Enabling efficient patient discharge with a mindset, toolset, and skillset framework.
Authors: Russell Corey , Wilson Kaycee , Alousi Amin Majid , Delanoix Catherine , Freeman Jennifer , Rivera Zandra R. , Brunelle Nicole , Seurattan-Smith Sascha , Gulbis Alison M. , Wallis Whitney , George Marina C. , Flowers Christopher , Wierda William G. , Shpall Elizabeth J. 
Published: September 2024

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Background:
Timely access to care for patients coming through the emergency center can be achieved by efficiently discharging patients. When continued bed growth is not sustainable, improvements in team-based approaches to discharges are necessary and require a multi-pronged approach. Our institution embarked on a process improvement effort anchored on completing 1 out of 2 patients discharged by 12PM. We hypothesize that a discharge before noon will assist with getting our next patient to a bed by 2PM. We conducted a pilot on our Stem Cell Transplant units to test and enable our case for change allowing for scale and spread to other units.
Methods:
Our multi-pronged framework was focused on mindset, toolset, and skillset. As our first step, executive leadership set direction to achieve a shift in mindset by socializing the case for change using a hospital throughput framework including a 9-12-2 branding. A discharge launchpad [toolset] was established to define expectations of discharge tasks including accountability within a 2-day window of medical readiness for discharge. This served as the tool aligning various teams to a date for task completion. Lastly, we evaluated skillset and defined best practices for the unit RN role and APP, along with others, which included empowering various roles to discharge patients.
Results:
For discharges during the baseline period of 12/1/2022 - 11/30/2023 from the Stem Cell Transplant service, the percent of discharge orders in by 9AM was 10.3% and discharges completed by 12PM was 12.2%. The pilot period month of April 2024 resulted in a month close performance of 52.5% for orders in by 9AM and 55.4% of patients discharged by 12PM. The average time spent by Stem Cell patients boarding in our emergency center during the baseline period was 6 hours and 34 minutes with a reduction to 2 hours and 23 minutes in April 2024. There were no Stem Cell beds added during the pilot period compared to baseline. The period of 12/1/2023 – 3/31/2024 was excluded to limit any improving data from the Hawthorne effect since throughput socialization began during those months.
Conclusions:
We met the goal within one month with plans underway to assess sustainability for implementation readiness for scale and spread to other units. Early efforts made to scale this model within the institution confirm the multi-pronged model approach is necessary. Additionally, we believe that a frontline leadership model would contribute best to implementation success. Missing any component of the multi-pronged approach or team member, such as the APP role without the RN role, will not yield the ultimate result of discharging patients by noon. This change requires a coordinated, team-based approach. The new institutional governance structure for hospital throughput, including academic and operational departments, and a logistics center in the future may contribute to building trust in leadership’s commitment to improving patient care.