Improving Patient Flow Through a Better Discharge Process

Abstract

Hospitals are now facing a dramatic challenge: improve the quality of care while simultaneously lowering costs. The Affordable Care Act of 2010 will add an estimated 32 million additional patients to the system (CBO 2011), and hospitals will need to improve efficiency so that capacity be expanded while still providing quality care.One way hospitals improve efficiency is to increase patient throughput, and many hospitals have a strategic goal to do just that. Yet, short of spending capital to expand facilities, hospitals struggle to sustain gains in this area. Patient throughput is complex, and many factors must be considered when balancing quality of care and speed through the system. The key to improving throughput is to focus on patient flow. Hospitals that succeed in improving patient flow realize that this complex process must include a disciplined and proven process improvement methodology. Patient flow must be viewed as a system, and the issues causing obstacles to smooth flow must be identified and eliminated or mitigated. Exhibit 1 shows some of the interconnected processes within a hospital. By systematically addressing key aspects of this system through rigorous analysis and redesign of the system and its interactions, effective patient flow be achieved.The patient flow improvement process has many stakeholders, so garnering senior leadership support is a critical first step toward developing a better process. Next, make sure the improvement activities are clearly defined and manageable. Most organizations don't have massive resources to dedicate for such a large, complex project; therefore, you need to break patient flow into essential parts. Covithen's Customer Excellence group emphasizes that an organization must embrace a Kaizen (continuous improvement) philosophy. Kaizen involves always improving and promotes a spirit of can do, breaking even huge problems into smaller components to make improvement efforts more manageable. Exhibit 1 is an example of breaking patient flow into six major subprocesses. Each of these subprocesses holds opportunities for improvement; one of the best opportunities involves improving the inpatient discharge process, the last subprocess within the hospital setting.While this column will focus on improving the inpatient discharge process, the first step involves understanding the patient flow process - also referred to as the patient flow value stream - in great detail. A value stream is an end-to-end series of activities that create or achieve a result for a customer (in this case, the patient). Analyzing the patient flow value stream involves gathering stakeholders from each process step from admitting to discharge and from a wide range of hospital functions: registration, lab, imaging, transport, nursing, physicians, housekeeping, and more. This extended team focuses on mapping the flow of a patient through the entire system (this process is shown in Exhibit 2). The value stream mapping allows team members to see the real process and always reveals variation and wasteful activities that create inefficiencies and reduce the quality of care. Once the key stakeholders have analyzed the interconnected system, clear goals for the desired future be established. Typical roadblocks to improved throughput include lack of collaboration between key functions, lack of effective communication systems and methods, and lack of standard work methodology. Lean Six Sigma methodologies and value stream analysis tools promote significant employee engagement and result in sustainable models for improvement.As the team maps the current state value stream and begins to analyze opportunities for improvement, they often discover a need to focus on the discharge process. As the last step in the value stream, discharge is a significant constraint on patient flow, because newly admitted patients cannot move into a bed until a bed is available for them. Thus, the discharge process becomes the flow regulator, and efficiency of the discharge process have significant impact on overall patient flow. …