Don’t let me be misunderstood: Discharge before noon measure

If you are a hospital administrator or a hospitalist leader, you most likely have an early discharge measure included in your hospitalist team performance scorecard. Despite its prevalence in judging hospitalist team performance, I find this measure to be the most misunderstood and misused. So, before you include an early discharge measure in your scorecard, take time to understand it.

Why are early discharges important to hospitals?

If you look at the peak admission and discharge times at your hospital, you will find that they typically overlap and peak in the late afternoon (See Camel # 1). That results in chaos and dissatisfaction of the hospital staff, scrambling to take care of departing and arriving patients; ED staff, trying to move sick patients out of the ED; and patients, who feel rushed and unprepared to leave the hospital. 

Moving discharge times to the early afternoon (See Camel # 2) allows smoother daily patient flow from the ED to the hospital bed to the next level of care and ensures appropriate on-demand hospital staffing.

Early discharges vs. length of stay

I often find that hospitals choose early discharges as a default intervention to improve LOS and use LOS to track the impact of early discharge interventions. That is a classic example of choosing wrong solution to fix the problem and wrong measure to evaluate solution effectiveness.  

Length of stay is a complex problem that is driven by:

• Patient factors (for example, age and severity of illness)

• Physician team processes (for example, staffing and sign-outs)

• Provider practice variations (for example, choice of diagnostic work-up or consultants)

• Inefficient hospital processes (for example, delays in test turnaround)

Typically, length of stay will have more than one underlying cause and will require more than one solution to see measurable impact. Just merely moving discharge time up a few hours will not have significant impact on the LOS. In the best-case scenario, it may shave off a few hours; in the worst case, the sole focus on early discharge time will have detrimental impact on the LOS by creating adverse incentives to keep patients an extra day.

Since early discharges improve daily patient flow, the more appropriate downstream measures are ED throughput and boarding measures: Median Admit Decision Time to ED Departure Time for Admitted Patients, Left Without Being Seen, Daily Boarding Hours or ED Boarding Load.

3 things to consider before including early discharge measure in your hospitalist team performance scorecard

1. Be clear on what problem are you trying to solve.

Including an early discharge measure makes sense if your hospital is struggling with inefficient daily patient flow from the ED. Hospitalists can help to clear the bottleneck by discharging patients before the late afternoon admission rush.

If your hospital’s goal is to decrease LOS, an early discharge measure may not be appropriate. As we discussed before, just focusing on early discharges will not solve (and may exacerbate) the problem.

2. Chose the measure that hospitalists can control.

The discharge process starts with a discharge order followed by additional steps before a patient leaves the hospital (for example, getting discharge instructions ready, arranging transportation).  Those steps may take a few hours to complete and are often outside of a hospitalist’s control.  A more precise measure of hospitalist team performance is discharge order time versus actual discharge time.

3. Select the right performance target.

The performance target should be based on the current performance and length of stay.  If your hospitalist team already has short length of stay, a “standard” target (for example, 50% Discharges Before Noon) will be unrealistic and potentially harmful.

Daily patient flow and length of stay are complex problems that many hospitals are facing. By taking time to understand the root cause and choosing the right solution along with the relevant performance measures and targets, you can help to solve both problems and create a more seamless experience for your patients.

Want to improve daily patient flow or length of stay at your hospital? Contact me if you have questions or want information about my services.