DISSERTATION PROJECT

IN

FORTIS MEMORIAL RESEARCH CENTRE, GURGAON

FROM 5th JANUARY 2015 TO 2nd APRIL 2015

“STUDY ON THE IMPROVEMENT OF DISCHARGE PROCESS BY

IDENTIFICATION OF CAUSES OF DELAY IN IPDS AND IMPLEMENT

THE RECOMMENDATIONS AT FMRI GURGAON”

BY:

DR. BAKUL ARORA

MHA (2013-2015)

UNDER THE GUIDANCE OF:

MAJ GEN (DR) MAHAVIR SINGH, MBBS, MD (HA)
CO-GUIDE: PROF (DR) HK SATIA, MBBS, MD (CHA), DNB (HA)

SUBMITTED TO:

DEPARTMENT OF HOSPITAL ADMINISTRATION

AMITY UNIVERSITY GURGAON
HARYANA
DECLARATION
I hereby declare that the content integrated in the document entitled “improvement of discharge
process by identification of causes of delay in discharge process in IPDs at FMRI Gurgaon” is the
outcome of the study conducted by me. I further affirm that it’s my effort research and not been
copied. This dissertation work has been conducted with a purpose of submission in partial fulfillment
of Masters in Hospital Administration in Amity University.

The above mentioned is the authentic to best of understanding.

The project was undertaken and carried out by me, under the guidance of Ms. Nidhi Sharma,
Associate Manager, FOS, Administration Department, Fortis Medical Research Institute.
 CERTIFICATE

This is to certify that the work which is presented in the project entitled “To improve the discharge

process by identifying the causes of delay in Discharge Process and give recommendations and

implement them to avoid delays & increase patient satisfaction in IPDs at FMRI, Gurgaon” in

fulfillment of the requirement of Dissertation at Fortis Hospital is an authentic record of Dr. Bakul

Arora, 2nd year student of Amity Medical School, Haryana carried out during the period from 5 th

January 2015 to 4th April 2015 under my supervision.

Guide Co-Guide
Maj Gen (Dr) Mahavir Singh Prof (Dr) H K Satia
Dean Faculty of Allied Sciences HOD, Department of Hospital Administration
HOI, Amity Medical School Amity Medical School
ACKNOWLEDGEMENT

I am using this opportunity to express my gratitude to everyone who supported me throughout the
course of this dissertation. I am thankful for their aspiring guidance, invaluably constructive criticism
and friendly advice during the dissertation work. I am sincerely grateful to them for sharing their
truthful and illuminating views on a number of issues related to the dissertation.

I would also like to thank Maj. Gen (Dr) Mahavir Singh (Dean Faculty of Allied Sciences), my
Academic mentor for his persistent motivation, support & guidance.

I would like to thank Prof. (Dr) Harish Satia HOD of Hospital Administration, Amity Medical
School

I would like to thank Dr Sheetal Yadav (Assistant Professor) & Dr Puneeta (Assistant professor) at
Amity Medical School for their guidance during the project.

I express my warm thanks to Ms Nidhi Sharma (Associate Manager, FOS, Administration

Department) for her support and guidance at FMRI Gurgaon.

CHAPTER NO. TITLE PAGE NO.

1 INTRODUCTION 9-21
1.1 Organization profile 9-14
1.2 Need for the Study 15
1.3 Introduction to Discharge Process 15
1.4 Aim of the Study 16-20
1.5 Objectives of the Study 21
 1.6 Significance of the Study 21
2 REVIEW OF LITERATURE 22-25
RESEARCH METHODOLOGY 26-27
3.1 Study Centre 26
3.2 Duration of Study 26
3.3 Inclusion 26
3 3.4 Exclusion 26
3.5 Research Design 26
3.6 Sample Size 26
3.7 Sampling Method 26
3.8 Study Type 26
3.9 Directionality 26
3.10 Data Collection Method 26
3.11 Procedure 27
4 Data Analysis and Interpretation 28-33
4.1 Pre Implementation Phase 28-29
4.1.1 Data Interpretation 30-32
4.1.2 Bottlenecks 33
4.3 Implementation Phase 34-36
4.4 Post Implementation Phase 37-38
39-40
5 Discussion And Conclusion

5.1 Discussion 39

5.2 Conclusion 40
6 Future Prospectus And Limitations 41-42
6.1 Future Prospectus Of The Study 41
6.2 Limitations Of The Study 42
7 References & Appendices 43-45
7.1 References 43
7.2 Appendices 44-45

TABLE OF CONTENTS

ABSTRACT
Discharge is a release of a hospitalized patient from the hospital by the admitting physician after

providing necessary medical care for a period deemed necessary. Any hospital needs to work on

finer aspects of the discharge process, to make it more patient friendly and less time consuming as it

directly connects to patient satisfaction. This observational study was carried out in a tertiary care

300 bedded hospital in Gurgaon on 251 discharged patients of all types of discharges, comprising of

Insurance patients (80), self-payment patients (93) & International patients (78). The results indicate

that there is a delay in all types of discharges in this hospital in all the steps except for the time

needed to return unused medicines to the pharmacy. The Average Time taken for the discharge

process was reduced from 5hours 49 minutes to 4 hours 57 minutes after implementing the given

suggestions in the study. Time and tedious discharge procedure, also contributes to patient

dissatisfaction.

Keywords: Discharge process, Patient Satisfaction

CHAPTER ONE

INTRODUCTION

1.1 ORGANIZATION PROFILE

Fortis Memorial Research Institute, Gurgaon

Fortis Memorial Research Institute, Gurgaon, is a multi-super specialty, quaternary care hospital
with an enviable international faculty, reputed clinicians, including super-sub-specialists and
specialty nurses, supported by cutting-edge technology. A premium, referral hospital, it endeavors to
be the 'Mecca of Healthcare' for Asia Pacific and beyond. Set on a spacious 11-acre campus with
1000 beds, this 'Next Generation Hospital' is built on the foundation of 'Trust' and rests on the four
strong pillars Talent, Technology, Infrastructure and Service.

Specialities

 Anesthesiology

 Bariatric Surgery

 Cardiology

 Dentistry

 Dermatology (Skin)

 Emergency Medicine

 Endocrinology

 ENT (Otolaryngology)

 Fetal Medicine

 Gastroenterology
 Gastrointestinal Surgery

 General Surgery

 Hepatobiliary Surgery

 Internal Medicine

 Joint Replacement Surgery

 Medical Oncology

 Micro-Biology

 Minimal Access Surgery

 Nephrology

 Neurology

 Neurosurgery

 Nuclear Medicine

 Obstetrics and Gynecology

 Oncology

 Ophthalmology

 Orthopedics

 Pediatric Orthopedics

 Pediatrics

 Physiotherapy

 Psychiatry

 Pulmonology

 Radiation Oncology

 Radiology

 Reconstructive Surgery

 Robotic Surgery

 Spine Surgery
  Surgical Oncology

 Trauma Surgery

Services

 OPD Services

 IPD-related services

 Ambulance Facility

 Health Awareness Lectures/ Workshops

 Blood Bank

1.1.1 INTRODUCTION TO IPD IN FMRI

FMRI has various types of ipds and wards such as single, twin-sharing rooms and suites. The

emergency and day care wards are located on the ground floor. The Nightingale wards are situated

on the first floor and on the third floor; there are 70 (single and twin-sharing) Insignia rooms. On the

fourth floor, there are 69 (single and twin-sharing) Executive rooms, and 15 Signature suites on the

fifth floor.

1.1.2 VISION

To be a globally respected healthcare organisation known for Clinical Excellence and Distinctive

Patient care.

1.1.3 VALUES

Patient Commit to 'best outcomes and experience' for our patients.

Centricity
 Treat patients and their caregivers with compassion, care and understanding.

Our patients' needs will come first

Be principled, open and honest..

Integrity Model and live our 'Values'.

Demonstrate moral courage to speak up and do the right things.

Proactively support each other and operate as one team.

Respect and value people at all levels with different opinions, experiences
Teamwork
and backgrounds.

Put organization needs' before department / self interest.

Be responsible and take pride in our actions.

Ownership Take initiative and go beyond the call of duty.

Deliver commitment and agreement made.

Continuously improve and innovate to exceed expectations.

Innovation Adopt a 'can-do' attitude.

Challenge ourselves to do things differently.

OUR LOG

1.1.4 THE LOGO

 The "Healing Hands" logo—two hands fusing seamlessly with a human form, expresses our

reassuring approach to healthcare and serves as a constant reminder of the patient-centricity that is

fundamental to our ethos.

The logo reflects our commitment to achieving excellence in healthcare delivery by bringing

together the best of technology, medical expertise, and patient care. It emphasizes the human values

that govern every facet of our organization.

Green, the dominant colour, is representative of the health and well-being we seek to bring to those

we minister to, while red indicates the dynamism with which we strive to make it a reality.

Distinctive, vibrant, memorable and contemporary, The Fortis Healthcare logo is a fitting visual

signature of an organization that seeks to excel, lead and serve.

1.1.5 LEADERSHIP TEAM

BOARD OF DIRECTORS

 Malvinder Mohan Singh, Executive Chairman

 Shivinder Mohan Singh, Executive Vice Chairman

 Mr. Sunil Godhwani, Chairman and Managing Director of Religare Enterprises Limited (REL)

 Harpal Singh,Mentor and Chairman Emeritus of Fortis Healthcare.

 Dr. Brian W Tempest, Independent Chairman of Religare Capital Markets, a Non Executive Director

of SRL Diagnostics, Fortis Healthcare and Glenmark Pharmaceuticals Ltd

 Mr. Gurcharan Das

 Dr. P. S. Joshi

 Ms. Joji Sekhon Gill, Strategic Human Resources

1.2 NEED FOR THE STUDY

Discharge is a release of a hospitalized patient from the hospital by the admitting physician after

providing necessary medical care for a period deemed necessary. Any hospital needs to work on

finer aspects of the discharge process, to make it more patient friendly and less time consuming as it

directly connects to patient satisfaction.

1.3 INTRODUCTION TO DISCHARGE PROCESS

Discharge process

 Discharging patients from the hospital is a complex process that is fraught with challenges

 Discharging patients in a timely manner is an issue that plagues most large hospitals. Patient

and family complaints were frequent and had started to adversely affect the hospital’s

reputation. Delayed discharges also blocked beds for new admissions and artificially drove

up bed occupancy rates and average length of stay.

1.3.1 ELEMENTS OF THE DISCHARGE PROCESS

Discharge planning — Discharge planning is the development of an individualized discharge plan

for the patient prior to leaving the hospital, to ensure that patients are discharged at an appropriate

time and with provision of adequate post-discharge services. Such planning is a mandatory part of

hospital accreditation.

 Discharge planning is a complex process that seeks to determine the appropriate level

of services required by the patient and then match the patient to an appropriate site of

care. This process ideally begins at the start of the hospitalization. The hospital case

manager should be involved as soon as it is clear that the patient will require services

at home, or will require transfer to an alternative level of care.

 Medication reconciliation — Medication reconciliation, or medication review, is the process

of verifying patient medication lists at a point-of-care transition, such as hospital discharge,

to identify which medications have been added, discontinued, or changed relative to pre-
 admission medication lists. Performing an accurate medication reconciliation is a critical

element of a successful discharge transition.

 Discharge summary — The primary mode of communication between the hospital care

team and aftercare providers is often the discharge summary, raising the importance of

successful transmission of this document in a timely fashion.

 Important elements in the discharge summary are:

 The outcome of the hospitalization

 The disposition of the patient

 Provisions for follow-up care including appointments, statements of how care needs

will be met, and plans for additional services (e.g hospice, home health assistance,

skilled nursing)

 Patient instructions — At the time of discharge, the patient should be provided with a

document that includes language and literacy-appropriate instructions and patient education

materials to help in successful transition from the hospital.

 These documents should be brief, focused on critical information to the

patient, and primarily directed at what the patient needs to understand to

manage his or her condition after discharge.

 Discharge checklist — Checklists provide an effective mechanism for ensuring that

discharge communications (the discharge summary and direct communication with both

aftercare providers and patients/families) reliably incorporate all key elements.

1.3.2 DELAYED TRANFER OF CARE

The problems concerning hospital discharges are of a number of different types, these include

discharges that:

• occur too soon

• are delayed

• are poorly managed from the patient/carer perspective

• are to unsafe environments.

The causes of these difficulties are diverse, and include:

• Internal hospital factors (e.g. the timing of ward rounds; the wait for diagnostic test results; the

delay in referring for a home assessment and of this taking place; the organisation and management

of medication; and the availability of transport)

• Co-ordination issues (e.g. the communication and organisation of different health, social care and

other community-based services):

• capacity and resource issues (e.g. the limited availability of transitional and rehabilitation places;

placement difficulties associated with care homes; and availability of a home care provider);

• patient/carer involvement/choice (e.g. the lack of engagement with patients and carers in decisions

about their care and the limited availability of choice of care options; and the lack of involvement by

independent sector providers in operational and strategic planning issues).

1.3.3 IMPROVING DISCHARGE PERFORMANCE

Discharge from hospital is a process and not an isolated event. It should involve the development and

implementation of a plan to facilitate the transfer of an individual from hospital to an appropriate

setting. The individuals concerned and their carer(s) should be involved at all stages and kept fully

informed by regular reviews and updates of the care plan. Planning for hospital discharge is part of

an ongoing process that should start prior to admission for planned admissions, and as soon as

possible for all other admissions. This involves building on, or adding to, any assessments

undertaken prior to admission. Local implementation of the single assessment process (SAP) needs

to take account of this critical issue. Effective and timely discharge requires the availability of

alternative, and appropriate, care options to ensure that any rehabilitation, recuperation and

continuing health and social care needs are identified and met.

1.3.4 KEY PRINCIPLES

The key principles for effective discharge and transfer of care are that:

• Unnecessary admissions are avoided and effective discharge is facilitated by a ‘whole system

approach’ to assessment processes and the commissioning and delivery of services.

• The engagement and active participation of individuals and their carer(s) as equal partners is central

to the delivery of care and in the planning of a successful discharge.

• Discharge is a process and not an isolated event. It has to be planned for at the earliest opportunity

across the primary, hospital and social care services, ensuring that individuals and their carer(s)

understand and are able to contribute to care planning decisions as appropriate

• The process of discharge planning should be co-ordinated by a named person who has

responsibility for co-ordinating all stages of the ‘patient journey’. This involves liaison with the pre-

admission case co-ordinator in the community at the earliest opportunity and the transfer of those

responsibilities on discharge

• Staff should work within a framework of integrated multidisciplinary and multi-agency team

working to manage all aspects of the discharge process

• Effective use is made of transitional and intermediate care services, so that existing acute hospital

capacity is used appropriately and individuals achieve their optimal outcome

• The assessment for, and delivery of, continuing health and social care is organized so that

individuals understand the continuum of health and social care services, their rights and receive

advice and information to enable them to make informed decisions about their future care.

1.3.5 BENEFITS OF DISCHARGE PROCESS

The benefits of effective discharge planning are:

For the Patient

• Needs are met

• Able to maximize independence

• Feel part of the care process, an active partner and not disempowered

• Do not experience unnecessary gaps or duplication of effort

• Understand and sign up to the care plan

• Experience care as a coherent pathway, not a series of unrelated activities

• Believe they have been supported and have made the right decisions about their future care
For the carer(s)

• Feel valued as partners in the discharge process

• Consider their knowledge has been used appropriately

• Are aware of their right to have their needs identified and met

• Feel confident of continued support in their caring role and get support before it becomes a problem

• Have the right information and advice to help them in their caring role

• Are given a choice about undertaking a caring role

• Understand what has happened and who to contact

For the staff

• Feel their expertise is recognised and used appropriately

• Receive key information in a timely manner

• Understand their part in the system

• Can develop new skills and roles

• Have opportunities to work in different settings and in different ways

• Work within a system which enables them to do so effectively

For organizations

• Resources are used to best effect

• Service is valued by the local community

• Staff feel valued which, in turn, leads to improved recruitment and retention

• Meet targets and can therefore concentrate on service delivery

• Fewer complaints

• Positive relationships with other local providers of health and social care and housing services

• Avoidance of blame and disputes over responsibility for delays.

1.4 AIM OF THE STUDY- To improve the Discharge Process by identifying the causes of delay in

Discharge Process and give recommendations and implement them to avoid delays & increase

patient satisfaction in IPDs at FMRI, Gurgaon.

1.5 OBJECTIVES OF STUDY

 To identify the major bottlenecks and their root causes

 To map each step in the discharge process and document the time taken for each activity.

 To give recommendations to improve process inefficiencies throughout discharge process to

reduce variability in discharge cycle time

 To implement the recommendations and analyze the findings

1.6 SIGNIFICANCE OF THE STUDY

The study helps in improving the discharge process by giving recommendations after tracking and

observing the data for one month. Based upon the observations, the recommendations are being

made and are implemented in the next month. After implementing the provided suggestions, it has

been found that the discharge process has improved immensely. This study helps in avoiding delays

in discharge process and increasing the patient satisfaction.

 CHAPTER TWO

REVIEW OF LITERATURE

2.1 Vinaya Kumari, Janita (2014)

This study was carried out with the aim to ascertain the average time taken for the patient to be

discharged in a tertiary care teaching hospital of Karnataka. Method: Registers were designed for the

study purpose and were kept in the ward and billing office. Instructions were given to the nurses in

the ward and clerical staff at the billing office about the study and entries to be made in the register.

The average time taken for the whole discharge process of an individual patient was calculated using

the data maintained in the registers. The statistical analysis was made to ascertain the average time

taken for discharge. Appropriate tables and graphs are used for representing various findings and

results. Results and Conclusion: The average time taken for the whole discharge process i.e. Intra

processing time +Inter processing time of an individual patient is 2 hours 22 minutes.

2.2 Vijaya, Arun (2012)

The objective of this research is to reduce the cycle time of the Patients discharge process using Six

Sigma DMAIC Model in a multidisciplinary hospital setting in India. This study had been conducted

through the five phases of the Six Sigma DMAIC Model using different Quality tools and

techniques.

This study suggested improvement strategies to reduce the cycle time of Patients discharge process

and after its implementation; there is a 61% reduction in the cycle time of the Patients discharge

process. Also, a control plan check sheet has been developed to sustain the Improvements obtained.

This Study would be an eye opener for the Health Care Managers to reduce and optimize the cycle

time of Patients discharge process in Hospitals using Six Sigma DMAIC Model.
2.3 Kathleen M. Finn, Rebecca Heffner, (2011)

A 5-month randomized controlled trial was conducted on the medical service at an academic tertiary

care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge

paperwork, arrange follow-up appointments and prescriptions, communicate discharge plans with

nursing and primary care physicians, and answer questions from discharged patients.

2.4 Theodore T. Allen1 , Shih-Hsien Tseng, Kerry Swanson, Mary Ann McClay (2010)

This study describes the application of a five-phase Six Sigma define, measure, analyze, improve,

and control (DMAIC) approach to streamline patient discharge at a community hospital. Within the

context of the five phases, the team applied statistical process control (SPC) charting, process

mapping, Pareto charting, and cause-and-effect matrices to make decisions. The findings suggested

that focusing on physician preparation for discharge order writing would have the greatest impact. A

significant reduction in the average discharge time from 3.3 to 2.8 h was realized (p ¼ 0.06) and

missing chart data was reduced by 62%.Intervention patients had more discharge summaries

completed within 24 hours (67% vs 47%, P < 0.001). Similarly, they had more follow-up

appointments scheduled by the time of discharge (62% vs 36%, P < 0.0001) and attended those

appointments more often within 2 weeks (36% vs 23%, P < 0.0002). Intervention patients knew

whom to call with questions (95% vs 85%, P ¼ 0.003) and were more satisfied with the discharge

process (97% vs 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45%

vs 31%, P ¼ 0.058), and residents signed out on average 46 minutes earlier each day. There was no

significant difference between the groups in 30-day emergency department visits or readmissions.

Helping resident physicians with the discharge process improves many aspects of discharge

communication and patient follow-up, and saves residents’ time, but had no effect on hospital

reutilization for a general medicine population.

 CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Study Centre: The study was conducted at Fortis Memorial Research Institute (FMRI)
Gurgaon.

3.2 Duration Of Study: 5th Jan 2015 - 2nd April 2015

3.3 Inclusion criteria

Only the Patients staying in Executive rooms at 4th floor were consider under study.

3.4 Exclusion criteria

The excluded patients were:-

 Patients staying in Signature Rooms at 5th floor

 Patients staying in Insignia Rooms at 3rd floor

 Patients staying in Nightingale wards at 1st floor

 Patients staying in Emergency & Day care

3.5 Research design: - analytical and experimental research design.

3.6 Sample Size: - 251 patients in which 165 patients were in pre implementation phase and 86
patients in post implementation phase

3.7 Sampling method: - Non-Probability Convenience sampling method

3.8 Study Type:- Prospective study

3.9 Directionality :- Forward

3.10 Data Collection Method

 Observation method
 Data sheet

3.11 Procedure- the study consists of 3 phases:

 Pre-implementation phase- 165 patients

 Implementation phase

 Post-implementation phase- 86 patients

 CHAPTER FOUR

RESULTS AND INTERPRETATIONS

4.1 Results

 Pre-implementation Phase

 Data has been collected by taking sample size of 165 patients in IPDs from Executive

rooms of 4th floor in FMRI for the month of January.

 Out of 165 patients, 35% are Cash patients, 31% are International patients and 34% are

TPAs.

IPD Patients

34% 35% Cash

International
TPA

31%

 Data is in terms of average time taken for all the different steps of discharge process like

Billing Activity sent time, Bill ready & settlement time, Consultant rounds, Discharge

Summary ready time, Clearance slip time, physical movement of patient time.

 The Average time taken for the Discharge Process is 349 minutes i.e 5 hours 49 minutes with

each step having following average time taken.

 This average time is taken from the time of written orders by doctors to the time of the

physical movement of the patient.

 Average Time Taken (in hours)
0:21
Bill ready

1:03
0:36 Discharge Summary ready

Bill settlement

1:20 Clearance Slip Handover

2:29
Physical movement

 It is inferred from the chart that each step in discharge process is mapped in terms of the

average time taken for each of it.

 The average time for the whole discharge process is 5 hours and 49 minutes in which the

average time taken for bill getting to be ready is 1 hour and 3 minutes, for discharge summary

getting ready is 1 hour and 20 minutes, for bill settlement is 2 hours and 29 minutes, for

clearance slip handover is 36 minutes and for the physical movement of the patient is 21

minutes respectively.
 Time Taken (in mins)
400

350
21
36
300

250
149
200
349
150

100 80

50
63
-
Bill ready Discharge Bill Settlement Clearance Slip Physical Discharge TAT
Summary Handover movement
Ready

 The above waterfall chart shows the average time taken for the whole discharge process i.e

from the written orders by the doctor to the physical movement of the patient, in terms of

minutes for each step in the discharge process.

 The average time for the whole discharge process is 349 minutes in which the average time

taken for bill getting to be ready is 63 minutes, for discharge summary getting ready is 80

minutes, for bill settlement is 149 minutes, for clearance slip handover is 36 minutes and for

the physical movement of the patient is 21 minutes respectively.

The major bottlenecks and their root causes for the delay in the discharge process are-

Bottlenecks-

 Delay in completion of discharge summary

 Summaries are not ready prior day before discharge and activity begins after

consultant signoff on the day of discharge

 Late consultant rounds

 Delay in preparation of final bill

 Delay due to Billing Activity

  Due to technical issues

 Delay in sending & receiving Billing Activity

 GDA comes late

 Medicines not returned on time

 Pending reports

 Informed late to DEO

 Delay in financial clearance

 Attendants were not immediately informed that the final bill was ready. Late entry of

charges led to a substantial hike between the interim and final bill that was often

questioned during settlement

 Late TPA approval

 Half day issues

 Re-opening of bills

 Planned discharges become unplanned

 Discharges information not mailed/informed in night

 Hold discharges by doctors

 Evening discharges

 Not written in files

 Others-

 Patient waiting for Interpreters, Wheel chairs, Doctors, drivers, Laundry stuffs

 Re-opening of bills due to wrongly charged, missing information/tests/consultant

rounds

 Late summary explained or giving handover to patients by Nurses

 Late Clearance slip received

 Reasons for Delay
5% 2% Bill Settlement
6% Discharge Summary
16% TPA Approvals
Unplanned
13% Wriiten Orders
Billing Activity
29% Waiting Time
6% No delay
15% Others
8%

 It is inferred from the chart that the major causes of the delay in discharge process are shown

in terms of percentage.

 Every cause has certain number of patients who had these causes for the delay in their

discharge process.

 No. of patients for late bill settlement is 27, for delayed discharge summary is 47, for delayed

TPA approvals is 13, for Unplanned discharges is 25, for late written orders is 10, for late

sending/receiving billing activity is 21, no. of patients waiting for wheelchairs, doctors is 10,

for the patients with no delay is 8 and for other reasons is 4.

 Implementation Phase:

Based on the above bottlenecks, the following recommendations have been made and

implemented in this phase of the study.

RECOMMENDATIONS

 Discharge planning begins at admission -Create a care plan for all elective patients within 24

hrs of admission

Impact- The patient, family and care team are all informed of the discharge date. The

discharge process can then begin predictably 24 hrs prior to the discharge day

 Update the discharge summary daily

Impact- Complete the discharge summary quickly within 10-15 minutes of discharge orders

 Update the patient’s case file daily

Impact- The case file is ready when the discharge orders are given - only services provided

on the morning of discharge are pending

 Return discontinued medications daily in the wards

Impact- Eliminate the pharmacy from the discharge process altogether

 Enter charges at the time and point of consumption

Impact- Generate up-to-date interim bills and minimize billing errors

 Discharge summary should be ready & typed one day prior of the day of discharge.

 Early round of Doctors `so that they can confirm the final summary.

 Nurses should explain summary and give handover to patients when clearance is given.

 Availability of Interpreters/drivers/wheelchairs/GDAs should be there.

 Post-implementation Phase:

The above recommendations then implemented in the month of February and then data of 86

patients was tracked to compare the reduction in time taken for the discharge process in

February to that of time taken for discharge process in January.

 Data has been collected by taking sample size of 86 patients in IPDs from Executive

rooms of 4th floor in FMRI for the month of February.

 Out of 86 patients, 41% are Cash patients, 31% are International patients and 28% are

TPAs.

IPD Patients

28%
Cash
41% International
TPA

31%

 Data is in terms of average time taken for all the different steps of discharge process like

Billing Activity sent time, Bill ready & settlement time, Consultant rounds, Discharge

Summary ready time, Clearance slip time, physical movement of patient time.

 The Average time taken for the Discharge Process is 297 minutes i.e 4hours 57minutes with

each step having following average time taken.

 Average Time Taken (in hours)

Bill ready
0:40
0:55

0:20 Discharge Summary ready

Bill settlement
0:55
Clearance Slip Handover

2:07 Physical movement

 It is inferred from the chart that each step in discharge process is mapped in terms of the

average time taken for each of it.

 The average time for the whole discharge process is 4 hours and 57 minutes in which the

average time taken for bill getting to be ready is 55 minutes, for discharge summary getting

ready is 55 minutes, for bill settlement is 2 hours and 07 minutes, for clearance slip handover

is 20 minutes and for the physical movement of the patient is 40 minutes respectively.
After comparing both the data, it is found that the average time taken for the discharge process has

been reduced from 349 minutes to 297 minutes by implementing the recommendations in the month

of February in the post-implementation phase.

Reduction in time (in mins)

360
350
8
340
330 25
320
310
349 22
300
290 19
16
280 297
270
260
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AT um il lS lip a l
AT
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g c g
h ar ar
g
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sc h a sc
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Di C Di

 The above waterfall chart shows the reduction in time of the delay in the discharge process

from 349 minutes to 297 minutes, with the mapping of time at each step of the discharge

process.

 The average time for getting bill to be ready has been reduced by 8 minutes, for discharge

summary to be ready has been reduced by 25 minutes, for the settlement of bill has been

reduced by 22 minutes, for the clearance slip handover by 16 minutes and for the physical

movement of the patients has been increased by 19 minutes respectively.

 CHAPTER FIVE- DISCUSSIONS AND CONCLUSION

5.1 Discussions

Hospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where

discharges are done by residents with competing demands. We sought to assess whether embedding

a nurse practitioner on a medical team to help physicians with the discharge process would improve

communication, patient follow-up, and hospital reutilization. The study has been conducted in three

phases which shows the major bottlenecks and their root causes for the delay in the discharge

process. In the pre-implementation phase, it is seen that the average time taken for the discharge

process is 347minutes. The Bill settling is found to be the highest time consuming step among each

step of the discharge process, and discharge summary also takes higher time to be ready. Every cause

has certain number of patients who had these causes for the delay in their discharge process. The no.

of patients for late bill settlement is 27, for delayed discharge summary is 47, for delayed TPA

approvals is 13, for Unplanned discharges is 25, for late written orders is 10, for late

sending/receiving billing activity is 21, no. of patients waiting for wheelchairs, doctors is 10, for the

patients with no delay is 8 and for other reasons is 4. Based on these root causes, some

recommendations have been implemented and the data for the post-implemented phase has been

tracked for a month which shows the reduction in time of delay in discharge process. And the results

are found to be improved as the average time taken for the whole discharge process has been reduced

from 5 hours 49 minutes to 4 hours 57 minutes.

5.2 Conclusion

The results clearly indicates that there is a delay in all types of discharges in this hospital in all the

steps except for the time needed to return unused medicines to the pharmacy, when compared with

prescribed standards for the same. The Average Time taken for the discharge process was reduced

from 5hours 49 minutes to 4 hours 57 minutes after implementing the given suggestions in the study.

Time and tedious discharge procedure, also eventually contributes to patient dissatisfaction and thus

reflects on future business of such hospitals. Thus, the recommendations proved helpful and effective

in improving the delay in discharge process and patient satisfaction.

 CHAPTER SIX
LIMITATIONS AND FUTURE PROSPECT

6.1 Limitations of the Study:-

The study had some limitations:

a. The study does not tell the analysis of planned and unplanned discharges.

b. The data collected is only for two months due to less time.

c. The data collected is inclusive of only the ward rooms of one floor of the hospital.

6.2 Future prospect of the study:-

The study would lead to further improvement of discharge process by separating the planned
and unplanned discharges. The effort has to be done to make unplanned discharges to planned
discharges and decrease the number of unplanned discharges. This will lead to improved
discharge process, increased patient satisfaction, higher financial performance and achievement
of organizational goals.
 CHAPTER SEVEN
REFERENCES & APPENDICES

7.1 References

1. Mogli GD.Medical Record Organization and Management, Jaypee Brothers, Medical Publishers
Pvt Ltd: New Delhi,2001

2. Goel S.L and Kumar R. Hospital Administration and Planning, 1st edition, Jaypeee Brothers,
Medical Publishers Pvt Ltd: New Delhi

3. Pigage,L.C. and Tucker, J.L. 1954. Motion and Time Study. Bulletin no. 24. Champaign, Ill.:
Institute of Labor and Industrial Relations. University of Illinois at Urbana-Champaign,

4. Gavriel Salvendy.Technology & Engineering John Wiely & Sons,New York, 2001.Section IV.C

5. Janita Vinaya Kumari,A Study on Time Management of Discharge and Billing Process in Tertiary
Care Teaching Hospital. Elixir International Journal Mgmt. Arts. 2012.52(A):p11533-11535

6. Hendrich, A., Chow, M.P., Bafna, S., Choudhary, R., Heo, Y., & Skierczynski, B. (2009).
Unitrelated factors that affect nursing time with patients: Spatial analysis of the Time and Motion
Study. Health Environments Research & Design Journal, 2(2): p5-20.

7. Sakharkar B.M(1998), Principles of Hospital Administration and Planning, 1st edition, Jaypeee
Brothers, Medical Publishers Pvt Ltd: New Delhi

8. Kulkarni GR(1995), Hospital Management, Accounting, Planning, and Control, National Health
Management Institute: Bombay
7.2 Appendices:-

Discharge D/c Dis

Payor plan planning Discharge Pending Billing Consulta summar summary
S.No Patient Bed (Cash/TPA/I (Planned/ summary reports activity nt round y signed scanned &
. Name UID no. Doctor name NT) Unplanned) status status sent time time time mail time

Investigatio
Pending ns to be
Medication reports done on day Bill clearance Physical
return time status of discharge Bill ready settlement slip received movement