120 ◾ Alexander Bohn and Sue Ann Te
days to 6.1 days. As the year approaches, Fairview’s peak admission period, addressing their capac-
ity has become a consistent topic of discussion at senior leadership team meetings. At last week’s
meeting, the chief operating ocer proposed that the PI department lead an initiative to address
the capacity challenge.
Dening Scope, Resources, and Goals
An initial meeting was held with key stakeholders from the ED and inpatient units since these
areas are known to be experiencing the eects of the capacity challenge. Sta attending the meet-
ing included inpatient nurses, ED physicians, ED nurses, hospitalists, and house supervisors. e
PI team facilitated a discussion to gather the sta’s input of potential root causes and factors con-
tributing to the capacity challenge. e team identied several items for consideration:
◾ Admissions from the ED were dicult to predict, so house supervisors were unable to plan
for and balance ED admissions with other admission sources (surgery, direct admits, hospi-
tal transfers, etc.).
◾ Nurses were unaware of hospitalist or attending physician plans to discharge a patient.
◾ Patients were often unaware of hospitalist or attending physician plans to discharge them.
◾ Once a physician discharge order was received, a nurse could spend up to 3 hours to com-
plete all the necessary paperwork required to discharge a patient.
◾ Once a patient was discharged, there were delays in getting the bed cleaned.
◾ Nurses noted that some ED admissions seemed questionable (i.e., in their opinion, the
patient did not need to be admitted).
While there were several factors contributing to the capacity challenge, the team agreed that
many of the factors centered on the discharge process. e goal of the project was determined to be
decreasing the time from a physician discharge order to the time the patient left the hospital. Once
the target process was determined, the team identied every role that participated in the discharge
process. is helped to identify the resources required for the initiative. A few of the new roles
identied were case managers, unit secretaries, pharmacy, and transporters. After the meeting,
the PI team worked to develop a process for gathering the current time between a physician order
and the patient leaving the facility. is not only provided a baseline for current performance, but
also provided a way to track and measure the impact of future improvements. It currently took an
average of 6.5 hours for a patient to be discharged once a physician order was written. Fairview’s
goal was to decrease that average to 2 hours.
Current State
Next, the PI team led a working session with frontline sta to document the current discharge
process. Because of the multiple roles involved and the various locations patients were discharged
to, a process ow map was used to document the process. e sta helped to identify steps in
the process that were barriers to patient discharge, and these steps were marked with a red dot.
Examples of barriers included steps not being completed consistently, delays in obtaining neces-
sary information or materials, and variability in the process based on resource.
After the working session, the PI team created an electronic version of the process documented
on paper during the session. is electronic version was distributed to the sta who participated
in the session for validation. As sta provided feedback, the document was revised until approval
Process Redesign in Healthcare ◾ 121
was obtained from all team members. e nal current state process ow was shared with key
stakeholders, including operational and senior leadership.
Future State
Once the current state was completed, the PI team led a second working session with the team
to develop a proposed future state process. Since this was a process redesign eort (as opposed to
a process reengineering eort), the team focused on the red dot items identied during current
state. For each red dot item, the team brainstormed ideas for improvement and all ideas regardless
of cost, eort, or impact were considered. For example, one of the red dot items identied during
current state was that patients were unaware of the physician’s plans for discharge. e team came
up with several ideas for addressing this barrier:
A. Hire a team of discharge nurses who focus on communicating discharge plans to patients
and preparing them for discharge.
B. Build a discharge lounge that patients could wait in for their loved ones to pick them up,
freeing up their bed sooner for the next patient.
C. Incorporate discharge planning discussions into the existing daily multidisciplinary rounds
on each unit. Develop a template to structure these discussions to ensure consistency across
the organization.
D. Post the patient’s expected discharge date on the white board in the patient’s room so the
patient and care team work toward a common goal.
E. Evaluate the tasks and the paperwork nurses were required to complete to discharge a patient
and determine if all are truly required and if any could be completed prior to a physician
discharge order.
Next, the team evaluated the eort and cost required (high or low) to implement the idea as
well as the expected impact of the improvement (high or low). Ideas that required low eort or cost
but were high impact were favored to be incorporated into the future state process ow. e team
also noted a risk to patient satisfaction with idea B (see Figure14.2).
D
C
E
A
B*
Low Effort or Cost High Effort or Cost
High ImpactLow Impact
Figure 14.2 Effort versus impact grid.
122 ◾ Alexander Bohn and Sue Ann Te
In this example, ideas C, D, and E were selected to be reected in the future state ow and
recommendations. After multiple iterations, the future state was nalized and implementation
plans were developed. Over the next few months, Fairview experienced a steady decrease in the
performance metric they chose to track (physician discharge order written to patient out of bed)
and a signicant increase in patient satisfaction. is was a direct result of the decrease in the
amount of time patients waited to leave the facility as well as the increased communication, giving
patients a sense of involvement in their care.
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