If you’ve ever been a patient in a healthcare facility, you’ve experienced the patient discharge process. When you know—even without a medical degree—that you’re on the road to recovery, you probably also have the thought: I just want to go home!
Before patients can be released, however, many things must happen as part of the managed discharge process. These include actions related to health assessment, forward-looking care, in-house administration, and billing.
Pre-discharge communications
As a patient’s time in the healthcare facility is drawing to a close, typically both the patient and healthcare staff are anxious for the discharge to take place. Often the patient is told the night before or early in the day that discharge is likely, leading to high hopes and triggering arrangements for pickup and other activities outside the facility.
When the time between notification and discharge drags on for hours, the delay has at least two negative impacts: patient dissatisfaction and limited availability of the bed or room and care practitioners for the next patient. Part of the dissatisfaction can be a communications issue. The patient hears, “You might be able to go home today,” and the clock starts ticking. Anything from that time on is wait time, fully non-value-added, as perceived by the patient.
In fact, many things are happening during that time, including verification of patient readiness, follow-up on test results, preparation of outpatient materials, physician’s order for discharge, preparation of discharge summary, and closing components of billing. These events can become even more drawn out if the process stretches across a shift change.
What is the patient discharge process?
The patient discharge process closes the loop on care that started hours, days, or weeks earlier with patient placement. Like that process, discharge has clearly definable components and often can be improved with an operational excellence approach.
Within the patient discharge strategy, the facility can apply standard work methods, identifying the best-known methods, with the best materials, in the best amount of time to get the work done quickly and with consistent high quality for each patient.
Discharge components include a number of items:
- Final tests. This may include blood work, vital signs, bowel movements, breathing capacity, ambulatory abilities, and level of alertness or confusion.
- Physician approval. The verification of patient readiness assesses both physical and mental capabilities, along with level of pain and other specifics related to the patient’s diagnosis.
- Oral and written documentation.Follow-up care and cautions in the home are reviewed with the patient and often with the family caregiver with a check for understanding. Written materials are mandatory as patients may not yet be at normal levels of alertness and memory when oral instructions are reviewed.
- Training. Any required care, including items such as injections, dressing changes, and catheter management, must be reviewed. Ideally, demonstration and practice will help the patient and family caregiver have competence and confidence.
- Description of medications. Reason for use, dosages, and possible side effects are reviewed and documented.
- Required equipment. Wheelchair, walker, braces, oxygen tanks and other equipment must be arranged and ready for the patient to take home.
- Contact information. A complete list of who to call for what is provided.
- Follow-up appointments. At least the first follow-up appointment, if needed, is set up with the healthcare facility or with the primary care provider, therapy, or other facility.
- Prescriptions. A first supply of medications is filled by in-house pharmacy or ordered at the patient’s local pharmacy for pickup by the patient’s caregiver.
- Patient’s personal belongings. During check-in, clothing and other items were likely placed in a bag. Any other items, including flowers, gifts, and phone charger (very important to the patient), must be included. A final room scan is essential.
- Billing. While the final bill will be compiled later, most components can be closed by the time of patient discharge.
- Patient feedback form. The HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) or other survey is given to the patient.
- A farewell greeting. Ideally, one or more staff members make a final contact with the patient expressing sincere friendliness and good wishes.
How do you improve the patient discharge process?
Patient discharge must cover a variety of situations, with separate standard operating procedures (SOPs) for discharge to the patient’s home, another health facility, a rehab or nursing home, a hospice, and even the morgue.
One of the simplest of the seven basic quality tools is a check sheet or checklist. This simple approach combines standard work, mistake-proofing, and visual work systems. When applied to patient discharge, a checklist of the components listed above can help ensure that every patient’s current and future needs are addressed and that all the facility’s requirements are met before the patient is wheeled out of the facility.
Expanding on the checklist to create a standard time and activities flow for patient discharge helps to avoid miscommunications and delays. Precise departure times can be predicted based on the expected duration of required activities. From the patient perspective, this is very helpful for planning in-hospital meals, assisted pickup, even a shower before departure. All of these give the patient renewed control of his or her life.
On the hospital side of things, the biggest benefit of an accurate departure forecast is the ability to predict availability of the bed and care providers. A specified point in the procedure for any given patient should trigger the notification for call for transport so there is no wait time. Another point will indicate anticipated release time for the bed. This feeds into the patient placement census and the schedule for room turnover, allowing time for cleaning and resupply of materials in the room.
Stitching it all together
Just as patient placement is a process, with opportunities for optimization, so is patient discharge. In fact, the two are closely interlinked. Both are critical for customer satisfaction. Both impact the facility’s overall efficiencies and patient satisfaction scores.
The patient placement process transitions to patient discharge process to make the process steps more efficient, integrate the process across all dischargeable patients, and communicate effectively with the patient to set expectations. Discharge metrics then feed back into availability for new placements.
Metrics for both processes tie together. In addition, actual performance for patient discharge relative to original predictions at time of placement should be reviewed regularly. Analyzing overall times as well as a pareto of reasons for deviation from prediction—high or low—can help the team learn how to improve the process or improve communications to control expectations. For example, if late test results or late transport consistently show up as contributing to delays, these processes can be assessed and approved. On the other hand, if delays in patient readiness occur, an earlier notification can be implemented.
Importantly, discharge metrics can be used as predictors. With a reliable process, the patient can be given an expected time for discharge with an explanation of what is happening during the wait so he or she realizes it is not non-value added time. It’s important to note that while it may seem to be a positive to “beat the prediction” and release the patient earlier than expected, if that means the patient has to wait for arrival of the family caregiver problems may arise, both for the patient and the facility. Being able to deliver the patient OTIFNE (on time, in full, no errors) is a good approach. Readmission should also be tracked as a measure of “right the first time” performance.
Bottom line
Responsibility for patient wellness and care starts from patient placement and continues through discharge. Healthcare facilities have responsibilities to provide appropriate care throughout this process. Discharge is the last step, with the opportunity to close the loop on all the patient activities, both medical and administrative. You might think of it as the “final inspection point” of the healthcare process.
Patient discharge and related transport also represents the final touch point the patient has with the facility. This last point of contact forms a lasting memory that can create an overall impression of the facility, either good or bad. This is an excellent opportunity for staff members in the facility to show competence, empathy, and compassion that will stay with the patient.
