Imprving Inpatient Discharge Cycle Time and Patient Satisfactin An SBTI White Paper Clumbus Reginal Hspital (CRH) is a 325-bed hspital prviding care t a 10-cunty service area surrunding Clumbus, Indiana. CRH ffers cmprehensive services including acute care, emergency care, surgery, cancer care, birthing center, cardiac services, rehabilitatin, a wide range f utpatient services and prgrams, psychiatric services and wellness services. Since 2005, CRH leadership has been integrating Lean Sigma perfrmance imprvement int the way they d business. Understanding the hspital as an inter-dependent netwrk f departments and activities, the prgram cncentrated n linking and sequencing Lean Sigma prjects acrss the rganizatin. Prject Backgrund Patient satisfactin surveys revealed that fewer than half (47.6 percent) f discharged patients rated the timeliness f the discharge prcess as Very Gd. A preliminary review f the discharge prcess revealed that much f the wrk was being deferred until the day f discharge. An imprvement in the discharge prcess will result in: Nursing staff: less time spent n the discharge prcess, mre hands- n time with patients, and mre time fr persnal develpment. 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm
Finance: cst savings frm decrease in supply csts Patients: imprved satisfactin with timeliness f discharge prcess; less wait time in ED fr bed availability ED/Surgery: increase in surgical and emergency department capacity by prviding timely access t inpatient bed; assured cntinuity f care thrugh prmpt transfer t the nursing unit. The prject fcused n patients discharged hme frm an acute care Medical/Surgical flr. The prject leader anticipates rlling ut the imprvements t ther areas nce results are validated. The prject was managed by a Black Belt fllwing the DMAIC (define, measure, analyze, imprve, cntrl) radmap. A crss-functinal team supprted the effrts. Classrm training and prject mentring were prvided by SBTI. By evaluating the quantity prduced and the cycle times, it became clear that Step 2 is the bttleneck f the prcess. This was ne initial fcus as it is the pacing item in flw f the entire prcess. Measure Phase The key measure fr this prcess is the cycle time frm the physician telling the patient (s)he will be discharged until the bed is available fr the next patient. In the baseline perid, the average time was 202 minutes. There are tw secndary measures. One is the measure f patient satisfactin as described abve. The secnd is the cst f nn-chargeable items (dressings, etc.) sent hme with the patient upn discharge. The rate at baseline was $37.17 per discharged patient with a 20% reductin gal f $29.74. Multiplied ver the number f discharges frm the study flr, the prjected savings t the hspital frm nnchargeable supplies exceeded $64,000. Figure 1 High Level Prcess Map Analyze Phase The team used a detailed prcess map and a Failure Mdes and Effects Analysis t further study the prcess. These helped t identify areas f risk in the prcess and were used t find pssible rt causes f failure. Imprve Phase Based n the findings, the team revised the discharge prcess, lading mre actins earlier in the patient s stay. 1. During Pre-Admissin Testing (PAT), surgery patients: 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm
Learn the anticipated discharge date and time Receive pre-printed discharge instructins, including supplies needed at hme after discharge and where t purchase them 2. During inpatient stay: Patients with ne f five tp medical diagnses receive pre-printed discharge instructins Anticipated discharge date and time is cmmunicated t physician(s), staff, patient, and patient s family (imprtant because the primary reasn patients dn t leave when ready is because the ride is nt available) Nursing ensures educatin, hygiene addressed befre discharge day, the bath being ffered t the patient by the evening shift nurse the day prir patients were still assisted with minr hygiene care the day f discharge Patients pre-purchase supplies fr use at hme 3. One day f discharge: Night shift nurse ntes any last day educatin needs Discharge nurse in prtected status cmpletes discharge prcess: Assure medicatin recnciliatin Cmplete discharge instructins Arrange physician fllw-up Update PAM Call physicians, if necessary Prvide final educatin Assemble 2 days wrth f patient hme dressing supplies Attending physician cnfirms medicatin recnciliatin is accurate Unit Supprt Partner (USP) assembles discharge packet with: Orders Instructins Face Sheet Prtal Care Partner dresses patient and gathers supplies, takes patient t car when ride is ready 4. If patient is discharged sner that expected: 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm
USP prmpts entry f discharge rders The chart is flagged by the attending physician Cntrl Phase A cntrl plan was put in place t ensure that these imprvements wuld cntinue in the future. Cntrl charts were used t mnitr nging perfrmance f the key variables. With a highly peple-dependent prcess, the cntrl chart can be an essential tl t verify cmpliance. Figure 2- Cntrl Chart Cnclusin and General Results Using the Six Sigma methdlgy and DMAIC radmap, the prject team greatly reduced the cycle time required t discharge patients frm a baseline average f 202 minutes t 115 minutes. In additin, within a few weeks f implementing the changes, patient satisfactin with timeliness f the discharge prcess imprved frm a baseline f 47.6% indicating Very Gd t 76.0%. Finally, the team was able t reach the target f $29.67 fr the cst f nn-chargeable items per discharge, resulting in substantial savings t the hspital. A particularly bdurate issue, waiting n ride time, cntinues t perplex the team and accunts fr mst f the variability in current discharge time. The team is wrking n this issue as well as rlling ut the changes t the rest f the hspital. References: 1. Wedgwd, Ian. Lean Sigma: A Practitiner s Guide. Prentice-Hall: Upper Saddle River, NJ, 2006. 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm
2. Zinkgraf, Stephen. Six Sigma: The First 90 Days. Prentice-Hall: Upper Saddle River, NJ, 2006. Methd West Gergia Health began by chartering a prject that included team members frm all impacted areas, which included a Hspitalist, ED Manager and Directr, Flr Nurses, Pharmacists and IT. The prject was scped t fcus imprvements n the flr, but was given permissin t explre imprvements in the ED. It was determined that a five-day event shuld be sufficient t permanently slve this prblem given the dedicated participants. The team was taught basic Lean principles t understand the imprtance f identifying waste and imprving flw. Initially the Hspitalist and ED members were asked t jin nly part f the five-day 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm
agenda. Once the infrmatin began t surface, the ED elected t remain a part f the team t see the slutin thrugh. Prir t the week-lng event the team walked the prcess and gathered relevant IT screen shts, key metrics, emplyee feedback, and a basic prcess understanding. The team discvered during this time that there was incnsistency in the way Medicatin Recnciliatin was measured. This led t the fllwing imprved Operatinal Definitins: Medicatin Recnciliatin Cmplete Baseline Medicatin List Cmplete This means that the medicatin list is current with medicine name, dsage, frequency, rute and last dse taken fr each medicatin listed. This means that the medicatin list is current with regards t medicine name nly. Mapping t See The team started the analysis by prcess mapping what actually happens in the areas. This became the nging reference t assist in understanding hw each f the steps culd impact the thers. The team ppulated the steps f the prcess with apprximate labr cst, time and quality. This was perfrmed t get an verall feel fr where their nurses spent time addressing the medicatin recnciliatin. The team used this prcess t discver areas where there was high vlume, delays, duplicate wrk, and steps lacking standard wrk. Thrugh this discussin several strm cluds were identified and placed n the map fr further investigatin. 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm
Once the areas f high vlume and tuch time were understd an apprximate cst culd be assigned t shw the magnitude f the wrk required by individuals perfrming this activity. This analysis allwed the team t see the impact each step has n the prcess. By recgnizing that the bulk f the impact is being felt in the ED nt the flr allwed WGH t better understand where ultimate slutins needed t be addressed. The team then fcused n brainstrming ideas t address the discvered areas. Each slutin was categrized by the step it impacted and then weighted accrding t an Ease vs. Impact chart. The team was then split int teams with each team respnsible fr creating cncepts that wuld slve the issues. The cncepts were made up f the abve ideas. The cncepts were then scred versus patient criteria t determine the best slutins fr implementatin. The final slutin addressed bth the ED and Flrs and is reflected in the fllwing flw: Inquire Hme Meds Create Med List Baseline Med Rec Cmplete Ask abut Meds List Med name nly in narrative field Send Ntificatin Edit/ Existing New List MD Perfrm Med Rec Pharm Perfrms Med Rec Discharge Med Rec Legend ED Nurse Med Rec Tech Pharmacist ED Dr Attending Dr Primary Nurse Review narrative Perfrm med rec CPOE cmpleted by ED Nurse Review the hme meds Write rder fr bed Ntificatin received Admit patient Enter med rec cmplete Call pharmacies Edit existing/new list Send ntificatin (change t Yes) Errr checks Apply frmulary Reslve remaining pending issues Discharge med rec CPOE Print discharge packet The abve slutin was then pilted using the Pharmacist in the rle f the Med Rec Tech t assure that the prcess was rbust. The pilt cncluded successfully and the Directr f Pharmacy mved frward with the hiring prcess. Based n vlume it was determined that the ED wuld perfrm the abve activities 24/7 while the Med Rec Tech wuld nly need t be staffed frm 11AM t 11PM. The fllwing issues were uncvered and mitigating actins were assigned: 1. Need a mbile cmputer statin (cmputer in rms are being used) 2. Interruptins n flr during Med Rec by admissin prcess. 3. Unsure if admitting dctrs are getting the ntificatin that Med Rec has been perfrmed. There was ne minr hurdle that happened after the pilt. Existing Pharmacy Techs desired the newly created psitins. While this created a mre experienced staff fr the new prcess it als created a vid in the current pharmacy rles. 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm
Once the new Med Rec Techs are n barded the fllwing benefits are expected frm this new prcess flw: Mre cmplete Med Rec list Decreases wrk lad by being mre efficient Speeds the time patients are required t spend in the ED CPOE speeds discharge n inpatients Less ptential fr medicatin errrs Better PSO visibility via All scripts 123 N. Edward Gary, 2 nd Flr San Marcs, TX 78666 sbtinline.cm