A Study of the Causes of Delay in Patient Discharge Process in a Large Multi-Speciality Hospital with Recommendations to Improve the Turn around Time

Abstract

On an average, around 25–30 discharges occur/day which includes cash and insurance patients. Approximately 45% are cash discharges and 55% are insurance discharges. This study deals with an analysis and evaluation of the delay in discharge process of cash and insurance patients once the discharge advice is given by the treating doctor. Methods of analysis include pareto analysis and descriptive statistics. The study draws attention to the fact that the average time taken for discharge of cash patients is 3 h and 57 min and for insurance patients is 5 h and 9 min that is a delay of 1 h and 41 min and 1 h and 23 min for cash and insurance patients, respectively. Results of the analyzed data show the delay in each process of discharge excluding the process of file sent to billing after discharge intimation is done by the nurse. Hence, improvement is required at each and every step involved in discharge process. Pareto analysis is used to prioritize the factors responsible for causing major delays and recommendations are given for the same. Most of the time was consumed in the process of bill preparation due to the delay in getting clearance from laboratory, pharmacy, and radiology department followed by finalization of discharge summary.

Following are the recommendations based on the study:

• Reducing the time taken for clearance from various departments
• Improving and making some changes in the Hospital Information System (HIS)
• Delegation of work.

INTRODUCTION

A hospital mainly provides two types of services being outpatient or inpatient services out of which the outpatient is a person who receives ambulatory care in the hospital, which do not require an overnight hospital stay. An inpatient is a person who has been admitted to a hospital for purposes of receiving inpatient hospital services Health Law Professional Series (2004). The inpatient in a hospital has to go through and experience three different stages. First is the admission next is intervention and the final stage is discharge.[¹] During a discharge of patient after a necessary intervention, a number of procedures have to take place by engaging various staff members and departments making the process complex. As per Mogly, discharge is a release of a hospitalize patient from the hospital by the admitting physician after providing necessary medical care for a period deemed necessary.” As per Sakharkar, “Discharge is a release of an admitted patient from the hospital. As per National Accreditation Board for Hospitals (NABH), “Discharge is a process by which a patient is shifted out from a hospital with all concerned medical summaries insurance stability. Discharge process is deemed to have started when the consultant formally approves discharge and ends with the patient leaving the clinical unit.” The admission and the discharge processes can act as bottlenecks in many of the hospitals and thus adversely affects the efficiency of the hospital (Davies and Macaulay). It is the very important indicator for quality of care and patient satisfaction. Delay in discharge of a patient also increases the pressure of beds in a hospital. Delay in discharge is bad for both hospital and patient. It increases the cost of a hospital and is depressing to a patient. Delay discharge also increases the exposure to hospital-acquired infection (P Hendy et al., 2012). Hence, effective strategies must be in place to solve this issue.

Discharge involves the medical instructions that the patient will need to fully recover. However, one of the primary factors that affect the operational efficiency is the delay in discharge process. As per the Attunelive, the average time taken for the discharge of patients in most of the hospitals is in the order of 5–6 h. The delays seem inevitable at the time of discharge; they are a direct result of poor bed management, lack of proper coordination between the medical staff as well as lack of efficient planning from the time of patient admission.

In the late 1940s, Romanian-born American engineer and management consultant, Joseph M. Juran suggested the principle and named it after Italian economist Vilfredo Pareto, who observed that 80% of income in Italy went to 20% of the population. Pareto later carried out surveys in some other countries and found to his surprise that a similar distribution applied.

We can apply the 80/20 rule to almost anything:

• Eighty percentage of customer complaints arise from 20% of your products and services
• Eighty percentage of delays in the schedule results from 20% of the possible causes of the delays
• Twenty percentage of your products and services account for 80% of your profit
• Twenty percentage of your sales force produces 80% of your company revenues
• Twenty percentage of a systems defects cause 80% of its problems.

The pareto principle has many applications in quality control. It is the basis for the pareto diagram, one of the key tools used in total quality control and Six Sigma.

Pareto ordering is used to guide corrective action and to help the team take steps to fix the problems that are causing the greatest number of defects first.

BACKGROUND

According to the study conducted in April 2014, in multispecialty 500-bedded hospital, it was found that the reasons for delay in discharge process was late round of consultants, delay in correction of discharge summary, delay in insurance clearance, delay after billing settlement when patient is not prepared for discharge, and delay in arrival of stretcher (Priyanka Shrivastava, 2014).

Another study conducted in a 305-bedded hospital it showed that the delay in discharge process was due to delay in discharge planning and unsynchronized patients' flows that is due to shorting treatment procedure time, the time patients spend at the hospital are also shorten as a result nurses now have shorter windows of opportunities to get to know the patients and their needs that are critical for discharge planning.[²]

Moving to a study done in Iran to analyze the waiting time for the discharge, the author SimoAjami, (2007) collected the data using questionnaires observation and checklist. The collected data were analyzed using SPSS and OR methods. Queuing model was used to study the reasons for delay in discharges. Average waiting time for all the wards was found to be 5:33 h. As per the hospital personal opinion, the main reasons identified for the delay were delay for the discharge summary completion, lack of proper guidelines for the staff involved in discharge process, and absence of hospital information networking system.[³]

Janita Vinayak model (2102), the final stages of hospitalization, i.e., the discharge and the billing process is more likely to be remembered by the patient. Study was conducted in a tertiary care teaching hospital to calculate average time taken for the discharge from a hospital. For the purpose of collection of data for the study, registers were designed and kept in wards and the billing office. Two thousand and two hundred and five patient records were analyzed. The average time taken for discharge of patient was 2:20 h.

A time motion study conducted in a hospital by Swapnil Tak etal., (2013), observed that there is a delay for all the types of discharges, i.e., insurance patients, cash patients, discharge against Medical Advice (DAMA) in the hospital. The total time taken for the discharge was compared against the NABH standards. The total time taken for cash, insurance and DAMA patients was 278, 337, and 302 min, respectively. As per the satisfaction survey conducted by the author, 69.80% of the patient felt that the discharge process was lengthy and 61.53% of the patient believe that the process can be speeded up.

The main reason for discharge delays is the processes and can be improved by appropriate interventions, as per the study of Silva etal., (2014). The study was conducted in two teaching hospitals by reviewing the medical records of the patients admitted to internal medicine ward. A pilot study was conducted to determine the sample size. The delays in discharges that occurred in two hospitals were 60% and 50.7%, respectively. The main reasons identified for delay were waiting for the test reports, delays in making clinical decisions, and in providing specialized consultation.

In nuts shell, a study was conducted to find out the significant causes of delays in discharge process which is one of the most important factors affecting the operational efficiency of the hospital in terms of discharge process.

MATERIALS AND METHODS

Interdisciplinary team of clinicians, nursing and hospital administrators including experts in system improvement/process improvement to examine the problems in discharge process were created. A descriptive cross-sectional study design was conducted in the four wards of the hospital, i.e., surgical, medical, pediatric, and women. Only the cash and insurance patients of these wards were included under the present study and various schemes such as ECHS, Corporate tie ups, and Government schemes were excluded. Before the collection of data on these patients, discharge process was observed for 2 weeks to have a better understanding of the process. Materials and Methods Interdisciplinary team of clinicians, nursing and hospital administrators including experts in system improvement/ process improvement to examine the problems in discharge process were created. A descriptive cross-sectional study design was conducted in the four wards of the hospital, i.e., surgical, medical, pediatric, and women. Only the cash and insurance patients of these wards were included under the present study and various schemes such as ECHS, Corporate tie ups, and Government schemes were excluded. Before the collection of data on these patients, discharge process was observed for 2 weeks to have a better understanding of the process [Image 1]. The time taken at each process of discharge for cash and insurance patients were observed and recorded for 2 weeks approximately. The time at which each process being done was system generated except the time at which the discharge summary printout and explanation of discharge summary to the patient was taken manually. The total of 100 inpatients for discharges was considered for analysis. The exclusion criteria for the study was (1) the time at which Operation Theatre (OT) clearance were obtained for those patients who have undergone any surgery (2) time at which implant clearance was obtained in case of surgeries which required any implants and (3) discharges that took place after 6:00 pm were not recorded. Sample size taken was 100 inpatients since the discharges from the hospital on an average were 20 and the discharges taking place in the above mentioned four wards on an average were 15; hence, for 8 days the sample size came out to be 120. Out of 120 patients there were ECHS and corporate patients which were not included in the study. Due to the lack of resources, i.e., time and manpower; hence, difficulty in tracking all the discharges.

Figure

RESULTS AND ANALYSIS

The analysis that was done with quality tool called pareto analysis. Pareto analysis is a statistical technique in decision-making used for the selection of a limited number of tasks that produce significant overall effect. It uses the pareto principle (also known as the 80/20 rule) the idea that by doing 20% of the work you can generate 80% of the benefit of doing the entire job. Take quality improvement, for example, a vast majority of problems (80%) are produced by a few key causes (20%). This technique is also called the vital few and the trivial many. In relation to the study conducted, it could be 20% factors results in 80% delays.

Pareto analysis

Here are 8 steps to identifying the principal causes you should focus on, using Pareto Analysis:

1. Create a vertical bar chart with causes on the X-axis and count (number of occurrences) on the Y-axis
2. Arrange the bar chart in the descending order of cause importance that is, the cause with the highest count first
3. Calculate the cumulative count for each cause in the descending order
4. Calculate the cumulative count percentage for each cause in the descending order. Percentage calculation: (Individual Cause Count)/(Total Causes Count) × 100
5. Create a second Y-axis with percentages descending in increments of 10 from 100% to 0%
6. Plot the cumulative count percentage of each cause on the X-axis
7. Join the points to form a curve
8. Draw a line at 80% on the Y-axis running parallel to the X-axis. Then drop the line at the point of intersection with the curve on the X-axis. This point on the X-axis separates the important causes on the left (vital few) from the less important causes on the right (trivial many).

Since resources are limited in relation to their uses; hence, these resources need to be put in best use. For this reason, it is important the resources be used to solve problems that will give the most benefits or reduce the maximum number of hassles. Thus to ensure the discharge process for cash and insurance patients is efficient and effective, pareto analysis was carried out to find out the significant causes in the discharge process, i.e., to find out the chief factors that cause variation and correct them.

As per Figure 1, all the factors that are within the intersection of target line and Pareto line/cumulative line depicts chief factors that are causing 80% delays in Turn Around Time of discharge process, i.e., from “file sent to billing-bill preparation” to “finance clearance-discharge clearance slip receives to the patient.” So these are the factors where the improvement needs to be done.

Figure 1: Pareto chart of discharge process for cash patients

As per Figure 2, all the factors that are within the intersection of target line and Pareto line/cumulative line i.e., from “file sent to billing-bill preparation” to “t0- discharge summary finalization” depicts chief factors that are causing 80% delays in turn-around time (TAT) of discharge process for insurance patients. Hence, these are the factors where the improvement needs to be done.

Figure 2: Pareto chart of discharge process for insurance patients

Figure 3 is depicting a graphical representation of actual and proposed TAT of discharge process for cash patients. The x-axis represents the process involved in discharges. The y-axis represents the time taken in each step of discharge process. Blue dotted line depicts the Actual TAT and the orange bold line depicts the Proposed TAT. From the figure it is clear that, almost all the steps except “discharge intimation-file sent to billing” are completed in a time being proposed.

Figure 3: Graphical representation of actual and proposed TAT of discharge process for cash patients. TAT: Turn around time

Figure 4 depicts a graphical representation of Actual and Proposed TAT of discharge process for insurance patients. The x-axis represents the process involved in discharge process of patient. The y-axis represents the time taken in each step of discharge process. Blue line depicts the Actual TAT and the orange bold line depicts the Proposed TAT. From the figure it is clear that, almost all the steps except “printout of discharge summary-discharge intimation” and “discharge intimation-file sent to billing” are completed in a time being proposed.

Figure 4: Graphical representation of actual and proposed TAT of discharge process for insurance patients. TAT: Turn around time

Comparison between turn-around time of discharge process for cash and insurance patients at each step of discharge process

Figure 5: It depicts that the time taken from doctor's discharge note to discharge summary finalization is more in case of discharge of insurance patients than cash patients i.e., 48 min and 32 min respectively against the proposed TAT i.e., 15 min.

Figure 5: TAT from “T0 - Discharge Summary Finalization.” TAT: Turn around time

Figure 6: It depicts that the time taken from Printout of discharge summary to discharge intimation is more in case of discharge of cash patients than insurance patients i.e., 28 and 26 min respectively against the proposed TAT i.e., 25 min.

Figure 6: TAT from “Printout of Discharge Summary - Discharge Intimation.” TAT: Turn around time

Figure 7: It depicts that the time taken from discharge intimation to file sent to billing is more in case of discharge of cash patients than insurance patients i.e., 38 and 28 min, respectively, against the proposed TAT, i.e., 25 min.

Figure 7: “Discharge intimation - File Sent to Billing”. TAT: Turn around time

Figure 8: It depicts that the time taken from clearance from various department to bill preparation is more in case of discharge of insurance patients than cash patients i.e., 21 and 20 min respectively against the proposed TAT i.e., 10 min.

Figure 8: TAT from “Clearance from Various Departments - Bill Preparation”. TAT: Turn around time

Figure 9: It depicts that the time taken from finance clearance to discharge clearance slip received to the patient is more in case of discharge of insurance patients than cash patients i.e., 11 and 10 min respectively against the proposed TAT i.e., 5 min.

Figure 9: TAT from “Finance Clearance - Discharge Clearance Slip Received By the Patient”. TAT: Turn around time

Figure 10: It depicts that the time taken from discharge clearance slip received to the patient to patient leaves (t1) is more in case of discharge of cash patients than insurance patients i.e., 32 and 26 min respectively against the proposed TAT i.e., 25 min.

Figure 10: TAT from “Discharge Clearance Slip Received By Patient - T1.” TAT: Turn around time

DISCUSSION

Discharge process for the patients begins with the doctor's discharge note. Once the discharge note is entered into the software, all the unused medicines of the discharge patient that was indented earlier is returned to pharmacy under the name of issue return. Similarly, the unused medical supplies like syringes, thermometer, mask, etc., are returned to the pharmacy store under the name of medical supplies return. If a patient has undergone a surgery, then OT clearance and implant clearance (if used implants) is done form OT. The medication indenting for the discharged patient is done by the Medical Officer (MO) after the doctor's advice note. All these steps are performed simultaneously after the doctor's discharge note. Finalization of discharge summary is done by MO or treating doctor after taking rounds of the patients. After the finalization, nurse takes out the printout (2-cash, 3-insurance) and cross check and verify indented medicine and duration from the system. The nurse then makes sure all the required documents are there in the file and send to billing department after putting discharge intimation note in HIS. After sending file to billing department the staff present there is responsible for getting the clearance from various departments like laboratory, radiology, pharmacy of the discharge patient depending on which tests patient has undergone. After getting the clearance from these departments, for the cash patient they prepare the bill including the room charges, doctor's visits, surgery charges if any etc., and asks the patient to pay for the same. For the insurance patient, they mail the scanned copy of reports of the tests done along with discharge summary and final bill to the health insurance company in which the patient is insured. After getting the approval, finance clearance is done. Similarly, after the payment made in case of cash payment clearance from is done. After finance clearance discharge clearance slip is received to the patient, then discharge summary is being explained to a patient by a nurse and once the cannula is removed, the patient leaves the hospital. Following are the roadblocks observed by the team while studying the discharge process. Following are the roadblocks observed by the team while studying the discharge process [Table 1].

Table 1: Roadblocks

Recommendations

Following are the recommendations for the concerned departments as per the study findings and the observations made [Tables 234]

Table 2: Nursing department

Table 3: Radiology/laboratory/pharmacy department

Table 4: IT department

CONCLUSION

An effective discharge process for cash and insurance patients in the hospital require coordination among the departments and all the stakeholders who are involve in the process, so if a step is completed on time then the subsequent steps will also more likely to complete on time. Apart from this proper delegation of work among the staff need to be ensured for further smoothening of the discharge process. Discharge of the patient directly related to a patient satisfaction as it is a last quality experience of the patient in the hospital so it should be dealt effectively and harmoniously so that patients can take good memories with them back home. Pareto Analysis helped up in prioritizing problem and taking suitable actions on it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.