Average Time of Discharge: Why a Hospital is Not a Hilton

Do you get as annoyed as I do about being pressured on your “Time of Discharge?” I just received my monthly report, and we’re in The Doghouse again: our average TOD – 3:28 pm – is hours after “check-out time.”

But when did we turn into the Holiday Inn?

Let’s start by appreciating where this comes from. Many hospitals, including mine, tend to run full – given the huge fixed costs of operating a modern hospital, being full is probably the only way you can be profitable, just like the airlines. Queuing theory (don’t tell me you’ve forgotten your queuing theory!) tells us that, when you’re full, you should look for fundamental choke points and do your best to relieve them. There are PhDs working for McDonald’s whose lives are dedicated to figuring out how to avoid lines at lunchtime rush hour, and others working in aviation who model the best ways to load passengers onto planes (latest answer courtesy of a Fermi Lab astrophysicist: start in the back and load every third row, back to front, sequentially). 

The main stenosis in hospitals occurs in the early afternoon: the morning’s OR cases are finishing, the ED is heating up, the clinics are sending over elective and urgent admissions, the respiratory therapists have done their weaning and “liberated” a few patients from vents… and everybody needs a floor bed. Now! But they’re all taken, since nobody’s gone home yet.

Gridlock. Bad for business.

How do you fix this? About a decade ago, some smart consultant (I can’t figure out who, but he or she must have had a terrific PowerPoint slide making this point since every hospital I know of picked up on it) came up with the solution: let’s measure and report the time of discharge by service, shining the holy light of transparency on service chiefs like me to get them cracking. And since everybody likes Goals, how about we set a guideline – “The Discharge Time on 5 South is 11 am” – and post it in every room and nurse’s station. Then it won’t be a shocker to the patients when we try to hustle grandma into the wheelchair and roll her out of her room before noon.

This all seems fine so far, particularly if I’m the COO or CFO. But from what I’ve seen visiting scores of hospitals in the U.S., achieving an 11 am discharge time, at least on medical services, is all-but-impossible. (If your hospital has met this goal, particularly on a medical service, I’d love to hear about it.) Why is this so hard, naturally asks the C-Suite Folks, who sees “good business” being turned away because sluggish physicians aren’t getting with the discharge-time program?

Because a Hospital is not a Hilton. If I have 14 patients on my service, my mornings are spent running around seeing them all, waiting for their labs, checking in with consultants, talking to family members and primary care physicians, and more. I’m also prioritizing my work – though the hospital undoubtedly wants me to see potentially discharge-able patients first, that violates the first rule of triage: see my sickest patients first. Until the cloning thing gets a bit more advanced, I can’t do both.

In other words, the morning of discharge is an amazingly active time – whereas, at the Hilton, I just have to get up, pack my bag, finish my brunch, ready my USA Today, and I’m A La Casa. Moreover, the Hilton might hit me up for an extra $225 if I don’t get out on time.

All of this makes the hotel analogy fundamentally flawed.

For certain patients, of course, the morning may not be quite so active, and an 11 am checkout might be quite do-able. On surgical services, for example, discharge might hinge simply on whether Mrs. Jones has bowel sounds and kept down her breakfast; on medicine, on whether Mr. Diaz can walk or is no longer confused. But these patients, who can leave by 11, are the outliers.

In fact, with lengths of stay as short as they are now, the morning of discharge is not just active, it is hyperactive. So when I am pressured to “improve” my time of discharge, I usually respond, “If you’d like, I can move the average discharge time up to 8 am. It’ll just be one day later than I had planned.” CFOs don’t like to hear that.

Which brings me to my final plea: I believe it should be illegal to report Time of Discharge without also – in the same document – reporting adjusted average length of stay (or LOS against appropriate benchmarks). Time of discharge and ALOS are inextricably linked. The service that has a long length of stay AND a late discharge time might really have a problem. But the service with a short length of stay and a late discharge time is probably doing very good work, and harassing it over its TOD is annoying and counterproductive.

Can any good come out of the focus on time of discharge? Sure. Late discharges sometimes truly do highlight systems problems that need fixin’ – the teaching service that should be restructured so that the attending “card flips” with the housestaff to identify potential discharges before teaching rounds; the lab that needs to get its morning blood work out by 9 am, not 10:30; the social work/case management enterprise that needs streamlining. In such cases, the average discharge time can be a useful metric for QI projects that map out the mornings and shave some minutes here and there. And preparing patients and families the night before for a potential discharge makes good sense.

But just pressuring docs with a flawed and all-but-irrelevant hotel analogy – particularly when the data are presented without also considering performance on overall length of stay – is just plain silly.

Robert Wachter is widely regarded as a leading figure in the modern patient safety  movement. Together with Dr. Lee Goldman, he coined the term "hospitalist" in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as "an epidemic" facing American hospitals. His posts appear semi-regularly on THCB and on his own blog, "Wachter’s World."

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  1. I can appreciate all of the above comments but in a nutshell, it all boils down to co-ordinating all departments and having the Physician’s on board. A bad plan is better than no plan because at least with a bad plan you are attempting to address a problem and can improve on it.

  2. Is it the Hilton? Certainly not. There are very few who could afford the $1000+ in daily bed charges on vacation. Society has expectations. Pre MBA school I called it “one-stop shopping”. Post it is known as moral hazzard. “Can I get my colonoscopy today because I was scheduled for on at the end of the month anyway?” are all too famliar requests from those with insurance (Medicaid HMO or not).
    On the hospital side, any good CFO worth their salt will you that turn around time and “appropriate utilization” is key in driving the budget forward. A selling feature of the hospitalist. But, maybe the CFO doesn’t believe it and has to hear this from an overpaid consultant touting the latest software and is convinced many thousands of dollars later (nature of the CFO to see it in dollars and cents). Of course, this is after the beautifully presented power point presentation confirms that the average MD makes his hospital rounds around his “business” not theirs.
    But, let’s say you are the average patient with or without insurance; your driving factor is to get the out of hospital as fast as you can (for most) feeling better or with a plan for what to do when you get home. My question then becomes; why is the day of discharge so “hyperactive”? This totally goes against many manufacturing models that gets applied to healthcare. That is the inherent trouble with applying these models to living organisms.
    My initial response is that many physicians and hospital staff make it that way. It goes back to training and that allocation of their time and resources are not equal.
    A little pearl: a key element to a happy patient is one that is prepared for their discharge before the day they leave. Hospitalists have it bad from this perspective. A new doctor who is telling them what to do the day they leave who no perceived investment in their tomorrow (just check their customer satisfaction scores). So get your rounds together, provide consistency, spend TIME with your patient sooner than later (yes, because it really does make your time spent on the day of discharge better…check the literature). Days of the “drive by rounds” will be coming to an end soon with reimbursement restructuring. Not to mention it may be why most of us entered the field in the first place. Seems like it is time to stop blaming the “system, process, hospital” for doing what we should have been doing all along.

  3. Of Hospitals and Airlines
    [A Dissimilar Fixed-Cost Structure Argument]
    Now, here’s my take on the airline analogy – and Bob Wachter is pretty much correct on this point – hospitals and healthcare is different; very different regarding its cost structure.
    For example, Bob stated in his post:
    “Let’s start by appreciating where this [airline analogy] comes from. Many hospitals, including mine, tend to run full – given the huge fixed costs of operating a modern hospital, being full is probably the only way you can be profitable, just like the airlines.”
    And, then he also says:
    “Queuing theory (don’t tell me you’ve forgotten your queuing theory!) tells us that, when you’re full, you should look for fundamental choke points and do your best to relieve them.”
    Well, true enough, but there is more to it than just queuing theory and capacity. It’s about human psychology and behavioral theory, as well. So let’s examine the airline analogy, relative to hospital under-capacity and health plan contracts and Medicare reimbursements for a moment. Why?
    Because most hospitals ought not [should not] be operating at full capacity, and maybe the best patient care is driven by demand (needs) – and not the supply driven (wants) of administrators, stockholders and private [physician owned] hospitals and/or other stakeholders.
    Of course, a pragmatic caveat worth noting is that even not-for-profit entities are affected by similar funding and capacity issues relative to foundation grants, etc. And, I am certainly a humane capitalist at heart, so let us examine this model further.
    The “Faux” Airline Scenario
    If an airplane has a single remaining seat, it can be sold at a last-minute discount, and still make a profit, since the fixed costs are covered and the plane will fly regardless of under capacity. Therefore, hospital administrators and MBAs argue that they should strive to fill every bed, all the time – right? This might be called the fix-cost scenario. But, it is a faux one. Again … Why?
    It’s because MBAs have a cost-volume-profit-analysis (CPVA) or merchandising / manufacturing bias from B-school that is not so easily transferable to the medical services sector. Bob rightfully illustrates this with his everyday examples as a patient-discharging hospitalist [hotel model].
    Now, further appreciate that the less than full airplane may make a return flight at full business fare to recoup the discount loss in our example.
    The Healthcare Difference
    Not so – in the services or healthcare sector, however!
    Once locked into a managed care plan, Medicare RRG payment schedule or new MS-DRG reimbursement scheme, no similar upward pricing pressure is available. Competition is not free. Thus, the airplane scenario is wrong; ceteris paribus.
    Still, traditional healthcare administrators or management gurus counter that a discounted patient in a hospital bed is better than no patient at all.
    The reason? Again, it’s because more services can be supplied for additional profit? This is the stuff of CVPA, marginal costs and marginal revenues.
    For example, I recently utilization reviewed [UR’d] a case where a lovely, but unsophisticated patient, was hospitalized two weeks for an uneventful and solitary pinky toe amputation; under general anesthesia.
    Of course, she also had bilateral prophylactic mammograms “just in case” – and – hyperbaric oxygenation therapy despite great circulation and pedal profusion. Throw in some respiratory and physical therapy to assist her breathing and ambulation. Oh, don’t forget the blood transfusion for the mild anemia of chronic disease that her longtime GP knew of, and was heretofore unconcerned.
    Pre-Disease Fear Factor
    But, here it comes – the supply-side pitch – “we better check it all out because you sure don’t want to loose your leg – do you?” Over-treated, only because she was a middle-aged stable diabetic patient, who happened to have health insurance. She is doing fine to the best of my understanding and retrospective utilization review, five years later.
    So, supply {legal and/or misplaced caution} side economics does rule in some instances; and beyond appropriate [demand] care. And, more care is not necessarily better medical care, as oft iterated.
    Now, extending our airline analogy back to the business of medicine; suppose your empty hospital bed, medical treatment room or office time-slot was occupied by a non-compliant and litigation prone patient? Economic considerations aside, don’t the potential medical, legal and emotional entanglements of these situations exceed their marginal benefit?
    Philosophically, one could argue that these possibilities also exist in full fee-for-service environment [full business class plane ticket price] and be quite correct. Therefore, rest assured that I don’t advocate the wholesale non-treatment of patients in real need. I am noting the dual and conflicting capitalistic and very demoralizing human feelings of “why bother.”
    Or – shall we doctors and medical providers accept the socialistic epistemology of laborers who “pretend to work, while the government/third parties pretend to pay?”
    Indeed – Bob is right as he stated elsewhere – a hospital is not a Hilton Hotel. And, allow me to add … the healthcare industry is not the airline industry (thank goodness).
    At the same time, medical professionals are struggling to maintain adequate incomes and a certain level of real or perceived “success.” While some specialties flourish, others like primary care barely moved forward, not even incrementally keeping up with inflation.
    In the words of Atul Gawande, MD, a surgical resident at Brigham and Women’s Hospital in Boston, and one of the best young medical writers in America, “Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice”.
    And so, perhaps different definition should emerges which entails a very unusual concept of medical practice “business success.”
    But, here is the rub of the patient-centric model of healthcare under my new paradigm as “king of the world”. The efficient hospital or medical practice is “not necessarily the one that makes the most profit -rather it is the one that produces the most profit at the most appropriate level of patient care and service.”
    In other words, the futuristic highly efficient physician – or hospital – may be deemed prosperous and “successful” if only 90% of the prior year’s profit is made. Yet, has an office face time – or has a hospital bed capacity – of only 70%.
    Then, perhaps we can afford appropriate healthcare for more of our citizenry, and those doctors so-inclined [not me], will have more time for the golf course?
    Candor, intelligence and goodwill to all!
    Your thoughts and comments are appreciated.
    More info: http://www.springerpub.com/prod.aspx?prod_id=23759
    Institutional: http://www.HealthcareFinancials.com
    Terms: http://www.HealthDictionarySeries.com
    Dr. David Edward Marcinko; MBA
    Chief Executive Officer

  4. Of Hospitals and Hotels,
    I read with interest – and a bit of sad amuse’ – the above post by Bob Wachter and felt compelled to respond affirmatively to his comments … and more!
    As you may know from my prior posts elsewhere, speaking engagements and books, I am a big Bob fan [although not necessarily of the hospitalist movement] referencing him from our material on http://www.MedicalBusinessAdvisors.com and http://www.HealthDictionarySeries.com and periodicals like http://www.HealthCareFinancials.com where I serve as Editor-in-Chief.
    Moreover, his interests seem to be favoring a more process-driven and quality improvement zeitgeist that’s in the long-term best interest of all of us.
    So, what he says about the sad state of hospital discharge planning is not only true in my experience, but nothing new for the industry and hence the cause of my dismay.
    Unfortunately, it seems that sans some disruptive influence that overcomes inertia; little seems to change in the healthcare industry status quo.
    Hopefully, Bob’s notoriety will help change the discharge practice situation he highlights; while my personal industry infamy serves to reinforce similar bottleneck situations that not only impact the bottom line – but patient safety – as well.
    After all, these issues have plagued hospitals for decades now, and are often accepted as de rigor. However they should not be; for example:
    1. The July starting point conundrum for training new hospital interns, residents and fellows.
    2. End-of-shift nurse “reporting” and (mis) communications.
    3. Weekend or “after hour” admissions and departmental scheduling.
    4. Similarly named patient and drug mix-ups.
    5. Wrong site surgery; lost or stolen infants, etc
    Yes, some issues are being address with powerful information technology systems. But, do we really need RFID tags to ensure proper side surgery, or bar codes bracelets for newborns?
    As for me, I helped deliver my daughter and immediately splashed a (far-too-large) swatch of gentian-violet on her left heel as an identifier; cheap … effective … simple.
    And, these other issues might be alleviated with some managerial common sense; along with a dose of mindset change.
    Well, for starters, how abut staggering employee schedules; providing rolling medical student admissions; placing name tag warnings on patient room doors and extremities [HIPPA be darned] and/or the timely outsourcing of laboratory/pathology and other off-hour hospital services?
    And yep, even my infamous gentian-violet episode is discussed years later, as -um- “insightful.”
    Candor, intelligence and goodwill to all!
    Dr. David Edward Marcinko; MBA
    Atlanta, Georgia USA

  5. Hmmm! Planning this tight may indicate that we really aren’t supporting enough capacity.
    The Hilton may have an 11 AM check out but I have only rarely been booted from a hotel because I overslept. Its bad for business.
    But then hospitals are mainly pleasing insurance companies and the government by delivering services at low prices.

  6. OK, Bob, it’s not a hotel. But if poor co-ordination at discharge causes the entire system to back up, and shuts down the ER, it can actually kill people who get redirected. Conveniently, those deaths occur on someone else’s watch. This process is a clusterfuck nearly everywhere, and the reason is that almost nobody in the relevant hospital departments actually cares if the patient goes home on time. It’s not like patients or their families want to stay in the hospital, and to them, the process is maddeningly vague and bureaucratic.
    The term “discharge planning” reminds me a lot of what chemical plants do w/ toxic waste, and the real tragedy isn’t stressing out the doctors. It’s that “toss the body over the fence” feeling the family gets when they realize that, upon “discharge”, THEY are now the care manager for the patient and that their hospital and “team” of doctors really doesn’t care what happens to them after they roll out the door.

  7. I’ve got the argument against Robert. The metric that you’re looking for is the average number of patients moved in/out per hour and the variation associated with it. One would assume that between 9am and 9pm it will be n +/- x patients per hour. The optimal system is one-piece work flow, in other words, one patient in, one patient out (low variation of x-value on an hourly basis). This optimizes the workload on the hospital resources and keeps patients happy. It’s well proven that low variation in work-flow causes increases in efficiency (in any queuing model).
    What the 11am brainiac has done (other than make me get up at 7am every Saturday) is to switch the entire hospital to batch processing which is notoriously inefficient because it increases variation. I think they do it to somehow help plan staffing. The time of discharges will vary floor to floor (medical will be driven by ICU and emerg whereas surgery by the OR) so have them do stepped discharges. It may actually save them money 😉 I have some queuing add-ons – if you every feel inclined email me and we can run some models to see how it works out.

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