon and early evening, particularly near shift changes, the information resonated with them, she says.
"There was an 'Aha' moment of 'No wonder we feel so crazy our workload is clustered around the late afternoon,'" she says.
The staff helped to identify a more optimal discharge time. They preferred to shift many discharges to before 3 p.m.
So, Rigney-Radford met with physicians, attending physicians and surgeons, and staff on the units who would be piloting the change to educate them about the new discharge goals.
"We had another 'Aha' moment when we met with the surgeons themselves," Daymont says.
"We saw how our surgeons would come to do their rounding in the wee early hours, 7 a.m., and usually by themselves," Daymont says. "They would talk to our residents and medical students and then go off and do surgery all day."
Everyone would wait until the surgeons came out of surgery to make discharge decisions.
Also, residents have schedules that often push discharge planning to the back burner.
For instance, at academic institutions, residents often have daily teaching rounds from noon to 1 p.m., and one day a week they do an afternoon clinic, Rigney-Radford says.
"So there's this dead time between noon and 1:30 p.m. when no paperwork is being done or prescriptions filled," Rigney-Radford says. "Unless you get the physicians to pay attention to discharges early in the morning when they're on rounds or the night before, you won't get anything done until later in the afternoon."
Unfortunately, the late afternoon often is a busy time because of shift changes and late admissions. So, hospitals might experience an afternoon and evening bottleneck that negatively impacts both staff and patients.
One potential solution to this is to add afternoon rounds. Another might be to hire physician extenders to focus on discharging patients.
Children's National Medical Center has employed both strategies and achieved success in improving its discharge process as a result.
"There was a lot of wasted time during the day because, generally, the surgical residents were not comfortable in making discharge decisions without approval of the surgeons," Daymont explains. "The surgeons were incredulous, saying, 'They clearly know when I want the patient to go, and there was no reason to wait.'"
But the residents responded that they didn't really know what the surgeons were thinking, and they weren't comfortable making the discharge decision without their input.
"For the surgeons, getting this feedback was eye-opening for them," Daymont says. "So, the surgeons agreed to be more articulate about what the discharge criteria [were] in the progress note, saying the patient could be discharged when he or she met these criteria."
Also, around mid-day the surgeons would send out a senior fellow to further identify patients to be discharged.
"We rolled out afternoon rounds and physician extenders, and we continually educate physicians on specifying discharge criteria," Daymont says. "Everyone knows what we're aiming for."
Since the hospital's changes have increased volume and decreased length of stay, the cost savings have offset the costs of hiring physician extenders, Daymont notes.
"We have more patients coming through the door, and there's more income for the hospital," she adds.
Another problem was that some discharges were made in the evening, between 5 p.m. and 7 p.m., when it was very inconvenient for nurses, who were changing shifts and handling a multitude of other activities. This also posed problems for families.
For example, previously families would arrive at the hospital right after work to pick up their children. There might be a group of parents waiting for the discharge, and nurses were already busy with shift changes and other evening work, Daymont explains.
So, the families would wait around at the nurse's station and become frustrated, she adds.
"It was chaotic and dissatisfying for the family, because they'd think they were being held up and the nurse wasn't taking care of them," Daymont says. "Nurses had multiple orders and new admissions to handle."
The hospital moved these discharges back to 8 p.m. or 8:30 p.m.
Once these later appointments were changed to 8 p.m., the families were more content because they could arrive later and then wait briefly in their child's room.
"It was more satisfying for family members," Daymont adds.
Patient satisfaction scores since the discharge process was changed have reflected increased satisfaction among families.
"The patient satisfaction scores went up by 10%, and the family's perception of the length of stay went up by 10%," Daymont says. "We've seen more positive patient satisfaction results by having a more efficient and organized process."
Also, with these changes and others, the surgical unit reduced its average discharge time to 2:30 p.m., Daymont says.
To maintain these improvements, the hospital manages the discharge process by using score cards on each unit, Daymont says.
"In the score card we look at some very common benchmarks on a quarterly basis," she says.
The benchmarks are as follows:
cases per month;
case mix index;
percent of discharges made before 3 p.m.;
average time of discharge.
The score card helps managers ascertain where to put educational and process improvement resources.
For instance, when afternoon rounds and physician extenders are shown to work well for units piloting the changes, they could be extended to other units.
The hospital's benchmarks have highlighted the success of the surgical unit in improving and streamlining its discharge process, Daymont notes.
"We found that having physicians write in their progress notes the discharge criteria was a number one benefit," she says. "Also, having afternoon rounding was very effective in progressing the care and identifying discharges for the following day."
Source
For more information, contact:
Mary Daymont, RN, MSN, CCM, CPUR, Director of Clinical Resource Management, Children's National Medical Center, 111 Michigan Ave., NW, Washington, DC 20010. Telephone: (202) 476-2338. Email: [email protected].
Kathleen Rigney-Radford, RN, MSN, CCM, Manager of Case Management, Children's National Medical Center, 111 Michigan Ave., NW, Washington, DC 20010. Email: [email protected].
As hospital systems nationwide struggle with more medically and economically challenging patient populations, they might look to discharge planning improvements as a way to better handle the situation.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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