Designing and Implementing a Multi-Site Optimal Discharge Process

The discharge process is a critical time for patients. The transition from hospital to home is known to be a risk for adverse events,(1) and yet the process varies significantly from hospital to hospital.(2) To improve outcomes at discharge, a comprehensive discharge process to address patients’ needs during the transition is critical.(3) This can be challenging in today’s large healthcare systems, which may include multiple hospitals and clinics.

A patient-centered discharge process with adequate and clear communication among all parties is vital.

Evidence of ineffective care transitions is abundant. The fact that the CMS has chosen to use the hospital 30-day readmission rate as a quality measure recognizes that it should be possible to lower the rate of returns to the hospital after discharge with an improved discharge process. Other quality measures, such as 30-day mortality, also may indicate an ineffective process.

Several elements are recognized to be important in devising an ideal discharge practice. A patient-centered discharge process with adequate and clear communication among all parties is vital.(4-6) A multidisciplinary team, including all members of the care team (e.g., nurses, providers, therapists) has been shown to be necessary for a successful transition.(7,8) Strong patient and family engagement must be incorporated into all of the processes, and planning for discharge must begin at admission.(9)

Given the critical requirement of an effective discharge process for best patient care, we sought to identify evidence-based principles and key components of an ideal discharge process. The project included the desired outcomes and measures to evaluate the success of the process. The goal was to identify the ideal discharge process and then implement it throughout our entire healthcare system.

Setting

This project was developed in the Mayo Clinic healthcare system, consisting of multiple sites with integrated inpatient and outpatient facilities. The main campus is in Rochester, Minnesota, with two hospitals and a total of approximately 56,500 annual admissions. There are two smaller destination campuses, one in Phoenix, Arizona, with approximately 13,000 annual admissions, and one in Jacksonville, Florida, also with 13,000 annual admissions. In addition, there are 17 smaller hospitals in the upper Midwest, with approximately 98,000 total annual admissions combined.

A multidisciplinary team was formed with representatives from the medical staff, hospital administration, case management, social workers, nursing, and pharmacy. Representatives from each of the larger sites and at least two of the hospitals in the Midwest system were included. The team was authorized by the system-wide hospital leadership and was charged with developing the ideal discharge process. The team met once per month by video conference.

Stakeholder Surveys and Results

A stakeholder analysis was performed to identify opportunities for process improvement. Key stakeholders included patients, physicians and advanced midlevel practitioners, nursing, and members of the care management team (social workers and case managers). Surveys were developed and completed by stakeholders at the time of hospital discharge. Each survey included both questions with a 1 to 10 scaled response and also questions that provided an opportunity to comment on the discharge process. Surveys were completed at each of the Mayo Clinic hospitals that participated in the project.

Patient Survey

The following questions were asked of patients after discharge:

1. From 1 to 10, with 10 being the highest and 1 being the lowest, how well do you think your discharge from the hospital helped you to be successful at home?

2. If not a 10, do you have any suggestions for improving the discharge process?

3. What did you need in the discharge process that you didn’t get?

4. What did you get in the discharge process that you didn’t need?

For question 1, 38% of the respondents scored the full 10 points, in agreement that the discharge process helped them to be successful at home (Figure 1). The cumulative average was 8.5; 10% of the patients gave a score of 5 or lower. Many of the 62% of patients who rated their discharge less than 10 gave suggestions for improving the process. Three themes received repeated attention.

Figure 1. Patient survey response to question 1: “How well do you think your discharge from the hospital helped you to be successful at home?”

• Information: Patients reported feeling overwhelmed by the volume of information that was being presented during the discharge process. Some felt that it was too much information at once. The written instructions were sometimes limited or vague and represented a very small portion of the actual discharge paperwork.

• Time: Some respondents indicated that the time required for the discharge process was excessive. Some patients reported that they had to wait for discharging physicians to arrive, and others had to wait for orders to be acted on.

• Medications: Several patients suggested that having prescriptions filled prior to discharge would relieve some of the anxiety associated with starting a new medication, especially when discharges occurred later in the day.

When asked what they did not receive at discharge, the most common answer was in regard to future outpatient appointments. Several patients expressed concern regarding the lack of follow-up appointments or uncertainty regarding the date and time of a follow-up appointment.

The question regarding what they received at discharge that they did not need did not elicit many responses or reveal any consistent themes.

Provider Survey

The following questions were asked of providers during the discharge process:

1. How would you rate the discharge process (10 = best)

2. What variables would have improved your rating (if <10)?

3. What processes went well with the discharge?

4. Did any of the following influence your rating? If so please provide comments (if not included above): Social Work/Case Management, Nursing, Consulting Services, PT / OT, Patient or Family, Post-discharge follow up, Medication Reconciliation.

Fifty-seven surveys were completed, with 25% of respondents rating the discharge as a 10 and an average ranking of 8.4 (Figure 2).

Figure 2. Provider rating of the discharge process (10 = best).

In answering the second question, providers cited several obstacles to discharge, including:

• There was inconsistent availability of diagnostic services (e.g., stress testing, echocardiography), especially on weekends and holidays.

• Securing durable medical equipment (DME) prior to discharge, especially home oxygen, proved both to be time intensive for providers and to prolong length of hospital stay.

• Patients requiring transfer to skilled nursing facility sometimes had delays to discharge as arrangements were being coordinated.

• Completing a hospital discharge within the electronic medical record (EMR) was cited as a source of frustration for some providers. Specifically, some discharge processes within the EMR were felt to be redundant. Additionally, pop-ups designed to ensure compliance with national quality reporting did not apply to most patients.

• Lack of consistent communication with primary care providers and the uncertainty or lack of post-discharge follow-up appointments were common observations.

When asked about the aspects of discharge that went well, effective coordination of care with supporting services was the most common theme. Providers frequently mentioned “teamwork” when describing processes that went well with the discharge. Care coordination was noted to improve when social workers and case managers worked closely with providers, patients, and family members. Advanced planning and proactive anticipation of discharge needs optimized patient care and the discharge process. There were a few comments about the time associated with the medication reconciliation process; however, providers did not single this step out as being excessively cumbersome or unnecessary in the in the discharge process.

Finally, when asked about the specific services that influenced their opinions, providers described the challenges of coordinating complex care for patients during and after their hospitalization that either prolonged the patients’ hospital stay or created barriers to discharge.

Case Manager/Nurse Survey

The following survey questions were sent to both case managers and nurses:

1. How would you rank the discharge process?

2. How prepared do you feel patients are to transition out of our acute care setting?

3. What three components of the discharge process do you feel to be most important?

4. What components of the discharge process do you feel need to be added, removed, or improved?

A total of 144 surveys were completed by case managers or nurses. Most of those who responded to question 1 ranked the discharge process either a 7 or 8 (51%). Eighteen (12.5%) ranked the discharge process at the highest level of 10, and 6% ranked it a 4 or less. Overall, they graded the discharge process lower than the providers did, giving it an average score of 7.0 (Figure 3).

Figure 3. Case managers’/nurses’ ranking of the discharge process (10 = best).

When asked how prepared they felt patients were for discharge, most ranked preparedness a seven or higher (72%); only 26%, however, felt they were very well prepared (ranked 9 or 10) (Figure 4).

Figure 4. Case managers’/nurses’ perception of patients’ preparedness for discharge (10 = best).

The case managers and nurses outlined several components they felt were essential to an excellent discharge. The most often cited were:

• Education: Patient education was one of the most frequently cited variables contributing to a successful patient discharge. Education about new medications was mentioned most frequently.

• Early assessment and screening: Social workers, case managers, and ward nurses use various tools to identify patients with specific discharge needs and need for post-discharge services. Consistent multidisciplinary “discharge rounds” were commonly cited as being important to the discharge process. The example cited was discharge rounds that occur Monday through Friday in the late morning at Mayo Clinic Rochester hospitals and are attended by the primary service, social workers, case managers, ward nurses, and physician advisors. The goal of discharge rounds is to identify barriers to discharge and anticipate discharge needs. Early assessment and reassessment of discharge needs also were commonly mentioned.

• Teamwork and communication: Effective communication and teamwork among the multidisciplinary team were mentioned by many as important variables in the discharge process. The needs of a patient may not be apparent in the screening process, and communication and teamwork are needed throughout the hospitalization.

• Expectations: Establishing expectations for discharge readiness and aligning patient and family expectations with those of the hospital care team were felt to be important.

Nursing and case management also gave several suggestions for improving the discharge process. Many acknowledged the challenges of care coordination and the increasing complexity involved with navigating a patient from the hospital to home. Increasingly, patients require home infusion therapy, wound care, or other complex home health services on discharge. Some members of the care management team expressed concern about the shifting expectations of their role. Some feel that they are migrating away from a clinical patient-centric role to one that is more task-oriented (e.g., securing home health services, coordinating care with payers, preauthorization of medications and DME).

Many thought that residents and new hospital providers do not have sufficient knowledge or training about discharge planning. This may lead to identification of discharge needs late in the hospitalization and late referrals for post-discharge care needs, both of which ultimately lead to avoidable delays to discharge and patients who may be more prone to hospital readmission.

Nurses commonly mentioned the medication reconciliation process. Medication duplications or incomplete instructions regarding the timing or dosage were noted.

Literature Review

The team engaged the Center for the Science of Health Care Delivery at Mayo Clinic to assist with a literature review of the existing body of evidence related to improving hospital discharge processes. A systematic review and meta-narrative synthesis of the literature was performed after searching multiple databases in English from each database’s inception to December 14, 2015. The databases included Ovid Medline in-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systemic Reviews, and Scopus.

The approach was to identify the following: what interventions are described in the literature for improving hospital discharge processes; what is the quality of evidence to support each identified intervention; and, ultimately, what recommendations does this evidence from the literature support?

The review included 86 articles, including 4 systematic reviews, and generated 36 recommendations (18 with high quality of evidence and 18 with low quality of evidence). The quality of the evidence was evaluated using the GRADE approach for qualitative criteria. To match the framework of the project team’s approach, each recommendation was stratified as being applicable in one of four settings: at admission; during hospitalization; at discharge; or after discharge.

The results of the analysis of the literature review are summarized in Table 1.

Developing the Ideal Discharge Process

The project team considered each of the 36 recommendations in conjunction with an assessment of the current state discharges process practices at each site within the Mayo Clinic Enterprise and the Voice of the Customer surveys. This assessment allowed the team to determine the ideal discharge process. Gaps in current processes at one site or another were subsequently analyzed and addressed.

Tactics

After compiling the results of the stakeholder surveys and summarizing the literature search, the multidisciplinary, multi-site team met to identify tactics to include in the ideal discharge process based on those results. Tactics were classified as those related to:

• Stages of hospitalization: pre-admit, admission, during hospitalization, and discharge; and

• Timeframe for implementation: 6 months, 12 months, more than 12 months. Decision on the time frame was made by analyzing the complexity of the tactic and the magnitude of the change from the current practice.

• Pre-admission

  • Perform early screening, assessment, and discharge planning in the outpatient setting for planned admissions. Timeframe: 12 months.

• Admission

  • The early screening tool should be used within 24 hours of admission to estimate discharge needs and to identify patients in need of specialized discharge planning. Timeframe: 6 months

  • The primary team should estimate the discharge date at the time of admission, document in the health record, and communicate to the multidisciplinary team. The care plan and estimated discharge date should be communicated to patients and caregivers. Timeframe: 12 months.

  • Nurses, case managers, and/or social workers should follow an enterprise-wide checklist at admission and throughout the stay to prepare the patient for discharge. Information should be provided to patients that includes expectations of the discharge process. Timeframe: 12 months.

  • It is the responsibility of the multidisciplinary team to involve the patient and caregiver regarding expectations of the discharge process. Timeframe: 24 months.

• During hospitalization

  • Disease-specific education should be provided as appropriate throughout the hospitalization. Timeframe: 12 months.

  • If Mayo Clinic outpatient appointments had been scheduled to occur during the hospitalization, the admission should be communicated to the appropriate outpatient department. Timeframe: 6 months.

  • The discharge checklist should be reviewed and progress communicated to the patient and caregiver daily. Documentation should be placed in the electronic health record (EHR) Timeframe: 6 months.

  • Coordinate and collaborate daily with the multidisciplinary team regarding the discharge plan. The enterprise discharge preparation video and other discharge materials should be reviewed with the patient and caregiver prior to discharge. Timeframe: 12 months.

• At discharge

  • Medication reconciliation should be completed by discharge and a copy of current medications provided to the patient, ensuring accuracy. Pharmacist involvement is recommended. Timeframe: 6 months.

  • Patient education materials provided at discharge should be based on primary diagnosis as well as chronic diseases that impact the patient’s overall health. Timeframe: 36 months.

  • Inform the patient and caregiver of applicable follow-up appointments that are scheduled or need to be scheduled. Complete handoff to next provider, if applicable. Timeframe: 36 months.

  • Patient-specific discharge instructions should be provided to all patient populations. The instructions should include a Mayo Clinic contact number for questions that arise post-discharge. Timeframe: 6 months.

  • Complete and transmit an accurate discharge summary to outpatient providers within 48 hours. Timeframe: 12 months.

  • The primary team ensures pending results after discharge are reviewed and significant results communicated to the patient/caregiver. Document this communication in the EHR. Timeframe: 36 months.

Metrics and Timelines

As the site teams were being implemented, the institution-wide committee met to determine metrics and timelines. Given the complexity of several of the tactics, it was understood that not all of them could be accomplished in a short time period. To determine the timeline, each tactic was analyzed for complexity, automation potential, and resource utilization. Those tactics that were known to require changes in the EMR or that would need greater resources were given longer timelines for implementation. Timelines for completion were set at 6, 12, 24, or 36 months.

In addition, enterprise-wide were teams assigned to deal with two tactics:

• At admission, tactic 1: Use the early screening tool within 24 hours of admission to estimate discharge needs and to identify patients in need of specialized discharge planning. Every patient must be screened and have a discharge plan.

• During hospitalization, tactic 3: The discharge checklist should be reviewed and progress communicated to the patient/caregiver daily. Documentation should be placed in the EHR.

The early screening tool was developed at one of the sites, and was validated (ref). This was then shared and implemented at all of the sites. An enterprise discharge checklist multi-site work group was created with representation from our various key stakeholders. The discharge checklist was developed by this team and was improved upon over the course of several meetings to make it flexible and applicable to the entire enterprise hospital practice. The goal was to explore options for potentially integrating the checklist into the electronic environment and hospital practice workflows in the future.

The institutional team also met to set metrics, so that progress and outcomes could be tracked. Not all tactics were determined to have metrics; metrics were chosen based on ease of collection, value of data, and importance to the institution and the patient (Table 2). In addition, the teams planned to follow the outcomes of patient satisfaction, readmission rates, and length of stay, with the expectation that successful implementation of the discharge improvement plan would positively affect these outcomes, all of which are high priority for each institution.

Efforts were identified to secure resources to enable full implementation of the tactics (e.g., pharmacy engagement with the accuracy of discharge medication reconciliation, 24-hour phone line for patients who have questions post-discharge, integration of efforts with the EHR).

Implementation

After development of the tactics, the final discharge improvement plan was approved by the clinical practice governing body for the entire institution. At that point, the hospital institutional committee charged each site with implementation of the plan. Each site developed a local multidisciplinary team with membership similar to that of the original enterprise wide committee, including physician leaders, hospital administration, nursing, and case management. The teams did an initial gap analysis at their respective sites to see where efforts would need to be expended to meet the tactics. The gap analyses were presented to the institutional hospital committee.

Individual smaller teams were created where necessary to begin determination of processes and quality improvement strategies that would meet the requirements for necessary changes to meet the goals.

As a result of the gap analyses, each site team began to meet regularly to devise a plan to meet the tactics in the discharge improvement plan. Individual smaller teams were created where necessary to begin determination of processes and quality improvement strategies that would meet the requirements for necessary changes to meet the goals. These teams continued to meet and update the site leaders on progress. Each of the site team leaders then reported progress to the institutional committee on a regular basis.

Conclusion

We have outlined a process followed at our multi-site institution to design and implement an ideal discharge process. Changing established processes and implementing a standardized process throughout a large institution with many diverse hospitals can be a challenge, but is necessary to improve patient care in a reasonable time period. Our project was particularly challenging because there was no example of an evidenced-based process encompassing the entire discharge practice, only literature with portions of the process reported. However, using feedback from stakeholders, evidence-based examples from the literature, and a multidisciplinary team with significant leadership support allowed us to successfully implement our agreed-to processes. Outcomes of these changes are now being tracked to confirm that our changes are having the desired effects.

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