Optimizing the Patient Discharge Process

How can we optimize the discharge process for patients going to home?

Discharge is a complex process that involves coordination with over 20 groups and many handoffs. Although discharge coordination typically involves providers, nurses, and the care coordination team, numerous other stakeholders play direct or indirect roles in the discharge process. The alignment of all these stakeholders is critical to timely patient discharge.

We used an 8-week design sprint and conducted contextual inquiry, site observations and shadowing with 83 UChicago Medicine staff (53 nurses, 11 physicians, 7 care coordinators, 15 patients, and other staff). We created a journey map to define workflows and describe coordination and communication between all stakeholders. These methods revealed in 1) overlapping workflows between nurses and providers directly affecting timely discharge; 2) gaps in communication tools and usage of tools by different stakeholder groups, impeding communication; 3) a series of non-medical variables adding to patient’s longer length of stay.

Effective discharge requires precise alignment of three significant and autonomous work streams. We call this the “three keys of discharge” because, like a nuclear warhead, all three keys need to present simultaneously for launch. Further, each discharge key has its own internal coordination challenges.

We recommended 4 changes to improve the odds that these work streams not only align but are coordinated:

1. Separate Nursing tasks from Discharge tasks

Nurses must prioritize urgent patient care over discharge tasks—a clash of responsibilities. A better solution would:

• Create a dedicated role to manage day-of-discharge needs to prioritize discharge and manage non-medical coordination.

• Clarify and integrate the new role with the existing team

2. Directly involve nurses and providers together to design effective tools and processes for communication

Communication tools don’t align: nurses use pagers, while physicians and care coordinators use texting and standing meetings to coordinate. The timing and frequency of these communications often conflicts with scheduled nursing tasks, causing reply delays. A better solution would:

• Track and incentivize communication

• Engage leadership to redefine expectations in support of daily communication between nurses and physicians

3. Explain the steps of discharge to patients to create transparency

Patients hear they are ready for discharge — sometimes before the nurses know — and are confused and irritated when hours pass and nurses don’t seem to know what’s going on. A better solution would:

• Align nurse and providers and their talking points before speaking to patients

4. Increase Meds-2-Bed and Internal Transport Capacity

These critical day-of-discharge services are in high demand; capacity issues mean patients are occupying badly-needed beds.

Click the button below to see the final presentation delivered to UChicago Medicine Leadership.