European Journal of Cardiovascular Medicine

playing an important role in the modern society.¹ Among various factors affecting the health care system, discharge process is one of the important factors related to patient satisfaction.² It is the process that occurs when the patient leaves the facility. It implies that the patient has previously been admitted to the facility. As the final step in the hospital experience, the discharge process is likely to be well remembered by the patient.³ Even if everything else went satisfactorily, a slow, frustrating discharge process can result in low patient satisfaction. It is an important area which touches the patients’ emotion; influence the image of the hospital and patient satisfaction. ⁴ Therefore, the demand for effective health services is ever increasing.

The hospitalization process has three main stages: an admission, an inpatient period and a final stage with the discharge process. An inefficient bed management in any of the three stages of the hospitalization can cause a mismatch between demand and capacity. ⁵ It has been proved that when bed demand exceeds capacity, patient admissions and scheduled surgical procedures can be delayed or cancelled. ⁶ Moreover, the discharge process should start at the point of admission in the case of planned admissions, as in some cases the estimated length of stay without a medical complication is known. ⁷

All admissions and discharges of the hospital should be centrally managed⁸ and planned, as single-department solutions may create or worsen bottlenecks in other areas. During the hospitalization process, patient flow is a strategic aim for the healthcare enterprise. ⁹ Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Information is the foundation of any patient flow initiative. Patient flow is built upon the capture, integration and sharing of information, both within and across the different departments and staff¹⁰.

Therefore this time management study on discharge process is undertaken with the aim of giving better services for the patient satisfaction within the minimum time. This can be done only with the help of thorough study of time taken for the whole discharge process beginning from Discharge order time till the patient leaves the Hospital.

It is a prospective interventional study was carried out in Nizam’s Institute of Medical Science, a tertiary care teaching hospital located in Hyderabad, Telangana, India.

Various elements of discharge process are studied using data collection forms which were developed suing Time Motion Study, enclosed in annexure 1 and 2 designed as per events in discharge process. Discharge time is calculated for study sample and steps contributing to delays are noted.

Based on the steps contributing to delay, possible interventions are planned and implemented to reduce the delays at necessary steps of discharge flow. The difference of time taken in discharge process before and after intervening is analyzed. The intervention steps contributing to maximum benefit to reduce the total discharge time will be suggested for implementation by the institute.

The present study involves the population group which includes any patient being discharged from Hospital. The following inclusion and exclusion criteria will be considered while drawing the sample.

Inclusion criteria:

• Paying and credit patients under Aarogyasri(ARSR) being discharged during the study period

Exclusion criteria

• Credit Discharges other than ARSR

    STATISTICAL ANALYSIS:

Data on discharge process of patients being discharged from different wards before and after intervening is collected by trained health care management graduates. Data collectors were pre-trained in an effort to ensure uniformity in data collection using data collection forms enclosed in Annexure 1 and 2. Collected data is compiled and analyzed using descriptive statistics in MS Excel 2010.

Table 1: Comparision of Mean Times taken for each step of the discharge process for PAYING patients.

Table 2. Comparison of Mean Time taken for each step of the discharge process for ARSR patients:

Fig.1: Graphical representation of time taken for each intermediary step in the discharge process of PAYING patients before and after Interventions

Step 1: Mean time to receive discharge summary.

Step 2: Mean time to obtain Xerox copies from the time of receiving discharge summary.

Step 3: mean time taken to file the case sheet from the time of receiving discharge summary

Step 4: Mean time taken for initiation of billing process.

Step 5: Mean time taken for completion of billing process.

Step 6: Mean time taken by patient’s attendant to clear the bill.

Step 7: Mena time taken for the patient to move out of ward from time of submission of No dues.

Step 8: Overall Time taken for the discharge process from the time of Discharge order.

Step 1: Mean time to receive discharge summary.

Step 2: Mean time to obtain Xerox copies from the time of receiving discharge summary.

Step 3: Mean time taken to file the case sheet from the time of receiving discharge summary.

Step 4: Mean time taken to submit the case sheet in ARSR office.

Step 5: Mean time taken for verification of documents.

Step 6: Mean time taken for completion of scanning the case sheet.

Step 7: Mean time to send the case sheet to Billing.

Step 8: Mean time taken for completion of billing.

Step 9: Mean time taken for the generation of No Dues.

Step 10: Mean time taken for the patient to vacate the bed from the time of no due’s generation.

Step 11: Mean of Total time taken for discharge.

According to a 1988 survey of discharge planners in 229 California hospitals found that 52.4% of hospitals located discharge planning services within the social service department, 31.4% in administrative department and 16.1% in a nursing a department. The above study shows that most of the hospitals in California accept discharge process as one of the objectives in hospital organisation. Therefore, if we consider discharge process as an objective in our hospital organisation, we can definitely strive to achieve the targets effectively and efficiently. During my study I have observed that discharge process was not included as an objective of any of the departments of the Institute. It is one of the functions of the ward.

The discharge process would be initiated during clinical rounds when patients fit for discharge would be identified by the consultant. The junior resident initiates the task of writing the discharge summary after the end of the rounds. It is observed in my study that the basic step to reduce the overall discharge time is by providing the discharge summary at the earliest.

By intervening on this single step, it has been observed that the average time of discharge process can be reduced by more than an hour. Some of the discharge summaries are hand written and some are typed. The hand written summaries are entrusted to the personal secretary or assistant of the department concerned either by the junior resident or the class IV employee of the ward. Immediate availability of the class IV employee was observed as an issue since he/ she would be multitasking in the ward functions. The discharge summaries are typed by the personal secretary in the department office who would also be attending to other works of the department.

The staff nurse would telephonically check the progress of the discharge summaries to be typed at her convenience and wait for the class IV employee to fetch them to the ward.

After the patient attendant gets the photocopies, the patient’s case sheet, along with the folder was sent to the billing section by the staff nurse. Again, waiting for a class IV employee was identified as a bottle neck. It was noted that up to date billing was not done on a daily basis in the ward concerned. The reported reason was lack of sufficient staff.

In case of the patients who were admitted under the government sponsored health insurance scheme, Aarogyasri, the patient’s case sheet is first sent to the Aarogyasri office. The entire case sheet is scanned by the Data Entry Operators. The case sheets would be returned to the respective wards in case of insufficient documentation of data. It was observed that 18% of the case sheets received by DEO are lacking all the evidences and are being returned to the concerned ward. After the end of the scanning, the case sheets are stamped and signed by the medical officer concerned. These case sheets are sent to the billing section. Availability of class IV employee was again the issue causing delay.

The case sheets are processed by a billing clerk specific to Arogyasri cases which are then handed over to the cash counter. It was identified that there was only one billing clerk attending to arogyasri cases who would not be available on Sundays.

The staff nurse would track the discharges by telephoning the billing section intermittently during the day. Due to pressure on bed availability, often the discharges in line are tracked in a reactive manner to provide bed to new admissions. There is no flow of information to the next source in the process map. The need for a hospital discharge co-ordinator was recognised as a need during the study.

The patient is discharged once the patient hands over the ‘no dues’ slip to the ward nurse. The patient’s discharge summary is handed over to him along with instructions regarding medications.

Some of the delays encountered at this stage were, the credit patients awaiting his medications to be issued from the hospital pharmacy, the patient and his attendant waiting for their personal transportation. Some of the patients were also requesting for an overnight stay due to prior transport arrangements made for the next day morning.

The issues of poor communication and poor organisational co-ordination were already identified as bottle necks in discharge process ⁷

In conclusion, the discharge process at Nizams Institute of Medical Sciences demonstrates that targeted interventions can significantly streamline discharge workflows, reduce delays, and improve bed availability. This study identified inefficiencies primarily due to the lack of dedicated discharge coordination, inadequate staffing, and bottlenecks in document handling. Implementing a structured discharge coordinator role, enhancing communication across departments, and optimizing task allocation among ward staff could substantially improve discharge timelines. By adopting these recommendations, hospitals can enhance patient satisfaction and operational efficiency, better supporting overall patient care and resource management.

1. Mogli GD(20001), Medical Record Organization and Management, Jaypee Brothers, Medical Publishers Pvt Ltd: New Delhi
2. Sakharkar B.M(1998), Principles of Hospital Administration and Planning, 1st edition, Jaypeee Brothers, Medical Publishers Pvt Ltd: New Delhi
3. Goel S.L and Kumar R, Hospital Administration and Management, Deep and Deep publications: New Delhi.
4. Hendrich AL, Lee N: Intra-Unit Patient Transports: Time, Motion, and Cost Impact on Hospital Efficiency. Nurs Econ 2005, 23:157–64.
5. Allder S, Silvester K, Walley P: Understanding the current state of patient flow in a hospital. Clin Med 2010, 10:441–4.
6. Management B: Review of national findings. National Health Service of England and Wales: Audit Commission; 2003.
7. Management of admission in acute hospitals: Review of the national findings. National Health Service of England and Wales: Healthcare Commission; 2006.
8. Howell E, Bessman E, Kravet S, Kolodner K, Marshall R, Wright S: Active bed management by hospitalists and emergency department throughput. Ann Intern Med 2008, 149:804–11.
9. Tamames S, Perez Rubio A, Castrodeza Sanz J, Canton Alvarez MB, Luquero FJ, Santos Sanz S, Lopez Encinar P, de la Torre Pardo MP, Gil Gonzalez JM: Factors associated with the appropriate use of preoperatory hospital stays: historical cohort study. BMC Health Serv Res 2007, 7:187.
10. Ronen B, Pliskin J, Pass S: Effects of Fluctuations, Variability, and Uncertainty on the System. In Focused Operations Management for Health Services Organizations. Edited by Wiley. San Francisco, CA: Jossey-Bass a Wiley Inprint; 2006:219–35.
11. 10 High Impact Changes for service improvement and delivery: a guide for NHS Readers: NHS Modernisation Agency. 2011. http://www.ogc.gov.uk/ documents/Health_High_Impact_Changes.pdf.
12. Black D, Pearson M: Average length of stay, delayed discharge and hospital congestion. Br Med J 2002, 325:610–1.
13. Zwarenstein M, Goldman J, Reeves S: Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2009, 8:CD000072.
14. Blegen MA, Sehgal NL, Alldredge BK, Gearhart S, Auerbach AA, Wachter RA: Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project. Postgrad Med J 2010, 86:729–33.
15. Proudlove N, Boaden R, Jorgensen J: Developing bed managers: the why and the how. J Nurs Manag 2007, 15:34–42.
16. Salazar A: Gestión centralizada de los ingresos hospitalarios: modelo de priorización de camas. Emergencias 2008, 2(suppl 1):1–3.
17. Mahaffey S: Optimizing patient flow in the enterprise. Hospitals can combine process management with information technology to redesign patient flow for maximum efficiency and clinical outcomes. Health Manag Technol 2004, 25:34–6.
18. Anderson P, Meara J, Brodhurst S, Attwood S, Timbrell M, Gatherer A. Use of hospital beds: a cohort study of admissions to a provincial teaching hospital. BMJ. 1998;297(6653):910-2.

19. Carey MR, Sheth H, Braithwaite S. A prospective study of reasons for prolonged hospitalizations on a general medicine teaching service. J Gen Intern Med. 2005:20(2):108-15.
20. McDonagh SM, Smith DH, Goddard M. Measuring appropriate use of acute beds: a systematic review of methods and results. Health Policy. 2000;53(3):157-84.
21. McClaran J, Tover-Berglas R, Glass KC. Chronic status patients in a university hospital: bed-day utilization and length of stay. CMAJ. 1991;145(10):1259-65.
22. Panis LJGG, Gooskens M, Verheggen FWSM, Pop P, Prins MH. Predictors of inappropriate hospital stay: a clinical case study. Int J Qual Health Care. 2003;15(1)57-65.
23. Ahmad A, Purewal TS, Sharma D, Weston PJ. The impact of twicedaily consultant ward rounds on the length of stay in two general medical wards. Clin Med 2011;11:524–8.
24. Tennier, Linda D. 1997. “Discharge Planning: An Examination of the Perceptions and Recommendations for Improved Discharge Planning at the Montreal General            ” Social Work in Health Care. 26(1):41-60.
25. Oldfield, Peggy. 2006. “Tools to Predict Survival.” American Journal of Nursing. 106(2):72A-72G. Literature Review November 2006 22
26. Lipson, Amy R. 2006. “’My Mother’s Leaving Today?’: A Pilot Study on Awareness of Discharge Date in the Chronically Critically Ill.” MEDSURG            15(1):8-13.
27. Kadushin, Goldie & Regina Kulys. 1993. “Discharge Planning Revisited: What Do Social Workers Actually Do in Discharge Planning?” Social Work. 38(6):713-726.           Literature Review November 2006 21
28. Iglehart, Alfreda P. 1990. “Discharge Planning: Professional Perspective versus Organizational Effects.” Health & Social Work. 15(4):301-309.
29. Holland, Diane E. et al. 2006. “Development and Validation of a Screen for Specialized Discharge Planning Services.” Nursing Research. 55(1):62-71.