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Are Process Efficiency and Effectiveness Possible in Hospital Improvements?

hospital patient AMCan hospitals provide streamlined processes that are faster and cheaper than today, while at the same time providing better outcomes for patients?  Patients want both! They want efficiency and effectiveness improvements.  They want costs to go down to decrease their out of pocket expenses and hopefully reduce insurance costs; they want more streamlined processes to make it easier and faster to schedule appointments and hear about test results.  On the effectiveness side, they want procedures that produce healthy outcomes, and reduce chances of reoccurrence; they want at home recovery methods that they understand and can maintain.

Here’s a case example of an important hospital process improvement effort—the patient discharge process.  The challenges with the current situation were

  • Orders were not written early enough in the discharge process
  • Patients were not informed about discharge date and time
  • Rides were not being arranged in advance of discharge day

 The Process Owner set these three initial improvement targets:

  1.  (1) Increase the number of patients discharged off of Adult Services Units
  2. (2) Increase the number of discharged orders written by the physicians
  3. (3) Predict the number of discharges the evening before the day of discharge

The vision for the process was:

Patients are discharged by 1:00 p.m. when the census of new patients increases increases (patients coming out of the Emergency Department and surgery) and staffing for the next shift occurs. 

Both the improvement targets and the vision concentrated on efficiency implications –rooms available for more patients (which often reduces need for additional facilities) and better staffing scheduling and turnover. 

So I asked the client to articulate the effectiveness benefits.  This was easy:  Higher success rates of patient health outcomes after the hospital visit and greater patient satisfaction.

Actually potential health benefits could be inferred by looking at the process model itself.  The current process model showed the nursing station receiving patient discharge orders from the doctors, prescribing and ordering medications, providing the patient a briefing on important after care procedures, requesting a ride home, and scheduling of the next patient visit. These items would enable the patient to leave the hospital expediently with the right information, medication and next steps.  But many of these steps were not happening in a timely, complete, and helpful manner.

Here are some baseline metrics which objectify the situation.

Discharges by 1 PM

These measures start from January and the data shows that discharges before 1PM were increasing.  Once data was gathered the Process Owner set this quantifiable improvement target:

  • Increase the number of daily adult discharges by 1PM to 50% of the relevant patients.

This measure is a good efficiency outcome measure for the process.  It would be good to have some real numbers of patients discharged too, to show the size of the population.

The team also found out when discharged orders were being written and the graph below shows the percentage written before 10AM. When discharges were written later than 10AM, patients were delayed in getting meds, hearing their needed at home instructions, and getting out of the hospital in a timely manner. They knew increasing the discharge orders written before 10AM would positively impact would the 1PM discharge goal. Here is the baseline data for discharge orders written.

Orders before 10  AM

Another quantifiable improvement target became:

  •  50% of HBS Discharge orders are written before 10:00 AM. 

As you can see there is wide variation in these discharge order times. With further analysis and observation, the team found that there were high performing and low performing processes and doctors, and they decided to standardize the process so that all could benefit from one best practice method.

The final recommendations and To Be process model concentrated on changes that impacted several causes of longer discharges.  For example,

  • They developed and used a standard discharge checklist.
  • They got doctors to write conditional discharge orders the night before.
  • They got nurses on the night shift to start preparing patients for discharge the night before.
  • They coordinated patient rides home earlier.
  • They decreased med turnaround times with the pharmacy so more patients left with their meds vs. having to purchase them on the way home.
  • They increased number of post-operative appointments scheduled before discharge.

 These improvements impacted both efficiency and effectiveness. 

The Project Lead said,  “The most important things for the patients are often very simple.  They want to understand in advance when they are leaving, what do they need to do at home to continue to mend, and if something happens, what do they need to do.  As an organization, if we can be consistent with these needs, we will be really successful.” 



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1 comment to Are Process Efficiency and Effectiveness Possible in Hospital Improvements?

  • Phil Chadbourn

    Yes it is possible just like it doesn’t always require an extra inspection step to improve quality in manufacturing.
    Any LOS reduction also helps reduce the probability of hospital acquired infection or illness.
    I worked on a similar discharge project as well. We found another benefit to early discharge was post acute facilities better equipped to care for the patient, where late discharges could lead improper staffing and availability of meds.
    In healthcare it can be more difficult to see since there’s many moving parts or people involved. So at some point in the line it can cause an individual more work (like the person facilitating discharges) but the minutes they spend can save hours or days in LOS.

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