Published in the December 2013 issue of Today’s Hospitalist
IT’S 11 A.M. Have you discharged enough patients to make your bonus incentive?
That’s the question some hospitalists are asking themselves as their hospitals test new morning discharge initiatives and incentives to unclog EDs and free up beds for afternoon admissions.
Related article: Want to prevent readmissions? Speed up discharge summaries, November 2016.
Everyone agrees that discharging patients more efficiently is a good idea. But some say the very nature of hospital medicine makes it a poor match for a by-the-clock approach, raising the risk of readmissions and creating a new breed of clock-watching hospitalists.
Proponents say setting a discharge target time encourages problem-solving and teamwork and resolves throughput dilemmas. It can also boost satisfaction scores not only from patients waiting in the ED for a room, but people antsy to return home to their own bed.
“The patients are happy and the hospital is happy,” says Michele Mohr, MD, chief hospitalist for the Sound Physicians group in the 191-bed Wyoming Medical Center in Casper, Wyo. Her group recently moved from distributing a list of discharges the day before to a full-fledged initiative with time targets.
Skeptics, however, say controlling patient flow is too complicated to rely on a single measure like time. And some say an incentive could result in patients being pushed out before they’re ready or sway hospitalists to delay an evening discharge to hit a morning metric.
Last year, for instance, a patient who had spent a long time in an ICU that encouraged “though didn’t incentivize “discharges before 11 a.m. was given his discharge medications and sent home in a taxi, rather than waiting for a family member to take him home. The patient, who had some dementia, soon bounced right back, ultimately ending up in a nursing home.
“It was a failure of the entire team,” says Vince Worthington, PhD, MSN, vice president of clinical operations for Hospitalists of Northern Michigan in Traverse City, Mich. It also taught everyone involved an important lesson: A safe discharge plan trumps discharge time.
Focusing on the clock
A better perspective, Dr. Worthington adds, is to look at readmissions and total LOS more globally. “Don’t get hung up on one statistic.”
Focusing only on the clock, for example, might miss the fact that an on-time discharge sign-out doesn’t always mean that patients actually leave the hospital by a target time. That’s a lesson learned by the 30-hospitalist group at New York’s Mount Sinai Medical Center.
Group members increased the number of patients discharged by 11 a.m. from 30% to the target of 50%. But as Andrew S. Dunn, MD, professor of medicine and chief, division of hospital medicine, explains, the effort was disappointing.
“It had almost no effect in getting patients out of the hospital earlier, which is really all you care about,” says Dr. Dunn, adding that the initiative saved at best only 20 minutes. That’s because many factors related to when patients can actually leave are beyond the hospital’s control, such as when a long-term care facility can accept a patient or when a family member will be available.
In some cases, early-discharge initiatives do help uncover problems that need to be ironed out. At Wyoming Medical Center, a lack of communication with housekeeping sabotaged a discharge initiative begun a year and a half ago.
Physicians had been generating a list of the next day’s anticipated discharges that alerted case management, charge nurses, PT and OT to arrange durable medical equipment and transportation. But housekeeping wasn’t being notified to clean empty rooms.
“Patients weren’t getting out of rooms fast enough for them to be cleaned for open admissions,” Dr. Mohr says. “We had a backlog in the ER of patients admitted with orders ready but nowhere to move.”
The hospital spent a year working on a solution. The result, called the 10-12-2 initiative, was implemented three months ago.
By 10 a.m., doctors make the call on whether or not a patient can be discharged. If so, they ask ancillary services ” such as diabetic educators “to have details done by noon. (Housekeeping is also alerted at that time.) The float nurse on each floor can work on the discharge until 2 p.m.
While it’s too soon to generate data on whether throughput has improved, Dr. Mohr says administration is satisfied with how fast patients are moving on the day of discharge.
A comprehensive approach
While Mount Sinai has not had particularly good luck in speeding up discharges, the hospitalist group has continued to aim for 11 a.m. discharges. The hospital recently added unit medical directors to help identify two patients on each unit who can go home early the next day so social workers and case managers can move on discharge details the day before.
The hospital also began an early discharge implementation program, with the overnight admitting team identifying patients who come to the ER and can go home the next day. That allows hospitalists to round on those patients first thing in the morning.
Preliminary data look promising: More patients are going home in one day. “All members of the team need to be firing on all cylinders to get patients out early,” says Dr. Dunn. “Even then, we might be waiting for the patient’s son to come home from work.”
Children’s Hospital of Philadelphia (CHOP) has similarly had mixed results with early discharge efforts. In 2010, its goal was to have half of all discharge orders entered by 1 p.m. In 2012, the goal was reset to have 27.5% of discharge orders entered by 11 a.m.
But while orders were being written in the morning, patients weren’t necessarily leaving to make beds available. This year, CHOP is still tracking discharge timing, but it is also monitoring the time it takes from the discharge order being entered to the patient leaving the hospital.
The experience has led some physicians to question discharge time goals. “Patients should leave the hospital when they’re ready to leave. Trying to put an absolute time on that is artificial because we’re not a hotel,” says Evan Fieldston, MD, MBA, MSHP, CHOP’s medical director of care model innovation. “In addition, many of our patients stay only one or two days and are on pathways that demand that discharge be a set number of hours after admission, not just in the morning.” Dr. Fieldston coauthored a recent commentary in JAMA Pediatrics noting that hospitals that focus on morning discharges “may become inaccurate, unfair, and even counterproductive.”
“Everyone’s on board with a balanced approach that does the right thing for patients, as opposed to setting arbitrary times that don’t always get you new beds,” Dr. Fieldston says.
Sharing information is critical to that “balanced” effort, he notes. At CHOP, floor-based multidisciplinary huddles occur during morning rounds and at the end of the day. Attendings and fellows are also encouraged to call the floor in the late evening to see who might be an early discharge and to try to see those patients before morning rounds.
Setting discharge times in advance
At Chambersburg Hospital in Chambersburg, Pa., hospitalists are taking a different tack. Instead of struggling to meet early morning discharge times, they are setting a discharge time in advance.
“Structured morning rounds” began this October at the 240-bed hospital. Physicians pre-round on potential discharge patients from 7-10 a.m., meet with the team, then go from room to room, spending five to seven minutes with each patient and family. The hospitalists then identify a specific discharge time for their patients.
The hospital learned that having everyone in a predictable place at a predictable time ensures that there are no communication lapses.
“It wasn’t uncommon for a specialist to tell a patient he can be discharged in the morning but not tell the hospitalist who sees the patient at 2 p.m.,” says David Hoffmann, DO, MBA, vice president and CMIO of Summit Health and the former medical director of the 25-hospitalist group that staffs Chambersburg Hospital. The hospitalist would then find the patient “with his suitcase packed and pissed off because he’s been waiting for four hours.”
The goal, Dr. Hoffmann explains, is to reduce length of stay, improve patient satisfaction and communication, and prevent readmissions by making rounding more patient- and family-centered.
“So far, it’s been very smooth,” says Dr. Hoffmann, who started rounding himself in mid-October.
Strategies that work
Those who say targeted-discharge times make a difference have concrete ideas of what make them work.
Viviane Alfandary, MD, a hospitalist with the 45-physician John Muir Medical Group in Walnut Creek, Calif., checks a 48-hour box on the patient’s EMR to let case managers at John Muir Medical Center know who’s being discharged within that time frame. But the day before discharge, she considers any issue that could cause delays.
“This isn’t about a push to get people out,” Dr. Alfandary says, “but to get them out earlier in the day through more efficient planning.”
Given the hospital’s older patient population, she says there’s less readmission risk if she spends the day before a planned discharge focusing “on basics “eating, pooping and walking.” She also makes time the day before to write the patient’s medication list. Modifying that slightly on the day of discharge for patients on 20 meds is much smoother and faster, she explains.
Patients’ families are brought into the loop at admission. “When we admit an elderly patient, we tell the family he or she may not make it back home. We ask, ‘If they have to go to a nursing home, which one do you want,’ so in three days, they don’t have to run around looking at them,” says Dr. Alfandary.
Katherine Hochman, MD, MBA, associate chair of quality for the department of medicine at NYU Langone Medical Center, likewise makes wise use of the day before discharge. That’s key, Dr. Hochman says, to eliminating last-minute delays or poor discharges. Her hospital began a new “discharge before noon” initiative last year. (See “Going for the gold,” below.)
“If you do your preparation the day before, you’re going to get discharges before noon,” says Dr. Hochman. “In the morning, I’m not looking at the clock as much as thinking if the patient is appropriate to leave.”
And advance planning is particularly important in rural areas, according to Dr. Mohr from Wyoming Medical Center. “If a patient lives 200 miles away, you have to get on the discharge right away in the morning so the patient can get on the road and get prescriptions filled,” she says. “You have to get creative when you send someone back to a town of 100 and they have to get their IV antibiotics there.”
The impact of incentives
Even a modest incentive can change behavior. Because it faces problems with nurse staffing, John Muir Medical Center offers its hospitalists a yearly bonus to discharge 65% of patients by noon “or at least have a written order by noon.
“That was surprisingly easy to do,” says Dr. Alfandary. Thirty of 33 hospitalists meet that mark, 12 with rates over 90%. Once the group’s average reaches 65%, the bonuses kick in. It works, she says, “because everyone wants to be a team player.” They typically each have only two or three discharges per day.
With earlier discharges, hospitalists are also helping the hospital reach its goal of bringing down length of stay. “If you write an order to discharge at 7 a.m. instead of 11 a.m.,” says Dr. Alfandary, “you’ve already improved LOS.”
At Mount Sinai, part of hospitalists’ bonus is predicated on having everyone meet a minimum threshold of 50% of discharges before 11 a.m. The bonus amount, Dr. Dunn says, needs to be enough to motivate physicians.
“To have a meaningful incentive to change behavior, the bonus needs to be 15% to 20% of salary,” he says. In addition, the top two performing housestaff teams each month receive gift certificates.
But some urge caution when it comes to financial incentives. “Money on the table becomes dangerous if it’s going to incent people to do a discharge in the morning and disincentivize an afternoon discharge,” says Dr. Worthington, who handles throughput issues for the 100 physicians at Hospitalists of Northern Michigan. The hospitalists work with six hospitals ranging from 90 to 400 beds. “Having an incentive on morning discharge looks good on paper, but did I really do you a service?”
CHOP’s Dr. Fieldston warns that financial incentives also can lead to gaming “holding a patient until the morning to hit metrics while actually increasing LOS and bed block.
“If you penalize clinicians for evening discharges they’ll say, ‘Fine, I’ll hold everyone until the next morning,'” he says. Instead, he says, balance the discharge time with overall LOS, patient satisfaction and readmission rates to get a “holistic picture of clinical performance rather than a single number.”
Changing your day
Despite those possible downsides, incentives can sweeten the impact of early discharge initiatives on how physicians structure their day. That’s not a bad thing, says Dr. Dunn from Mount Sinai, because it helps hospitalists develop better rounding strategies.
“It helps balance priorities in the morning when you have the sickest patients, new admissions and potential early discharges that all need to be seen at the same time first thing in the morning,” he says.
At Wyoming Medical Center, the 12 hospitalists round first on their sickest patients, then on those identified as being discharged the next day. “That frees everybody else to do what they have to do to get the ball rolling,” Dr. Mohr says.
But not everyone applauds the pressure to reorder their routine. Some hospitalists with Hospitalists of Northern Michigan, for instance, bristle when asked to move patients out earlier, says Dr. Worthington. “They get frustrated and say maybe we can or maybe we can’t.”
“A lot of people don’t like being told how to manage their day,” Dr. Alfandary points out. “They want to see their sickest patients first, go to the ER, then do discharges. Unstable patients obviously come first “but money talks, so discharges are seen earlier than they would have been otherwise.”
The bottom line
Even those who support early discharge initiatives note that if plans for patients don’t work out, there has to be room for exceptions. “Patient care comes first,” Dr. Dunn says. “If patients need to stay, they need to stay.”
But despite such reassurances, some are still wary of even the idea of attaching a time to a discharge. “A discharge should happen when it’s best to happen,” Dr. Worthington says. “The question is what is the right percentage of discharges expected and what’s the right time of day. I don’t know if arbitrary goals mean anything.”
Still, he acknowledges that lighting a fire under providers to work together to meet a goal isn’t necessarily a bad idea. “It’s not bad having targets, and everybody has a bed crunch,” he says.
And despite reservations about single metrics, Dr. Fieldston says promoting early discharges highlights the importance of good coordination, safe discharges and efficient patient flow. “It’s possible to strike the right balance,” he says. “Time of day of discharge is an element of high quality care, just not the sole measure of it.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
A NEW INITIATIVE OFFERING HOSPITALISTS modest incentives has paid off for NYU Langone Medical Center in New York. Within a month of the initiative’s launch last year, the number of discharges before noon jumped from 12% to 35%, surpassing the hospital’s original goal of 30%.
The project, prompted by patient backups in the ED and poor patient satisfaction scores, was dubbed “the 17th floor discharge before noon (DBN) challenge.” The idea was to see if shorter length of would be associated with safer discharges.
The floor’s two medical directors, Ramon E. A. Jacobs, MD, and Benjamin Wertheimer, MD, teamed up with Katherine Hochman, MD, MBA, associate chair of quality for the department of medicine.
They listed the challenges “such as having residents in charge of completing the discharge summaries “then potential solutions. One was to form a multidisciplinary team including everyone from care managers to housekeeping. “It was clear that you’re only as strong as your weakest link,” says Dr. Hochman. “Everybody has to be completely on board.”
The hospital also added 3 p.m. rounds to the morning rounds to talk about planned discharges. A checklist guides the discussion and includes any special medications needed, and possible challenges. Housestaff then finish paperwork, giving social workers and case managers time to talk to family and arrange transportation, says Dr. Wertheimer. For efficiency, morning and afternoon rounds were recently collapsed into one that’s held at 1:15 p.m.
Data from rounds were added to a Web site created for the initiative last May. The site includes the patient name, medical record number, room number, anticipated discharge for the following day and anything that needs to happen to make next-day discharge possible.
“An example would be an early dose of IV antibiotics or waiting for a creatinine to come back in the morning before discharge,” says Dr. Jacobs, assistant professor of medicine, hospital medicine center, division of general medicine.
Social work and case manager leadership access and input the information on handheld devices. The Web site information goes out in an e-mail at 4:30 p.m. to 250 key players on the floors. Changes made overnight by nursing leadership are reflected in an updated e-mail at 7 a.m. That list cues lab services to draw labs earlier for patients being discharged.
Success is measured by DBN stats for the entire floor, which are displayed on public boards for five medical teams. Three discharges before noon is considered the bronze level, four is silver and five is gold.
At the end of the month, the average of all days is tallied to determine the team’s final level. Reaching the bronze level earns a pizza party for the floor; silver, the party plus vouchers for everyone for a cafeteria meal; and gold, all that plus 10 $100 American Express gift cards with the recipients chosen by drawing names from a hat.
The new goal for discharges before noon is 42%. And surpassing the earlier goals set didn’t interfere with best care, Dr. Hochman says. “We took great pains to explain that if patients are ready to leave the hospital, they leave no matter what time it is,” she says. “The second question is, can they leave before noon?”
According to Dr. Wertheimer, HCAHPS scores have risen from 70% to 73%, and readmissions have decreased.
And staff buy-in is producing unexpected solutions. For example, the nurses began calling nurses in dialysis labs to arrange first appointments for the next morning to get dialysis patients out before noon.
Administration is so pleased with the results that it’s expanding the idea to other floors. Neurology and neurosurgery are particularly interested, says Dr. Jacobs.