Palmetto Health — Discharge Redesign Leads To Improved Efficiency On The Journey To Improved Patient Flow

By Hope Stack, RN, MSN and Harmony Robinson, CHES, Palmetto Health

At Palmetto Health System, our vision is to be remembered by each patient as providing the care and compassion we want for our families and ourselves. With close to 1,500 beds, 15,000 team members, and facilities that were typically operating at 95 percent capacity, it became apparent that we needed to find a way to improve efficiency by improving the way patients were flowing through our system. Specifically, some of our challenges included:

• decentralized patient placement, which resulted in patients not always being placed in the right bed the first time
• emergency department [ED] and post-anesthesia care units [PACU] holding patients because of delays in beds being ready for new patients
• upward-trending length of stay

Our executive team was also aware of the impact these issues were having on operations―as well as on patient and staff satisfaction. And so, with their support, a cross-functional team was created and tasked with analyzing our workflows and processes, establishing ways to improve efficiency and determining the best tactics to maximize our existing resources. Through our research we identified the discharge process as the area where we could truly make an impact, because in order to place new patients appropriately, we needed to find a way to help the patients who were ready to go home make that transition.

The team therefore decided that the first project would be discharge redesign, which would give us an opportunity to collaborate with individuals from across the organization, including nursing, physicians, radiology and case management. It also provided us with an opportunity to take a broader look at how the discharge process ties into overall patient flow strategy.

Using best practices as a guide, we worked on the following:

• Starting the planning for a patient’s discharge 24 hours in advance to help ensure all the necessary steps are completed [prescriptions, education, physical therapy, transport].
• Ensuring the dirty bed notification is made in real-time when the patient is discharged to create capacity earlier in the day.
• Organizing EVS to manage peak times, which involved changing shifts as a means of ensuring consistent and efficient bed cleaning 24/7. At the start of the project, EVS had a two-hour turnaround time—we established a goal of reducing that to 60 minutes.
• Defining prioritization processes to improve bed availability.
• Leveraging technology and automation for immediate notifications and escalations to improve resource efficiency and bed turns. This includes using transport, rather than nursing staff to move patients who are being discharged―keeping nursing teams on the units so they’re ready to receive new patients.
• Using technology to automatically discharge the patients when the transport job request is put in progress.

These tactics supported an aspect of our discharge efficiency plan that focused on planning for the timely transitioning of a few appropriate patients to increase capacity and decrease delays. So rather than solely concentrating on getting as many patients out by noon as possible, we concentrated on discharging a few appropriate patients in order not to overtax staffing resources―working towards a goal of 25 percent of discharges by 12PM.

Another way we supported the discharge efficiency initiative was through the implementation of Accountable Care Units. This is an approach that uses structured interdisciplinary rounding so every member of the care team is meeting with a patient at the same time. This allows team members to collaboratively come to a consensus on the patient’s next steps. To further enhance efficiency, we use patient flow automation and sensor network technology from TeleTracking―which provides portal views and displays pending discharges on big screens. In turn, visibility and communication is enhanced for the charge nurse during huddles with the physician group, pharmacy and case management. The team can update the status of the patient in real time—identifying if they’re ready to be discharged or what additional care is needed to move them along their treatment path.

Furthermore, we’ve also created interfaces between TeleTracking and the ADT system to assist both the charge nurses and the patient placement team. And we’ve interfaced pending and confirmed discharges, which helps the nurses see who is likely to be discharged 24 hours in advance, and allows patient placement to see how many beds are going to be available the next day.

Overall visibility is also enhanced with the reporting capabilities that are available. Reports are provided monthly, with the flow coordinators and facility leaders collaborating and using it to continue to improve operations. The end goal is the more we can integrate these systems, the more we're going really optimize the work that they can do to take care of our patients every day.

About the Authors

Hope Stack, RN, MSN, Director of Patient Flow Operations

Hope has a Bachelor of Science in Nursing from the University of South Carolina and a Master in Nursing Administration from Kaplan University. She has been with Palmetto Health since 1998 and has over 17 years of nursing experience, including over 12 years of nurse management experience.

Harmony Robinson, CHES, System Manager, Patient Centered Care

Harmony has a Bachelor of Science in Nursing from the Medical University of South Carolina and a Bachelor of Science in Health Science from Clemson University. She has worked with Palmetto Health System for 10 years and has three years of experience with Nursing Research and Program Development implementing Patient Centered Accountable Care Units™.