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Failing to Make Discharges Happen By Noon
The Problem
Our journey began with helpful discussion about the problem statement itself, casually referred to as a “discharges before noon project”. Is the goal really to discharge out before lunch? Are long length of stay patients always here longer than necessary? What about readmissions? Ultimately, we chose to frame our problem as discharge delays. Anything that keeps the patient in the hospital longer than is necessary would be considered our problem for solving
The Setup
On paper, we had all of the ingredients for a successful project: solid sponsorship, a fully represented interdisciplinary team, a mutually agreed upon problem (discharge delays) and approach for solving it (the A3 method). The team met every Friday and followed the process: mapping current state, observing, and tracing root causes. We eventually landed on the following key drivers (show in the image to the right).
The first, and arguably most important condition for success is what the team proved unable to solve for. But it was not for lack of ideas! We discussed Epic triggers for impending discharges, templates for discharge planning, and innovative ways of leveraging the Voalte communication system. However, these ideas proved either too difficult/costly to implement or too burdensome from a workflow perspective. For example, many of the EHR/Epic-related ideas were ultimately abandoned because they called for double or triple documentation of things.
The Brick Wall
It’s worth noting that the entire team agreed on the idea of bedside team rounding – at least in principle. What better way to get on the same page than rounding on patients with the whole team, in person? If we all agree this is a good idea, why not do it? A big part of this answer has to do with the way the care teams are organized. Patient Care Services, the nursing teams, are primarily organized by unit. Physicians, case managers, pharmacists, and other members of the multidisciplinary team are organized by service. This means that, for the non-unit-based teams, rounding on patients can mean traveling all over campus. For their workflow, it proved too difficult to attempt to schedule their appearances on the units for team rounds. And, even if they did, it proved too difficult from a nursing workflow perspective to interrupt patient care to participate in a round on only a few patients the team would arrive for. Another way this divide in team organization challenged the team was by limiting any unit-specific process changes. For the service-based part of the team it was not realistic to follow different processes on different units. The team asked then, and still asks now: How can we create a shared understanding of our patient plan of care and anticipated discharge date?
The Outlook
What advice might our team give future team’s hoping to address the discharge delay problem? Don’t give up on the dream of team rounds but be mindful of how much time you spend looking for the perfect solution. The key to solving this problem may be found in out-of-the-box thinking. When the COVID-19 pandemic struck we found ways to do in-person things virtually in ways we couldn’t imagine before the pandemic. Perhaps there is a way for us to build the shared understanding we seek using non-traditional methods. The last bit of advice would be this: Be kind to one another. Remember that we are all on the same team and trying to solve the same problems. Recognize we all share the concern that what we change might inadvertently make our jobs harder instead of easier. Lean in with compassion, speak up when you feel the need to, and persevere
Written by Hurley Smith
