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Expert offers tips on improving DP flow
Knowing bed needs is crucial
Hospitals can save hundreds of thousands of dollars, improve bed occupancy rates, and reduce staffing discontent by improving discharge operations and patient flow, an expert suggests.
The key is to know what kind of patient bed needs the hospital has and planning discharge and throughput to meet these needs resourcefully.
"The discharge process at one hospital isn't the same as it is at another hospital because each hospital's needs are different," says Michael Bundy, MBA, vice president of operations support at Wellmont Health System in Kingsport, TN.
"That's where we've missed out as an industry," Bundy adds. "We pick obligatory times in a day and send people out the door."
But hospital discharge timing should be determined by whether a hospital is surgery-driven, emergency room-driven, etc., he says.
"You need to analyze where the demand for inpatient services in-house are and then set a realistic target," Bundy says. "Figure out what the discharge targets are by unit and tailor your discharge planning."
Bundy offers these suggestions for how hospitals can improve their discharge planning operations:
* Pre-screen patients for discharge: Hospitals should have nurses or discharge planners pre-screen patients, even in the evenings, to find patients who are good candidates for discharging the next morning, Bundy suggests.
"You could call the doctor at 6 a.m. to say, 'We think he's a good candidate for discharge, and we need someone to write an order,'" he adds.
If the physician agrees, then someone needs to keep track of when the physician wrote the discharge order and when the patient left the hospital.
If there's a delay, the tracking metrics should show where the process failed and how it might be fixed, Bundy says.
* Train nurses to look for discharge barriers: Patients could be grouped into three categories, Bundy suggests. These include the following:
- Patients who will be discharged that day;
- Patients who probably could go home that day, but some obstacles need to be handled first;
- Patients who could not be discharged that day.
The key to improving discharge flow is to make certain the patients who are ready to be discharged are discharged and to remove the obstacles to discharging the second group.
This means nurses have to be trained to think about what needs to be done with patients today so that tomorrow some of them might be discharged.
"The nurse needs to say, 'This patient is not on PO pain medications, so I have to get the patient on PO pain medications during my shift so this is not a barrier to the patient being discharged tomorrow,'" Bundy explains.
Or a nurse will need to make certain the outstanding physical therapy (PT) order for a patient in group two is handled on a priority basis so that PT visit isn't an obstacle to the patient being discharged the next day, he adds.
Nurses need to review the groups of patients, looking at all of the multidisciplinary tasks that need to occur across the spectrum of care. Then they should take care of those up front, Bundy says.
"You tell the night nurse, 'This is your assignment: you're screening that patient for a discharge bucket,'" he says. "Then in the morning, part of the nurse's report is the discharge category the patient is in."
The key is to train nurses to think this way, Bundy adds.
* Use case managers for disposition of patients: Case managers become disposition managers who help nurses with discharging patients.
"The nurse manager ultimately is responsible for discharging patients on her floor, so the case manager does the same job in the discharge process that I did as an operations officer," Bundy says. "The case manager removes barriers to discharge."
For instance, the case manager will find a nursing home placement for a patient and start planning this when the patient is in the second category, he adds.
"This changes the function of case management and makes case managers more productive," Bundy says. "Before, case managers would be on a mission of trying to find which patients need their help."
* Stay on top of staff training: A medical-surgical director worked well with nurses and physicians as the discharge process changes were explained, Bundy says.
"She was a driver of the process and would show up at 6 a.m. to listen to a report and make sure patients were identified and outside barriers were honed into the support structure," Bundy explains. "She worked wonderfully with the night nurses to help them understand."
Initially, there was a large, multidisciplinary team involved. But this quickly evolved into a blame game, rather than serving as the necessary catalyst for physicians, nurses, and case managers to work together, he says.
The key to success was to have one director be the point person for educating staff on the changes and to collect metrics so people could be held accountable for their own roles in late discharges, Bundy says.
Also, Bundy spoke with nurses, answering their concerns.
When Bundy was forced to give nurses extra patients at night, he'd have a discussion with them and say: "I'll never break your nurse-to- patient ratio if you discharge by this time," he says. "If you're willing to begin discharging patients at 11 a.m. and give me three rooms in your assignment, then I'll have them flipped around by 3 p.m., and your personal ratio will be one to three, growing to one to six."
Then Bundy would speak with physicians, starting with those who had the most complaints about patients being stuck in the operating room suite for excessive hours.
"We'd go to each service line and go through the cool diagram that shows how the operating room hits the post-anesthesia care (PAC) unit and how everything hits the inpatient floor," he says.
"We'd show physicians their personal discharge times and demonstrate what capacity we could have created from their own individual waste of time," Bundy says. "They'd say, 'My one or two beds couldn't tie up the whole 500 bed system,' so I'd have to show them that we were at capacity every day, and one patient did make a difference."
Through these conversations, Bundy and hospital leadership obtained buy-in from nurses and physicians.