Case Study Number 2
Summary of Hospital Discharge Continuous Improvement Project
The discharge process at the Hospital is complex and requires teamwork to be effective.
Doctors, nurses, managers, case workers, unit clerks and others encounter delays and defects
in discharging patients. This case study describes the discharge processes and needed
changes to make discharge safer and more effective for patients and those who care for them.
This case study gives a brief overview of the project that focused on improving the discharge
processes, including:
A. Project Goal, Scope and Approach
B. Team Participation and Acknowledgement
C. Discharge Process and Improvements Needed
D. Next Steps in Improving the Discharge Process
A. Project Goal, Scope and Approach
Project Goal
The goal of this project was to improve patient safety and the quality of discharges by reducing
delays and defects and changing processes so 85 percent of patients are discharged by 2:00
p.m. each day. Patient safety issues occur at discharge when communication and instructions
are not clear or when there is a problem with a prescription or the prescription is not given to
the patient. Additionally, delays in discharging patients impact patient satisfaction. Other
defects and delays occur during discharge that impact doctors, nurses, case managers and
unit clerks.
Project Scope
The scope of this project was limited to the workflow and productivity issues related to the
patient discharge process. Workflow and discharge processes were examined on two nursing
units on the East floor and one the West floor working with doctors, nurses, managers, staff
nurses, case managers and unit clerks.
Project Approach
The approach used for this project included these major steps:
1. Selected nursing units of the hospital to begin analyzing the discharge process.
2. Observed and documented workflow process of staff nurses, case managers, residents,
unit clerks to define discharge process.
3. Obtained input on defects and delays in the discharge process from patients, doctors,
case managers, staff nurses.
4. Interviewed and documented workflow processes in testing and support departments that
provide services for the discharge process, including Radiology, OT/PT, Echo and
Reference Lab.
5. Worked with physicians to obtain input on project approach and assessment of results.
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James Shirley Management Consultants, Inc.
Case Study Number 2
Summary of Hospital Discharge Continuous Improvement Project
B. Team Participation and Acknowledgement
This project was a team effort with many people who participated in defining workflows,
identifying defects and delays, describing opportunities for improvement and providing insights
and perspective on discharge processes. We particularly appreciate the inputs and ideas for
improvement from the nurse managers, staff nurses, case managers and unit clerks on each
of the three floors.
During this project we met with a physician advisory team that included: Dr. B, Dr. C and
Dr. H. We appreciate their insight and perspective on setting priorities that have significant
impact on improving discharge processes.
The project team for this project included seven nurses from the quality department l. Each
brought insight and perspective to make the discharge process better for patients. We
particularly thank the manager in the Quality Department for her enthusiasm for improving
quality and management skills in working with others.
C. Discharge Processes and Recommended Changes
These are the recommended changes from this project:
Recommendation – 1 – Improving Communication at Discharge
Design and implement an education guide for medical students and residents describing what
should be said and not said regarding patient discharge and implement methods to track
compliance. An education guide has been developed for attending physicians to use with
medical students and residents to improve communication at discharge.
Recommendation – 2 – Early Communication on Discharge
Develop standardized work for residents to communicate bed number and patient name for
patients who will be discharged to case managers early in the day, typically before 9:00 a.m.
This communication should define any long lead time issues that may delay discharge and will
require research by the case managers.
Recommendation – 3 – Testing Delays that Slow Discharge
Examine testing and OT/PT processes beginning in microbiology and radiology to determine
changes that will produce the most significant reduction in discharge delays and defects and
implement needed changes.
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James Shirley Management Consultants, Inc.
Case Study Number 2
Summary of Hospital Discharge Continuous Improvement Project
Recommendation – 4 – Physician Rounding Early in the Day
Work with physicians to review schedules and evaluate alternatives for rounding
early each day.
Recommendation – 5 – Seeing Discharge Patients Early and Writing Orders Early
Change the rounding process so discharge patients are seen early in rounding and discharge
orders are written early.
Recommendation – 6 – Adding Staff Nurse to Rounding Team
Add staff nurses to the rounding team to improve communication among Attendings, residents
and staff nurses to enhance the effectiveness of the discharge process.
Recommendation – 7 – Discharge Documents and Processes at Discharge
Review and revise documents and processes used by staff nurses at discharge.
Recommendation – 8- Standardized Work for Discharge Processes
Develop standardized work on the best methods for the staff nurse discharge process and
train nurses on the new standardized work processes.
Recommendation – 9 – Gracious and Compassionate Goodbye for Patients
Implement new processes so each patient is escorted to the exit of the hospital in a wheelchair
and given a gracious goodbye from a person who demonstrates genuine compassion.
Recommendation – 10 –Transportation Processes to Next Destination
Evaluate and improve transportation processes used to schedule patient transportation with
family members and with other transportation services.
D. Next Steps in Improving the Discharge Process
We have developed an implementation plan that describes the priorities and resources
required to continue improving the discharge process, as described in final report.
Implementation Plans and Resources Required. We believe the plan will require 1024 hours
of Quality Department and consulting time over 16 weeks. We believe these priorities should
be used implementing the recommendation from this project:
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James Shirley Management Consultants, Inc.
Case Study Number 2
Summary of Hospital Discharge Continuous Improvement Project
D. Next Steps in Improving the Discharge Process (Continued)
First Priority Changes [Complete by July 20, 2012]
1. Improve Discharge Process Used by Staff Nurses.
(1) Recommendation III-7 – Discharge Documents and Processes at Discharge
(2) Recommendation III-8 – Standardized Work for Discharge Processes
2. Reduce Waiting Time for Test Results.
(1) Recommendation III-3: - Testing Delays that Slow Discharge
Initial Focus: Radiology and Microbiology
3. Improving Communication at Discharge (Recommendation III-1)
4. Early communication on discharge (Recommendation III-2)
5. Physician Rounding Early in the Day (Recommendation III-4)
6. Adding Staff Nurse to Rounding Team (Recommendation III-6)
7. Gracious and Compassionate Goodbye for Patients (Recommendation III-9)
Second Priority Changes [Complete by August 31, 2012]
1. Reduce Waiting Time for Test Results.
(1) Recommendation III-3: - Testing Delays that Slow Discharge
Second Focus: Stress Echo and Echo; OT and PT
2. Transportation Processes to Next Destination (Recommendation III-10)
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James Shirley Management Consultants, Inc.