PROJECT LEAD(S):

• Monisha Bhatia, MD – Assistant Professor, Division of Hospital Medicine
• Prashant Patel, DO – Assistant Professor, Division of Hospital Medicine

EXECUTIVE SPONSOR(S):

• Bradley Monash, MD – Vice Chief of Clinical Affairs, Hospital Medicine

ABSTRACT:

Securing on-time discharges improves hospital throughput and optimizes patient flow and capacity. This is especially important during times of high census and ED boarding, which have significant patient experience and safety implications. The Hospital Medicine Service (HMS) cares for the largest volume of patients at UCSF Health, but often faces challenges in securing on-time discharges. Estimated discharge date accuracy for the service was as low as 62% in 2023 while length of stay averaged 8.1 days. Obstruction in on-time discharges often results from (1) variability in discharge planning practice patterns, (2) inadequate alignment among care team members on which patients are expected to discharge, (3) insufficient communication of discharge barriers, and (4) lack of coordination on which team member will complete discharge tasks. Since October 2023, the HMS has piloted the interprofessional “Accelerated Discharge Program,” designed to enhance communication of anticipated discharge and streamline coordination on discharge tasks for patients most likely to discharge. Through the Caring Wisely program, our interprofessional team seeks to expand and sustain several priming, enabling, and reinforcing interventions that will directly target the key root causes of later-than-ideal discharges on the HMS. We ultimately aim to increase the number of on-time discharges, improve EDD accuracy, reduce LOS, and support UCSF’s global capacity optimization efforts.

TEAM:

• Brandon Scott, MD – Director of Value Improvement, Division of Hospital Medicine (DHM), Primary Project Mentor
• Rachel White, MHSA – Quality Improvement Program Manager, DHM, Program Manager
• Connie Li – Clinical Assistant, Goldman Medical Service (DHM), Team Member
• Sarah Apgar, MD – Director, Goldman Medical Service (DHM), Core Advisor
• Ethel Wu, MD – Assistant Director, Goldman Medical Service (DHM), Core Advisor
• Faye Chan, MD – Interim Director, Goldman Medical Service (DHM), Core Advisor
• Lourdes Moldre, RN – Patient Care Director, Interdisciplinary Partner
• James Darby, RN – Parnassus Medicine Unit Director (14L/15L), Interdisciplinary Partner
• Ongoing discussions with Medicine Case Management Leadership and Patient Capacity Management Center leadership on partnership and integration
• Bradley Monash, MD – Vice Chief of Clinical Affairs, DHM, Executive Sponsor

PROBLEM:

UCSF’s Parnassus campus frequently experiences challenges with high capacity necessitating focused efforts to optimize on-time discharges within inpatient care teams.  The quality, safety, and financial consequences of a lower than predicted number of on-time discharges and include but are not limited to:

• Suboptimal patient satisfaction due to prolonged ED and PACU boarding
• Suboptimal care quality and risk of patient safety events, as the number of admitted patients “boarding” in the ED and post-procedural patients boarding in the post-anesthesia care unit (PACU) increases  
• Significant provider burnout and moral distress due to caring for patients in the “wrong care location”
• Limitations in outside hospital transfers, interservice transfers within UCSF, and direct admissions of patients needing UCSF tertiary/quaternary care
• Prolonged length of stay for admitted patients (e.g. discharge barriers not addressed earlier in the admission, thus adding a subsequent day to the patient’s hospitalization for care coordination)

For patients on the HMS, UCSF’s largest service by volume with over 7,000 Parnassus discharges in 2023, many delays in on-time discharge stem from deficiencies in the care team coordination and communication processes. For example:

• HMS multidisciplinary discharge rounds (MDR) is intended to raise awareness of anticipated discharge and discharge coordination needs structurally lack participation from key team members from nursing and rehabilitation colleagues
• On HMS’s Goldman Medical Service (“GMS,” the direct care service) a solo hospitalist must prioritize urgent clinical needs over non-urgent discharge tasks, resulting in later discharges. There is no clear standard work nor guidelines on which interprofessional care team member could or should take on shared discharge tasks which leads to suboptimal discharge task coordination.

TARGET:

• We seek to increase the number of on-time discharges of HMS patients by increasing their Estimated Discharge Date accuracy (“EDD accuracy”) from a baseline of 65% to 70% by supporting primary teams with interprofessional coordination on discharge task management. Specific targets include:
• Early identification of which  patients are discharging and consistent dissemination to multidisciplinary team members
• Streamlined communication about patients most likely to discharge
• Define and assign discharge tasks: identify tasks that delay on-time discharges and help our care team with task management to facilitate smoother discharges, while optimizing role clarity and infrastructure
• Through these interventions we hope to achieve Reduction in Length of Stay (LOS): We anticipate expedited discharge barrier resolution resulting in earlier discharges that will lead in an average length of stay reduction of 0.2 days

GAPS

System issues and technological gaps include:

• Lack of interprofessional identification and consistent messaging of HMS patients who are expected to discharge the following day. Care team members use different platforms to message about discharge barriers, and the Voalte messaging platform does pose challenges to rapid identification of the correct individual to reach.
• Lack of standardized work or interdisciplinary role delineation on discharge task management. There is lack of consensus on which disciplines are responsible for which discharge tasks which risk both diffusion of responsibility as well as inefficient coordination discharge task completion
• Inconsistent use of existing EHR-based tools that can identify accelerated discharge candidates and proactively mobilize resources to support earlier discharges. Multiple EHR tools (like Estimated Discharge Date, Discharge Milestones, and Discharge Comments) exist to promote visibility around discharge planning, but they are inconsistently utilized by care team members.
• High workload for HMS teams in the morning can limit bandwidth for accelerated, earlier discharges. Multiple morning care activities – patient handoffs of overnight admissions, MDR, and rounding on acutely ill patients – can significantly limit the bandwidth of HMS teams to discharge medically stable patients earlier in the day unless proactive support is offered

Educational gaps include:

• Suboptimal HMS team and provider awareness of existing systems that can be proactively mobilized to support accelerated discharges.

INTERVENTION:

In October 2023 we initiated our Accelerated Discharge Program (ADP) pilot on the GMS which involved streamlining outreach to identify likely next day discharges, discharge barriers, and delegate task completion with our Clinical Assistant. Moving forward we will deploy multiple interventions that identify and implement opportunities to connect physicians with additional support to identify, delegate, and address discharge barriers. Our proposed multi-modal interventions will incorporate priming, enabling, and reinforcing tactics to yield sustained improvement.Specifically:

• Development of interprofessional standard work to proactively identify the ADP HMS patients to address discharge barrier prior to EDD. This would include using afternoon tee time (case manager – hospitalist meeting to discuss discharging patients) and the clinical assistant’s recruitment of the “Accelerated Discharge Program” patient(s) to add to a shared, visible APeX list
• Feasible EHR enhancements to existing discharge-focused EHR tools. We have laid the groundwork for cross-disciplinary communication using a radio button or order set to identify early discharges.
• Improve provider education about discharge-focused tools which can be leveraged to confirm and document barriers to discharge/discharge needs
• Augmenting physician-level discharge task completion by supporting hospitalists. This is currently in pilot phase. Multiple DHM hospitalist roles have bandwidth and expertise to assist the primary hospitalists with specific discharge tasks if delegated in an appropriate, timely, and clear fashion
• Data analysis to identify common discharge barriers for ADP patients, documenting which tasks are completed by which interprofessional team member.
• Enhanced provider- and service-line feedback about accelerated discharge efforts
• Development of interprofessional “discharge team.” Recently published literature by Falcetta et al. (Journal of Hospital Medicine, January 2024) saw improvement in length of stay (1.8 days post intervention) attributed to the development of a multiprofessional discharge team dedicated to proactively identifying and intervening on discharge barriers and addressing discharge tasks. Our ADP program is currently integrating HMS’s discharge team with a new Medicine Nursing discharge champion and will expand this scope to other disciplines (e.g., Case Management, Flow Team) to adopt a similar discharge team model proven to reduce length of stay, rates of morning discharges, and bed turnover

PROPOSED EHR MODIFICATIONS:

We will explore the following modifications which may impact EDD accuracy and LOS.

• Addition of “radio buttons” to identify/flag accelerated discharge candidates
• A case management-facing best practice alert to identify accelerated discharge candidates
• Possible modification of standard inpatient progress notes to include discharge barriers
• Reduce redundant areas for interdisciplinary discharge communication (e.g. Discharge Comments, Case Management Discharge Sticky Note)
• Addition of an Accelerated Discharge Order Set

RETURN ON INVESTMENT:

We anticipate the ADP producing cost savings through reduction of length of stay in HMS patients. In the latest analyzed data from our current pilot, we found that from December 2023-January 2024, 64% of the 160 GMS patients identified as possible next day discharged through the ADP actually discharged next day and these next day discharges had an average length of stay of 7.5. This was a 0.2 reduction from the average length of stay of all patients treated by the GMS hospitalists in that same time period (7.7). We identify this 0.2 day reduction in length of stay as a conservative estimate of length of stay reduction opportunity given that these results were based on current ongoing interventions that predate any future support from Caring Wisely.

With Caring Wisely’s support, we anticipate the ability to expand the impact of our efforts as described in our proposal, highlighted by the development of an multiprofessional discharge team and expansion of these efforts to serve the Wards teaching service in addition to GMS. Extrapolating the impact of this work from recent literature, we estimate that an optimistic estimate of reduction in length of stay could be 1.8 days, again as shown by Falcetta et. al.

Collectively, we anticipate direct cost savings to the health system attributed from reduction in HMS length of stay leading to decreased direct variable costs from bed days saved over one year’s time to range from $814,514 (0.2 reduction in length of stay for GMS service) to $13,363,219 (1.8 reduction in length of stay for GMS and Wards teaching service) as outlined in Tables 1 and 2 (see attached documents). True financial impact  expected to exceed these figures as these estimates do not consider savings from additional cost of care delivery beyond direct variable cost of a bed nor increase in revenue/contribution margin arising from backfill as UCSF Health Parnassus Heights’ hospital capacity increases as a direct result from the accelerated discharge program.

SUSTAINABILITY:

• We aim to intentionally implement interventions that integrate into existing resources/processes and care team members (e.g. Case Management MDR and tee time, Flow Control Team rounding, GMS clinical assistant, EDD and Discharge Report APeX tools, CARTBoard and enterprise throughput dashboards) to ensure long-term sustainability . The Caring Wisely funding year will be utilized to establish successful standard work that can be feasibly adopted by current process owners for hospital discharges and throughput and once adopted will not require ongoing support for maintenance. We anticipate success in this project to lead to adoption of ADP core features by other service lines.
• We believe our interventions will be able to achieve sustained cost-savings without the need to hire additional care team members. Our goal is to better leverage, connect, and streamline our existing processes to produce faster, safer, and higher quality discharges for patients and care providers alike through communication practices, establishing norms, and APeX enhancements as described above.

BUDGET:

• $40,000 – effort for project lead(s)
• $5,000 – reserved for as-needed clinical informatics support (e.g. data analysis, EHR modifications
  
• $5,000 – reserved for as-needed pilot financial incentives that award early discharges