PV: To what degree was the physician workday impacted by this process? In many places, they’re not finished with rounds until 11 a.m. or noon, and they don’t do discharges until after that.
Explore This IssueACEP Now: Vol 35 – No 12 – December 2016
“At 9 a.m., nurses and doctors, social workers, and care managers all get together and talk about the issues for the day. One of these issues is early discharge. The team identified the three to six patients on their unit that are being discharged home, and the doctors have already rounded on them; those people could be discharged early.” —Katherine Hochman, MD
KH: We tried to work smarter instead of harder. It meant adjusting the resident conferences from the morning conferences to the afternoon. We also created a daily safety huddle in the morning. At 9 a.m., nurses and doctors, social workers, and care managers all get together and talk about the issues for the day. One of these issues is early discharge. The team identified the three to six patients on their unit that are being discharged home, and since the doctors have already rounded on them, those people could be discharged early.
PV: Before we get to the nitty-gritty details of the obstacles, what was the overall end result?
KH: The effort was started in March 2012. We quickly rose from the single-digit percentage of discharge before noon to over our target, which was 30 percent. We’ve sustained that over the years, and our most recent discharge-before-noon rate has been over 40 percent.
PV: What did it take to accomplish this?
KH: I think it is important to note that this effort did not cost the institution any money except for some pizzas, cupcakes, and a few gift cards. In terms of our process improvement, everything we did was one big, giant PDSA cycle [Plan Do Study Act]. On occasions when we missed a target discharge, we did a mini root-cause analysis with the medical director and nurse manager to determine why. Some issues were very actionable. Other times, we understood that, for example, a patient waiting for dialysis really should never have been put on the discharge-before-noon list, but we did work with hemodialysis staffing, and sometimes those nurses would come in early to accommodate a discharge-before-noon patient.
PV: Did you have to extend more hours for care managers or social workers?
KH: No. Everybody, the care management and social workers, stayed during their current hours.