MMHA 6700 Week 9 Throughput Improvement Charter Example

Out by 13:30: A Throughput Improvement Charter for Medical Discharges on 5 West

Student Name

Walden University

MMHA 6700: Healthcare Operations

Instructor Name

Month Day, Year

Out by 13:30: A Throughput Improvement Charter for Medical Discharges on 5 West

Why a Charter

So far this term, every analysis of Linden Ford, the imaginary hospital standing in for a typical community facility, has pointed to one lever. Week 4 located the emergency department bottleneck in boarding; Week 7 timed a discharge day that stretched from readiness in mid-morning to a turned room around five in the evening; and Week 8 followed the delay back to the order of morning rounds. A charter turns those findings into a project with a fixed aim, a baseline, a method, a team and a date. Its purpose is to prevent the project from drifting into a general effort to improve discharge, which no one could judge as succeeding or failing.

Problem Statement

Medical patients on 5 West leave the hospital at a median of 15:50, although the charge nurse judges them medically ready at a median of 10:00. Beds vacated in the late afternoon are cleaned after the emergency department's admitted patients have begun to board, and the median boarding time for medical admissions is 4.8 hours. The late departure is not caused mainly by patients' rides, but by a sequence of waits beginning with rounds that reach discharge-ready patients late in the morning.

Aim

By the last day of the sixteenth week after launch, the median departure time for medical patients discharged home from 5 West will move from 15:50 to 13:30 or earlier, measured weekly from the admission, discharge and transfer system, without an increase in seven-day readmissions.

The aim follows the usual tests for a good improvement aim: it names how much, by when and for whom, and it includes a balancing measure so that speed does not come at patients' expense. Thirteen-thirty was chosen because the Week 7 future state projected about 13:00 if every change worked, and the team preferred an aim it could reach with most of the changes in place. Hospitals that set an explicit time-of-day discharge goal and changed team routines to meet it have moved their discharge times substantially (Wertheimer et al., 2014).

Baseline and Measures

Table 1

Measures With Baseline and Target (Illustrative)

One outcome, three process measures and two balancing measures. Process figures tell the team whether people are doing the new steps; the outcome tells them whether the steps pay off.

Method

The project uses the Model for Improvement with plan-do-study-act cycles, testing one change at a time on a small scale before spreading it. Reviewing published improvement projects, Taylor's team found that many called themselves cycles without actually testing changes iteratively or using data over time, and that the method works best when cycles are small, sequential and measured (Taylor et al., 2014). The charter therefore commits to weekly cycles and a run chart for the outcome measure.

Each week's median departure goes onto a run chart the team reviews together. Statistical process control methods give the team rules for telling a real shift in the median from week-to-week noise, so that one good week is not mistaken for success (Benneyan et al., 2003).

Table 2

First Four Planned Cycles

Each cycle tests one change from the Week 8 countermeasures, in the order of the causal chain.

Scope

In scope: medical patients on 5 West discharged to home or home with services. Out of scope: surgical patients, patients discharged to skilled nursing or rehabilitation facilities, and patients leaving against medical advice. Facility discharges follow a different path, with waits for bed offers and insurance authorization, and would need a separate project.

Team and Roles

Sponsorship sits with the hospital's senior nursing executive, who can remove barriers across departments. The project lead is the 5 West nurse manager. Team members are a hospitalist champion, the unit case manager, a charge nurse, a pharmacist and an analyst from the quality department who will produce the weekly data. The team meets for thirty minutes each week, after the data are refreshed.

Risks

Hospitalists may resist changing a long-standing rounding routine, and some will worry that seeing well patients first delays care for sick ones. The cycle design addresses this by starting with one willing team. Flagging may be inaccurate at first, so that some flagged patients are not ready. And a gain on 5 West may simply shift work elsewhere, for example to pharmacy; the evening prescription fill tested later will need its own measure.

Timeline

Weeks 1 to 4: cycles 1 to 4 on one hospitalist team. Weeks 5 to 10: spread to all teams on 5 West if run-chart rules show improvement. Weeks 11 to 16: hold gains and test the evening prescription fill. Week 16: report to the sponsor against the aim.

Conclusion

This charter fixes what the project will achieve and how anyone will know: medical patients leaving 5 West by 13:30 instead of 15:50, without more readmissions, within sixteen weeks. It names the measures, the team and the first four tests. Fixing those elements now keeps the work tied to the causal chain the term's analysis uncovered.

References

Benneyan, J. C., Lloyd, R. C., & Plsek, P. E. (2003). Statistical process control as a tool for research and healthcare improvement. Quality and Safety in Health Care, 12(6), 458-464. https://doi.org/10.1136/qhc.12.6.458

Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality and Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862

Wertheimer, B., Jacobs, R. E., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154