Background: Inefficiencies in the hospital discharge process can be a source of patient and provider dissatisfaction. Further, gaps in post-discharge care have been associated with increases in 30-day mortality and 30-day unplanned re-hospitalization. Addressing these gaps requires a specific focus on the development of a post-acute care treatment plan, identification of potential barriers to the individual patient’s success, and interdisciplinary teamwork.
Purpose: Our primary aim was to increase patient and provider satisfaction by improving the quality and safety of unit discharges. Secondary goals included improving the timeliness of discharge and realizing a financial gain.
Description: An interdisciplinary team created a process map of patient discharges on the Cardiology-Medicine unit at University of Colorado Hospital. This demonstrated a complex and non-linear process in which problems resulted in part from diffusion of responsibilities and no identifiable “expert” in the process. A budget-neutral position was created by re-allocating existing resources to a STEP RN (Successful Transition and Education for Patients RN) position to help address these issues. The STEP RN is a full-time position dedicated to recognizing and addressing barriers to discharge, without other competing patient care priorities, and allows for development of expertise over time. PDSA cycles were used to track progress. Cycle 1 focused on implementation of the new role, including defining role responsibilities. Cycle 2 included socializing the role with nursing staff and service-line providers. Cycle 3 focused on cultivating unit relationships, aligning with the 4C hospital goals (continuous clinical care cycle), and expanding the STEP RN footprint. Preliminary data from the first four months of collection indicate that implementation of the STEP RN position was associated with several significant improvements. There was a reduction in the overall time to discharge a patient by 26 minutes across all service lines, and reduction of time spent on discharge when supported by the STEP RN by 36 minutes (111 to 75 minutes per discharge). Length of stay (LOS) was reduced by 0.24 days (from 6.44, 6.2), and patient discharges prior to 11 am increased by over 50% (5.45% to 11.3%). Importantly, these changes have continued to improve during subsequent data collections, indicating sustained change. Overall to date LOS has been reduced by 1.23 days and discharge time prior to eleven am has increased to 12%. Additionally, HCAHPS scores improved in all dimensions, and the “overall would you recommend this hospital?” score improved from 58.1 to 63.6 which made it the top-performing medical-surgical unit for this dimension at University of Colorado Hospital (UCH). Due sustained impact on efficiency and throughput, the current goal is to spread to 6 units by the end of fiscal year 20.
Conclusions: Creation and implementation of the STEP RN position on the Cardiology-Medicine unit at the University of Colorado Hospital in an iterative, step-wise fashion utilizing an interdisciplinary team has had significant impact on patient and provider satisfaction as well as overall unit performance. Adoption of this model to other units for successful and safe approach to patient discharge is encouraged.