Discharge time final

Improving the Discharge Process

WHY IS IT NECESSARY?

We do not match NABH standards

Source:GLOBAL JOURNAL OF MEDICINE AND PUBLIC HEALTHGJMEDPH 2013; Vol. 2, issue 3

Please note: NABH does not Differentiate between Cash, Credit, Corporate cases


KIMS Discharge Turn Around Time(Based on sample size of 86 patients)

Cash - 3 hours 10 minutes Credit - 4 hours 2 minutes Insurance - 7 hours.


SATISFACTION SURVEY

Not Satisfied Satisfied very Satisfied0

5

10

15

20

25

Total - 41

Total

33.5 % patients report Under satisfactionwith the discharge Process !!

(In

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tag

e)

Comparison with other Hospitals

Apollo Hospital, Hyderabad

Screenshot taken from Official report prepared by Apollo Hospital in 2014


Medicity Hospital, Hyderabad

Screenshot taken from Official report prepared by Medicity Hospital in 2014


Hospital Cash Credit Insurance

Apollo 2 hours, 24 minutes= 144 Minutes

3 hours, 19 minutes= 199 Minutes


Medicity 2 hours, 55 minutes= 175 Minutes

- 5 hours, 04 minutes(Aarogyashree)= 304 Minutes

KIMS 3 hours, 10 minutes= 190 Minutes


7 hours= 420 Minutes

FINANCIAL IMPACT OF IMPROVING DISCHARGE PROCESS

Multiple Studies (both in India and Abroad) have shown the financial benefits that accrue from reducing the discharge time in a hospital.

Example: The following study at the 310 bedded Multispecialty Hospital(Sterling Hospital) in Gujarat.

Source: NABH Accreditation: Victories & Challengeshttp://www.qimpro.com/nabh/project_sterling.php


Sterling Hospital’s ApproachThe Turn around Time is reduced by working

on the bottlenecks of the process through DMAIC Approach.

D = DefineM = MeasureA = AnalyseI = ImproveC = Control


Results

150 Minutes •Reduced Discharge Time from approx. 300 minutes to 150 minutes

80Beds

•This enhanced the capacity of the hospital for admitting additional patients by 80 Beds per Year

•The hospital increased its profitability by approximately Rs 32 Lakhs per annum

AIM OF HEALTH CARE DELIVERY

HEALING

SATISFACTION

DEFINITION

Discharge from the hospital is the point at which the patient leaves the hospital and either returns home or is transferred to another facility such as one for rehabilitation or to a nursing home.

Discharge planning is a service that considers the patient's needs after the hospital stay, and may involve several different services such as visiting nursing care, physical therapy, and home blood drawing.

PURPOSE

In any hospital, time taken for Discharge process is a key indicator for efficiency, quality and patient satisfaction, etc.

The delays led to increased process time and reduced patient satisfaction which was evident from the patient satisfaction survey.

Rectifying the delay points reduces the process time which results in improved discharge process

DEPARTMENTS INVOLVED

Consultants/Residents and DMO’s.Patient Care Executive Dept.House keeping Dept.Nursing Dept.Typing Pool.Billing Dept.Internal Audit Dept.Insurance Dept.Corporate Dept.Security Dept.

PROCESS FLOW CHART OF DISCHARGE

Continued……

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cash54%credit

21%

in-suran

ce25%

Distribution of sample size

cashcreditinsurance

Sample

DISCHARGE SUMMARY PREPARATION PROCESS FLOW

Major Causes of Delay in Discharge process

Analysis:

Total

DISCHARGE SUMMARYOTHERSPHARMACY CLEARANCE

Pharmacy Clearance44.4%

Discharge Summary Preparation

45%

Others10.6%

DISCHARGE SUMMARY PREPARATION

More Time is consuming in preparation of Discharge summary

Analysis:

Summary of Analysis: DMO’s getting difficult to understand consultants handwriting.

Incomplete case sheets

No Departments DMO.

Residents are often in the OT. Results in delays in writing of discharge summaries.

Prior Discharge planning is Non-existent


1. DMO’s/Residents should type summary

Suggestions

Can reduce manual work by Typists and Transport Boys

Reduce Turn Around Time by eliminating many steps in the process

Reduce Errors


1. DMO’s/Residents should type summary

Suggestions

Alternative:Allocate one DMO per day to sit beside the typist and make Corrections simultaneously.

Floor DMO should be given some Departments.

Standardize work for Night DMO’s.


2. Standardize Discharge format for various departments and type of patients

Suggestions

Departments to provide:• Fill in the Blanks format• Headings• Topics specific to particular department• Template can be prepared for all the departments.


3. Discharge summary should be send online to Insurance Dept.

Suggestions

Current Process:The Final, Corrected Discharge summary is sentby the Typists to Insurance manually with a boy

Suggested Process:Sending discharge summary online would speed up the process


4. Changes in HIMS- A checkbox should be placed to indicate final, corrected copy

of discharge

Why?So that Insurance and Billing understand that this is the final version and can proceed with billing without waiting for discharge summary to arrive manually.

- Time of completion of discharge summary should be captured in the system

Suggestions


5. Consider using Dragon.

Suggestions

Dragon NaturallySpeaking – Demonstration (by Nuance)

https://www.youtube.com/watch?v=SMuU8OeJ2kk&t=81

PHARMACY CLEARANCE

PHARMACY CLEARANCE

Analysis:

Departments causing delay

Nu

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er

of

pati

en

ts

Conclusion:Up to 45% of delays are due to pharmacy clearance !

DIALYSIS CLEARANCE PAYMENT PHARMACY CLEARANCE0

2

4

6

8

10

12 Total

Total

PHARMACY CLEARANCE

1.Returns of unused Drugs should be avoided when a patient is shifted from one unit to another.

Suggestions

Current Process: Whenever a patient is shifted from one unit to another, his unused medications are returned to the pharmacy. - This increases the pharmacy’s workload.- Pharmacy is unable to prioritise medication returns for discharged patients

Suggested Process: Unused medications should be handed over to the receiving unit when a patient is shifted

PHARMACY CLEARANCE

2. Daily Returns of unused Drugs should be avoided.

Suggestions

Current Process:Unused drugs are returned to the pharmacy. Returns are being made at all times of the day.

Suggested Process:EITHER

Stop/Avoid returning unused drugs until the patient is being discharged. On discharge day, the amount for returned medicines is reduced from his bill.

ORLimit daily returns to Evenings/Nights to allow the pharmacy to prioritize discharge related returns in the mornings.

PHARMACY CLEARANCE

3.Stock level should be there, so that discharge medications did not get delay in dispensing.

Suggestions

In upto 10% or more patients being discharged, the medications to be taken by the patients at home are not available in the Pharmacy. These medications have to be brought from the central pharmacy resulting in delays. This is especially important for insurance/scheme patients for whom only certain brands of medication are prescribed.Suggestion:

IP Pharmacy should analyse its inventory levels for various discharge medications and maintain an increased stock of the ones that are frequently found to be unavailable

PHARMACY CLEARANCE

4.Pharmacy clearance copy can be send online to Billing Dept.

Suggestions

Current Process:IP Pharmacy sends clearance slip manually. Meanwhile billing people call up the pharmacy by phone to ask the amount. The billing personnel use the amount told to them over phone for billing purposes. The clearance slip from IP Pharmacy itself arrives much later.

Suggested ProcessChanges in HIMS- IP Pharmacy should be able to provide the IP Pharmacy clearance online- A checkbox should be placed to indicate final, corrected IP Pharmacy clearenceWhy? So that Insurance and Billing understand that this is the final version and can proceed with billing without waiting for Pharmacy clearence to arrive manually.- Time of completion of discharge summary should be captured in the system

PHARMACY CLEARANCE

5.Set turn Around Time for Nurses for sending Returns, especially those for discharged patients.

Suggestions

Suggested Process:

• Evenings time should be allotted to nurses to return the unused medications to the IP pharmacy.

• In nights separate time should be allotted for indents and returns.

PHARMACY CLEARANCE

6.When a patient has received drugs from both Block 3 and Block 1 Pharmacies, he is required to obtain two separate pharmacy clearances.

Suggestions

Suggestion: -Centralise the pharmacy clearance so that only one pharmacy can give clearance for patients. Patients whose last unit of stay was in Block 3 should receive clearance from Block 3 pharmacy and those from Block 1 should receive clearance from Block 1 Pharmacy-Make changes in HIMS so that both pharmacies can see when a patient requires clearance from the other pharmacy. An indicator on their screen could be built into the system itself.

PHARMACY CLEARANCE

7.IP Pharmacy not using proper Pneumatic Tube System.

Suggestions

Current Process:IP Pharmacy receives returns of medication manually, which is taking delay. Technical faults makes delay in the improper usage of Pneumatic chute. When find out, the main reasons for technical faults is due to improper users.

Suggested Process

•Training should be given to all the users.• Immediate rectification of the complaints should be there.•Major complaints needs to corrected immediately.

PHARMACY CLEARANCE

8.Nurses should be instructed to avoid rework by sending again and again.

Suggestions

Current Process:Unused medications are physically returned to IP Pharmacy where they are entered as “returns” into HIMS by the pharmacy staff.Suggested Process:Since the nurses indent the medications in the system themselves as of now, a similar module can be created in HIMS for them to enter medication returns. Process can be as follows:Nurse enters retured medicines - A printout with names of returned medicines is generated – printout is sent to IP Pharmacy by pneumatic chute – IP Pharmacy provides discharge clearance - Boy is sent to pharmacy with medications to physically return them - IP Pharmacy verifies the returned medications against the slip sent to them by pneumatic chute earlier.

BILLING PROCESS FLOWCHART

BILLING DEPT.

Any Delay face by Billing do inform Susan and Rajender.

Billing should accept Pharmacy clearance online.

Office Boy should check files every half an hour.

Ensure proper categorization/ordering of files.

Suggestions

INTERNAL AUDIT DEPT.

INTERNAL AUDIT

Analysis:

30 31 32 33 34 35 38 39 40 45 50 52 53 60 610

1

2

3

4

5

6

7

Total

Total

Total 85 patients

1.Case Sheet should be send on time to the Billing Dept.

suggestions:

Current Process:After completion of processing of the case sheet in the Internal Audit. Case sheet is not coming immediately to the Billing Dept.

Suggested Process:Since there is no office Boy in Audit Dept. There should be a Bell system which indicates the processing of case sheet is completed in Audit Dept. When the bell rings, office boy from Billing Dept. goes and collects the Bill and case sheet from the Internal Audit Dept.

2.Lunch Delay should not be there.

suggestions:

Current Process:As there is only one person in the Internal Audit Dept. Delay in Lunch causes accumulation of Bills and case sheets for Auditing. Billing persons creates Bills and sends to the Internal Audit Dept. During Lunch Billing persons always will be there.

Suggested Process:Try to avoid delay in lunch.

Hire extra staff so that there are two instead of one person in the Internal Audit department

3.Keep proper alignment of files and separation by types (trays)

suggestions:

Current Process:Case sheets are coming from the Billing Dept. and keeping one over another. This makes delay in the processing of Case sheet which comes earlier, because it is coming down due to upcoming case sheet on over another.

Suggested Process:There should be a trays systems which determines the Insurance and Corporate patients and there should be proper alignment of case sheet i.e., First comes First Service.

4.Roles to be given to Boy.

suggestions:

5.Order of priority: Cash>Credit>Private Insurance>Govt

Insurance FIFO (First In First Out)

suggestions:

OT CHARGE SHEET PROCESS FLOW

1. Delay is happening due to Implant invoices

Findings & Suggestions:

2. Call suppliers to find out Invoice verbally.


3. Standardize prices for Implants.


4. Invoice list can be prepared online.


5. Purchase dept. can ask for prices before and send list to OT Pharmacy.(can be do online)


6. If manual Bill prepared by OT pharmacy, Invoice is not required.


INSURANCE DEPT. PROCESS FLOW

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1. All the Discharge summaries should get online.

2. Any issues/Delays, please inform to Susan and Rajender.

3. Order of priority for filing of Approval Private insurance> Govt insurance.

Healthcare

Discharge time final