Background: Hospital overcrowding has become a widespread problem, with constrained bed capacity and admission bottlenecks having far-reaching negative impacts on quality and safety. Focus on timing of discharge may be the least disruptive and most effective way to address constrained bed capacity, yet there may be significant institution-specific barriers to implementation.
Methods: With the creation of a "Value Team," a 627-bed, tertiary care academic medical center embarked on a quality improvement (QI) project using Lean Six Sigma process improvement methodology. After defining the problems around timeliness of discharge, the team went through the steps in the Define, Measure, Analyze, Improve, Control (DMAIC) framework. Interventions, which were implemented on the basis of an in-depth analysis of barriers to the discharge process, included geographic cohorts of internal medicine physicians on specific hospital units and multidisciplinary huddles one day before anticipated discharge.
Results: After accounting for the concurrent trends in the control group, the percentage of discharge orders released by 10:00 a.m. increased by 21.3 points (p < 0.001; adjusted odds ratio [OR] = 2.62; 95% confidence interval [CI] = 1.91-3.59), and the percentage of patients discharged by noon increased by 7.5 points (p = 0.001; adjusted OR = 1.70; 95% CI 1.15-2.51). There were no significant changes in the 30-day readmission rate or length of stay.
Conclusion: A QI program shaped by Lean Six Sigma principles and reinforced by clinician huddles and geographic cohorting was associated with earlier posting of discharge orders and physical discharge by noon.
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