Improving patient flow through a better discharge process.
Subject: Medical care, Cost of (Control)
Health care reform (Evaluation)
Medical care (Quality management)
Medical care (Evaluation)
Hospitals (Admission and discharge)
Hospitals (Management)
Authors: Johnson, Michelle
Capasso, Vin
Pub Date: 03/01/2012
Publication: Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2012 American College of Healthcare Executives ISSN: 1096-9012
Issue: Date: March-April, 2012 Source Volume: 57 Source Issue: 2
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Legal: Statute: Patient Protection and Affordable Care Act
Accession Number: 285087584
Full Text: 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 can be expanded while still providing quality care.

One way hospitals can 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 can 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. Covidien'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 can 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 can have significant impact on overall patient flow. Often the discharge process is considered an extra step, outside of the patient care plan, when in fact it is a critical element of patient care. Improving discharge efficiency requires a focus on patient safety and readmission risk while minimizing delays and positively affecting the patient's experience.




In our experience working with healthcare providers, we've uncovered several key themes that can typically improve the discharge process.

Communication and Collaboration

Completing all the steps necessary to discharge a patient requires the efforts of many different resources within and outside the hospital. Physicians, nurses, case managers, physical therapists, unit assistants, diagnostic imaging services, and lab technicians are key players in this process. In addition, ambulance services, skilled nursing facilities, rehabilitation centers, and outpatient services can further influence a timely and effective discharge. Improving the discharge process requires streamlining and synchronizing communication between all groups involved while also promoting collaboration. Information systems, particularly those that provide visual indicators of workflow and patient flow status, can enhance the transparency of important information. But expensive information systems are not required. Simple visual techniques, such as the use of white boards, color coding, and modifications to existing paper forms, can accomplish the goals. The key is to establish a seamless information flow and ensure adequate communication of the plan for discharge.

Advance Planning

Once the discharge plan has been communicated, we identify tasks that can be completed before or after the actual discharge order is written and signed, rather than trying to complete all the needed tasks all at once (after order signature). This kind of scheduling reduces the effective discharge turnaround time. Many steps in the discharge process can be initiated 12 to 24 hours in advance of discharge. Most hospitals know that discharge planning actually begins at the time of admission. Planning for aftercare facilities or services often begins early in the patient's stay. Nurses often begin patient and family communication and teaching as early as possible in the process. But as a patient starts showing strong signs of improvement, it's easy for staff to become busy and preoccupied with the newer and sicker patients. As a result, many tasks fall to the last few hours before discharge, including extensive documentation (manual or computerized physician order entry system), gathering belongings and prescriptions, scheduling pickup times, and preparing information for physicians or other care facilities. By providing earlier communication about the planned timing of discharge, many last-minute tasks can be started earlier.

Balancing the Workload

Clear communication and advance planning can provide reliability to the discharge process. When the process is consistent and predictable, scheduling patient departure times and balancing the workload throughout the day becomes easier. It is not unusual for hospitals to choose an 11 am discharge as their standard operating procedure; some even have a "discharge lounge" where they place patients after 11 am (this does not address root cause flow issues and makes patients angry). 11 am discharge deadlines create a situation where nurses attempt to discharge a large number of patients at the same time each day, creating a huge bottleneck. To manage the supply and demand for beds, discharges should be distributed in a more planned manner throughout the day, preferably putting greater emphasis on discharging more patients earlier in the day, as this creates a logistic advantage for bed management and allows more flexibility in assigning beds. Using a simple schedule can ensure a manageable distribution of discharges throughout the day. While a managed scheduling tool is simple to use, success in balancing discharges depends on collaboration; open and timely communication; and a streamlined, predictable final discharge process.


The key to successfully transforming a complex system involves the ability to understand all critical processes and then to work on the subprocesses that offer the best opportunities for improvement. By breaking down departmental silos and opening the lines of communication, multidisciplinary project teams can often effect a level of change that no single group or department could implement on its own.

Successful patient flow initiatives share some key elements: a vision for system-wide improvement, a foundation of quality information, and efficient and synchronized workflows. A systems-based approach to improvement followed by effective measurements and employee engagement is critical to continual improvement in patient throughput and the optimization of patient flow. Improving the discharge process may yield these gains:

* Reduced crowding and wait times in the Emergency Department

* Reduced post-surgical wait times to get to an inpatient bed

* Proper nursing unit resourcing through better planning--the right number of clinicians for the right number of patients

* Improved clinician morale

* Increased patient satisfaction due to better communication and more thorough discharge planning

Improving patient flow is not an easy task, but it can be accomplished with strong leadership support, good planning, and the use of skilled process improvement facilitators. The benefits are substantial; removing waste and reducing process variability will create staff and patient satisfaction and significant financial benefits.


US Congressional Budget Office (CBO). 2011. "CBO's March 2011 Estimate of the Effects of the Insurance Coverage Provisions Contained in the Patient Protection and Affordable Care Act (Public Law 111-148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152)." Published March 18. InsuranceProvisions.pdf.

For more information about the concepts in this column, please contact Ms. Johnson at or Mr. Capasso at

Michelle Johnson, MBB, Lean Sensei, Director, Operational Excellence--Northeast, Covidien Customer Excellence, and Vin Capasso, LSS MBB, Manager, Operational Excellence--Northeast, Covidien Customer Excellence
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