The increasing average length of stay (ALOS) is a challenge that plagues adult and pediatric hospitals and health care systems alike. Lengthy hospital stays have proven problematic for several reasons. For one, they increase the probability that patients will develop hospital-acquired conditions such as pressure injuries, peripheral IV infiltrations and extravasations, central line-associated bloodstream infections, catheter-associated urinary tract infections, and more.
In addition, extended stays increase the probability that patients will experience safety events and higher costs at a time when payers are allowing payment only per Diagnosis Related Groups (DRGs), which means health care systems must take a loss. While the latter has been regulated in adult health care systems for years, those regulations are slowly migrating to pediatric hospitals.
Like other health care facilities, Children’s Hospital of The King’s Daughters in Norfolk, Virginia, faced similar problems. The hospital had an ALOS of 5.6 days for patients in its medical-surgical units. Instead of reacting after regulations are cemented, the organization is actively pursuing change. But rather than handle the problem using the traditional top-down approach where leadership drives the change, the organization wanted to empower frontline team members to create change.
Diagnosing the problem
The project team at Children’s Hospital of The King’s Daughters searched the literature to see if other organizations had figured out a solution to the ALOS challenge. The team members found several promising ideas, but when they implemented those changes, they were either not sustainable or just did not work. Next, the team reviewed the hospital’s internal survey results, thinking patients and families would offer the best information.
The team found some interesting ideas, but none was thorough enough to implement—not because the information wasn’t there, but because the problems patients and families mentioned seemed to be one-offs; the findings could not be validated from the medical records. And because health care is a data-driven entity, to make hard changes, the team needed to show an objective problem before they could address it with real, sustainable change.
Go to the location where work is happening, observe quietly, and learn the process to uncover the problems.
Eventually, they realized there was no easy way to tackle the work, so they decided to collect data using teachings learned from a partnership with Toyota. They proceeded with what is called genchi gembutsu, or “Go to the location where work is happening, observe quietly, and learn the process to uncover the problems.”
The group randomly chose patients upon their arrival to the emergency department who the team thought was likely to be admitted. Team members introduced themselves and followed the patients through their hospital stay. While this was an arduous process, the results revealed everything needed to reduce the hospital’s ALOS. The team also garnered feedback from patients and families to see what they preferred to experience while seeking care from the organization.
Improving the discharge process
After collating and analyzing information gleaned from observations, the team quickly identified the discharge process as the best opportunity for improvement. For one, they found many inefficiencies and breakdowns in intra- and interdepartmental communication. Intra-departmental communication broke down when clinicians needed additional information to perform tasks, but the initiating clinician was too busy with other patients to help.
Often, the team found that when the initiating clinician was no longer busy, the other clinician was causing further delays. An example of an interdepartmental communication breakdown occurred when orders were entered into the medical record, but, unbeknown to the physician entering the order, other departments had to wait for additional information before they could proceed.
The team also observed numerous occasions of education happening at discharge. However, when patients or families had additional questions for the physician, they had to wait sometimes hours to ask those questions. These communication breakdowns generated downtime as patients waited for the next step in the process.
The team also realized a key component in the discharge process was excluding patients and their families. After discussion and more analysis, they agreed that to increase capacity without engineering more bed spaces, they needed to send patients home more quickly and turn rooms over faster. The team hypothesized if discharge processing could be reduced by 30 minutes for each patient, then for every 48 patients discharged, the ALOS would reduce by one day.
Introducing a team concept
Using that hypothesis and patient and family feedback suggesting the discharge process should take an hour or less, the team began to formulate Team Discharge. First, the team looked for common themes among discharge delays.
What they found among the intra- and interdepartmental communication breakdown was a lack of notifications when something was wrong or missing. Similar to heart monitors and other devices that alert clinicians to changes in patient status, communication breakdowns could be remedied with an alarm in the medical record. But during this age of alert fatigue, the team struggled to implement one more alert.
Next, the team decided to align resources around a teamwork model that reflects the makeup of a softball team, where everyone has a role and responsibility associated with a process. This would allow the timeline of activities after discharge orders were entered into the medical record to be synchronized and aligned with the goal to discharge patients within an hour.
To accomplish this, the team involved the unit coordinator to use the overhead pager system. Using a script, the coordinator notified clinicians of the pending activity and oriented them to the location of the activity. Those assigned to the area where the discharge was announced then could sync their watches to know what task to complete based on their job title and when they needed to complete the task.
To complete the design of Team Discharge, the group fixed communication breakdowns within the process and built a model that put patients and families in the driver’s seat of care. The team created instructions similar to a map, titled “My Journey Home,” that contained seven learning milestones the patient and family should retain before discharge. The clinicians used the map to guide discussion and assess the patient’s and family’s knowledge. This hardwired the concept that discharge begins upon admission because clinicians need to establish a baseline of knowledge from the patient and family to begin the use of the map.
They also engaged physicians to enter discharge orders before noon. This would ensure rounding occurred in the morning and give patients who had met the seven milestones time to discuss questions or concerns with physicians during morning rounds, before discharge.
After all elements of Team Discharge were created, implemented, and sustained by the frontline staff, the organization successfully reduced discharge processing times by 31% (94.3 minutes at baseline, currently 65 minutes on average). The team also was able to reduce the hospital’s ALOS by 14.4%, beginning at 5.62 days and currently 4.81 days.
By empowering team members to facilitate change and to have leadership support those changes, the team at Children’s Hospital of The King’s Daughters fostered a culture where change is welcome. Adding feedback from families has also improved relationships between team members and families, and this is reflected in patient satisfaction scores.
This project has sustained positive results over time and continues to hold the gains. As a result, where possible, the organization now approaches problem-solving following a similar team-driven approach.