St. Mary’s hospital developed a structured discharge process to help care teams prepare patients for discharge.
Good transitions begin with a smooth discharge, where patients feel confident about how they’ll manage their condition. When we looked at our discharge planning, we realized that we were disproportionately focused on the in-hospital clinical care. Patients often didn’t know when they were getting discharged and our HCAHPS scores around discharge were lower than we wanted.
St. Mary’s Medical Center is a non-profit teaching hospital in San Francisco, CA. It has 300 beds and serves a primarily elderly Medicare population with multiple comorbidities. Their transitions program began in 2009 and is influenced by Project RED and IHI’s Transforming Care at the Bedside.
What We Tried
We start discharge planning on day one. Every morning we have plan of care rounds where the structure is “plan for the day, plan for the stay.” This keeps the care team and patient aware of when they can expect to go home. Every afternoon at 3:45 we have discharge rounds. These are faster, just two minutes per patient, where the hospitalist says which patients are ready to go home the next day and what needs to be done before that can happen. The PM nurse then reinforces the education we’ve provided and works with the patient to confirm transportation for the following day. The next morning, all the hospitalists will have their orders in by 10:30, the transitions team will meet with all the high-risk patients getting discharged, and patients are ready to leave by noon.
Adding structure around our discharge process and starting it on day one has improved many aspects of our program. Patients are more involved in their care because they understand what the plan is for their hospital stay. Also, staff are better able to prepare the patients for discharge when they have an estimated discharge date. This makes it easier for nurses to reinforce education in advance of discharge, social workers to prepare any post-discharge services, and physicians to schedule follow up appointments. Overall our patient satisfaction scores around the discharge process have gone up and more patients are going to follow up appointments.
Adding this structure to our discharge planning process has also increased our throughput. Previously, we would sometimes have patients who were ready for discharge but didn’t have transportation organized, so they ended up staying even though they didn’t need it.
Wrapping everything up and completing discharges by noon has been the biggest challenge in this process. We organized an informal competition between our units and it has encouraged people to improve their metrics.