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."