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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Report of Summer Training

A STUDY FOR IMPROVING THE HOSPITAL’S DISCHARGE PROCESS OF CARDIOLOGY DEPARTMENT PATIENTS IN NARAYANA HRUDAYALAYA HOSPITALS BY MEANS SIX SIGMA

Report prepared by Sandipan De PGDHM 2010-12 In Narayana Hruduyalaya Hospitals Bangalore

For the Partial fulfillment of completion of the Course: Summer Training PGDHM 2010-12 BATCH May-June 2011

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE Term-II: Summer Training Report Declaration by the Student This is to declare that the Report is made for the Partial fulfillment of completion of the Course: Summer Training in Term-II of PGP (PGDHM 2010-12 Batch) by me in Naryana Hrudayalaya Hospitals Bangalore under the supervision of Mr. Sunil Kumar and my Mentor was Dr. / Prof. Usha Manjunath. I confirm that this report truly represents my work and accomplishment undertaken as a part of my Dissertation work. This work is not a replication of work done previously by any other person. I also confirm that the contents of the report and the views contained therein have been discussed and deliberated with the (Supervisor) as well as the Mentor.

Signature of the Student Name of the Student (in Capital Letters) Register No: IHMRB/PGDHM/2010-12/19

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE Post Graduate Diploma in Hospital & Health Management (PGDHM) 2010-12 BATCH Term-II : Summer Training Report Certificate by the Guide This is to certify that Dr. Sandipan De Regd. No. IHMRB/PGDHM/2010-12/19 has done the Report in Narayana Hrudayalaya Hospitals Bangalore under the supervision of Mr. Sunil Kumar for the Partial fulfillment of completion of the Course: Summer Training in Term-II of PGP (PGDHM 2010-12 Batch) under our guidance.

Signature of Mentor

Name of the Mentor

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Signature of Director

(Dr. K.S. Srinivasa Rao)


INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Certificate from the Organization

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

ACKNOWLEDGEMENT

It is with great pleasure that I express my deep sense of gratitude and heartfelt thanks to Dr. K.S.Srinivasa Rao and all the faculty members for providing the opportunity to exercise the practical aspect of studies. I would like to thank our Supervisors: Mr. Sunil Kumar Chief Operating Officer Narayana Hrudayalaya Hospitals, Bangalore, Mr. Prakash Zakariah GM Administration Narayana Hrudayalaya Hospitals , Dr. Asha Naik Medical Director Narayana Hrudayalaya Hospitals, Ms. Reshmi Srivastava Quality Manager Narayana Hrudayalaya Hospitals, Mr. Ragvendra Rao Head Data Processing Department for guidance and support throughout the internship. They have always found time to help, guide and critically evaluate my work. Their sincerity and knowledge has enriched me and their experience has helped me not only professionally but also in day-to-day work. My special thanks to all the staff members of Narayana Hrudayalaya Hospitals, Hosur Road, Bangalore. They were very supportive and spent their precious time to clarify my doubts I would also like to thank my mentor Dr. Usha Manjunath for their technical and intellectual assistance without which this work would have not been so well materialized. SIGN:NAME:-SANDIPAN DE

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Table of Contents About the Hospitals........................................................................................................... 8 MISSION ...................................................................................................................... 8 Quality Policy and Objectives .......................................................................................... 9 Executive summary......................................................................................................... 12 Introduction ..................................................................................................................... 12 The problem symptoms................................................................................................... 13 The problem Statement ................................................................................................... 14 Objectives of the study.................................................................................................... 14 Methodology ................................................................................................................... 16 Define and Measure Phase 1.1 ................................................................................ 16 Analysis................................................................................................................... 20 Improve ................................................................................................................... 25 Control .................................................................................................................... 27 Discussion ....................................................................................................................... 27 Conclusion ...................................................................................................................... 27

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

About the Hospitals In its genre, Narayana Hospitals be one of the biggest Hospitals in the world. The rich come here for getting the world’s best cardiac care. The poor come here for the world’s kindest care; for no one is turned away for the lack of funds. This is the vision of Dr. Devi Shetty, who believed that no child should be deprived of the best healthcare, because their parents cannot afford it. CARING WITH COMPASSION, is the Motto in this world’s largest heart hospitals for children, and is set to be the world’s biggest health city, with all super specialties that the medicine offers. Narayana Hrudayalaya was founded India’s oldest construction company “Shankar Narayana Construction Company”. Narayana Hrudayalaya group currently has 5000 beds in India and aims to have 30,000 beds in the coming 5 years, to become the India’s largest healthcare player in the country. The groups two heart hospitals; Narayana Hrudayalaya Health City at Bangalore and Rabindranath Tagore International Institute for Cardiac Sciences in Kolkata is performing about 12% of the heart surgeries done in the country. The group performs the largest number of heart surgeries on children in the world. The post-operative pediatric surgical unit has 80 critical care beds which is world’s largest pediatric cardiac surgical intensive therapy Unit (ITU). The Narayana Hrudayalaya Health City at Bangalore is a conglomeration of hospitals in one campus: Narayana Hrudayalaya Heart Hospitals Asha Dinesh Institute for Organ Transplant Sparsh Hospital Narayana Netralaya Mazumder Shaw Cancer Center

Vision “Affordable Quality Healthcare to the masses worldwide”

MISSION We at Narayana Hrudayalaya have a dream! “A dream of making quality healthcare available to the masses worldwide” To make this dream a reality we commit ourselves to:  Being a tertiary care referral center for complex medical and surgical problems  Developing a Health City Model, to be replicated nationally and internationally  Excelling as an education, training and research center in medical, paramedical and allied specialties

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Quality Policy and Objectives Quality Policy “Narayana Hrudayalaya is committed to provide professional patient care at affordable cost to reach patients globally with holistic approach and continually improve the effectiveness of quality management system.” Quality Objectives: i. ii. iii.

Provide holistic, timely patient care Continually upgrade the knowledge and technique in patient care Customer relationship management

Hospital Committees Committee: A group of people officially delegated to perform a function, such as investigating, considering, reporting, or acting on a matter.         

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Few hospital committees are: Formulary committees Hospital Infection Control Committee Transfusion Medicine Committee Quality steering Committee Grievance handling Committee Safety Committee Medical Audit Committee Ethics committee


INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Organogram

The Services provided by the Hospital are  Cardiology and Cardiac Surgery  Neurology and Neurosurgery  Gastroenterology  Oncology  Solid Organ Transplant  Reproductive Medicine  Nephrology and Kidney Sciences  Urology  Pulmonology  Imaging and Radiology  Molecular Diagnosis’  Maxilo facial Surgery  Orthopedics  Dermatology

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE                 

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Psychiatry Anaesthesia Blood Bank and Laboratory Services Nuclear Medicine Bone Marrow Transplant Diabetology Emergency and trauma Nutrition and Dietetics Ophthalmology Pediatric Physiotherapy Plastic surgery Spinal surgery Sports Medicine Stem Cell Yoga Dental


INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Executive summary Discharge is a process where the patient is transferred from hospital setting to an alternative setting where appropriate. This study was taken at hand as there was huge number of complaints on delay in the discharge from the hospital in the department of cardiology. The first objective of the study was to find out the average time for discharging a patient and followed by a probe of the bottle-necks causing the delay. The method of choice to study was time and motion study of the whole process. The patients’ file was followed from the time the consultant’s orders for discharge till the patient is walks out of the hospital. Every time each case file changes the hands of members in the process, time was recorded. It was found that the average time for a patient to get discharged from the hospital in the department of cardiology was 7 hours 52 minutes with standard deviation of 1 hour 17 minutes. The major delay was observed between the summary dispatched to the ward and the patient walking out. The other important delays observed was; after the discharge summary was ready there was nobody to take the summary to the ward from data processing department hence it was taking 2 hours 7 minutes. These delays were analyzed in the pareto chart. The causes for the delay were identified with the help of Ishikawa diagram (fish bone). The Control matrix chart helped in prioritizing the causes which are under control of management to change and which are not. The key responsibility areas of the stakeholders involved in the process of discharge were also analyzed. After carefully dissecting KRA’s we can confirm that the shifting nurse had lot of responsibility due to which she was not able to bring the case file from the ward to the data processing department and take the summary back from the data processing department to the ward. The decision was taken that a new manpower was to be deployed for carrying the summaries to the ward from the data processing department. The cath reports were also streamlined so that the billing is done parallel to the main process. After taking the several such steps based on the recommendation, the same process was measured again. At our efforts we were able to reduce the average time for discharge of the patient to 6 hours 28 minutes, i.e., 17.62% decrease. It was also suggested that control mechanism should be in place for continuous monitoring and improvement. It was suggested that same control mechanism is the HMIS to ensure reduction of selection bias. Success of the project has come due to the commitment of the management to change for the good of the customers.

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Introduction Discharge from hospitals is a process, not an isolated event. It involves development and implementation of a plan to facilitate the transfer of an individual from hospital to an alternative setting where appropriate. Components of the system (family, care givers, hospitals and the administration, community and social services) must together work to achieve hassle free procedure. A lengthy, inefficient process for discharging in-patients is a common concern of hospitals. It not only causes frustration for patients and family members, but also leads to delays for incoming patients from Admitting, the tep-down Coronary Care Unit or the Emergency Department. Six sigma is of great interest in the corporate world. Since its initiation at Motorola in the 1980s, and then many companies including GE, Honeywell, Sony, Caterpillar, and Jhonson Controls have adopted six sigma and obtained substantial benefits (Pande et al., 2000; Snee and Hoerl, 2003). In the field of health care, six sigma has been utilized to address number of hospitals related problems in operations and quality management like decreasing the length of stay, reducing medication errors, and improving the admission process and the discharge process (castle et al. 2005; Christianson et al. 2005). The six sigma method is a project driven management approach to improve the organization’s product, services and processes by continually reducing the defects in the organization. It is a business strategy that focuses on improving the customer requirements, understanding business systems, productivity and financial performance (X. Zu et al. Journal of Operations Management 2008). From the statistical point of view, the term six sigma is defined as having less than 3.4 defects per million opportunities or success rate of 99.9997% where sigma is the term used to represent the variation in the process average. There was huge pressure on the management due to the rise in the dissatisfaction of the patient over discharge process; owing the accessibility to the hospital from the city of Bangalore. If the patient is not satisfied they may have a switching behavior in choosing the hospital. This study was focused on the discharge of the cardiology patient because these patients were admitted to the hospitals only for a day or may be for 7-8 hours stay and their discharges are not planned discharge. There was on an average 45 patient discharged from cardiology department, so it was huge load for the management to handle and hence there was need for streamlining the process and make minor changes to reduce the discharge time and also keep the customer satisfied.

The problem symptoms    

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Lengthy discharge Process Poor Satisfaction from the Patients reflected in the patient satisfaction forms Frustrated Patients and staffs More use of resources in the hospitals which is non-revenue generating


INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

The problem Statement “What are the factors responsible for lengthy discharge process of Narayana Hrudayalaya Hospital Cardiology department’s patients?”

Objectives of the study    

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To find out the average time taken for patient to be discharged from the hospital To search for the bottlenecks in the discharge process To look for the factors responsible for the Bottlenecks To give operational recommendations for re-engineering of the process


INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Review of Literature The studies done on the lengthy discharge process problem shows us that most of the hospitals have a common concern about the same. The patient satisfaction is fairly low and most of the studies shows that the discharge process is really problem which a hospitals operations needs to put lot of stress. Many of the studies show us that the problem can be solved with the help tools namely lean principles and six sigma tools. The six sigma approach is data driven approach by continuous efforts to reduce the defects in the process. DMAIC is a closed looped process that eliminates unproductive steps, often focuses on new measurements and applies technology for continuous improvement. Most of studies reveal that detailed process map need to be studied. The process map was formulated with the help of the nurses in this study and also the studies did the same way. It would be a bias if only nurses are used in mapping the process. In few of the studies they also have done Turn Around Time (TAT) of the process of discharge. Further scope of the study is to know the amount of time the patient may take if the patient is going for Discharge Against Medical Advice (DAMA) or Leave Against Medical Advice (LAMA). Even the average time required for the patient who has expired in a hospital. This same study could have been done using the principals of Lean and or Lean Six Sigma. Even the methods of Critical Path Method (CPM) can also be looked for the in the further studies to reduce the time. The same study should continue after couple of months in continuous search for other bottlenecks. Improvement the process thereby would help the administration to further satisfy the customers. Studies can also be done, which is the best tool to bring about change in the system. Studies can also be done about does discharge process really improves the patient satisfaction and help the patient not to think on the switching behavior.

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Methodology Define and Measure Phase 1.1 The primary goal of the project was to improve the patient’s satisfaction with respect to the Discharge process which was judged by the COO of the hospital to be a critical issue based on the Hospitals Mission, past complaints, and results of the patient satisfaction survey. The define phase involves documentation and evaluation of the system that existing in the hospital prior to any changes. (Theodore T. Allen, ShihHsien Tseng, Kerry Swanson, Mary Ann McClay). During this phase, mapping of the process was done. The process mapping was carried out by personal interview with the stakeholders involved in the process. Each stakeholder was asked about the process and their contribution in the same. There was lack of standard operating procedures which had led to widespread process variation.(Creating a Lean Six Sigma Hospital Discharge Process An iSixSigma Case Study, Chuck DeBusk and Art Rangel Jr.) The key processes and the supporting processes were identified. The process starts with the Consultants orders that the patient can be discharged and ends with the patient walking out of the ward. The sub processes were also earmarked. Every time the file changed the hand the time was noted. The time was noted according to the time showed by the Hospitals’ computers since computers were available at every counter and they were connected to the one server throughout the hospital. In total 25 files were followed for a month period. The samples were chosen from the list at the Data Processing Department, where the shifting nurses’ enters the details of the patient who are for discharge on the same day. Every forth patient’s id is taken and the case file is followed till the patient leaves the bed. Patient’s Id was considered for identifying the files but patient’s names were purposefully kept out of the list during measurement due to the reason of privacy.

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Discharge initiation by Consultants

Inform Patient Party

Send Billing sheet to Inpatient Billing

Send file to DPD Draft prepared by DPD

Medicine Return & Indenting

Cross verification

Corrections Present

Draft sent for Correction by Jr DR

Billing finalized

Credit Letter

No corrections

Final copy Prepared

Cash TPA through Corporate Cell with D/C summary

Letter Sanctioned

Corrections Present

Payment sanctioned

Final Copy sent for Correction by Jr DR No corrections

B

D/C summary sent to ward No

PTCA/Diabet ic Yes A

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C


INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

A Counseling By: Nurse, Diabetic, Diabetic, Physiotherapy & yoga

B

Billing Clearance Slip Issued

C

The patient walking out from the Hospital

In the Measure Phase, we had to make sure that data is to be continuous. The Time Motion study was chosen as method of choice to measure the delays in the discharge process, (See Annex1: data). A data collection log sheet was created to measure the time required between each process. (Faster TAT by Angelo Pellicone & Maude Martocci). The time was charted using individual moving range control chart method. The reason the individual moving range chart was used since the small number of samples that were taken and irregular time of discharge. In the fig 2 we can see that only 3 out of control signals in the chart. We concluded that the Average time for discharge is 7 hours 51 minutes & standard deviation of 1 hour 17 minutes before any interventions were implemented. Average Time: 7 Hours 51 Minutes Standard Deviation: 1 Hours 17 Minutes Median: 7 Hours 45 minutes Minimum Time: 5 Hours 10 minutes Maximum Time: 10 Hours 15 minutes

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE 4:48 3:36 2:24 1:12 0:00 1

2

3

4

5

6

7

8

9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Range

UCL

+2 Sigma

+1 Sigma

Average

-1 Sigma

-2 Sigma

LCL

Fig 2 Moving Range Control Chart. Brainstorming sessions were conducted where all the Managers and the In-charges of the concerned departments are invited. The meeting was headed by COO and presided over by GM Administration. The time and motion chart was shown during the session to make the non-technical persons in the brainstorming sessions understand the potential areas of delays.

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

With the help of the fish bone diagram (root cause analysis) and control impact matrix the recommended suggestions were brainstormed and consensus was reached about the solutions that are to be implemented to make some changes in the process. The medical fraternity was purposefully kept out of the brainstorming sessions as it was thought that we needed to first streamline the administrative process. Ten days time was given to the managers and other in-charges for implementation of the strategies that came out during the brainstorming session. Then again the same measuring of the process was started. The second phase of measuring the process the same methodology was used. Same sampling procedure was followed as above. Here again 25 files were followed to look for the changes.

Analysis During the analysis phase, the variables that had most impact in the process were discussed and targeted for statistical analysis.

Pareto Analysis The pareto analysis of the variables taken as the best tool to segregate the sub-process (variables) that were contributing to the delays in the discharge process. The pareto analysis is a quantitative tallying of the type of defects that occur with a service. (Ken Black Statistics Pg715).Here the pareto chart shows the various bottlenecks those are responsible for the Average delay of discharge process is 7hours 51minutes. If we apply the 80-20 rule in the pareto analysis then we can conclude from the chart the number of the bottlenecks:  Time interval between Summary dispatch and the patient walking out of the Hospital  Time interval between Completion of the summary and file dispatch  Time interval between Consultant’s order for discharge and Case file received at the Data Processing Department  Time interval between the Draft complete and the Junior doctor starts correction

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100.00 90.00

2:24 2:07

2:09 1:55

71.86

70.00 % 60.00 D e 50.00 l a40.00 y s 30.00

Time in hours

80.00

1:40

1:26

1:26

1:11

1:12

0:53

0:57

0:48

0:43 0:31

0:30

20.00

0:28 0:12

10.00

0:11

0.00

0:00 Between Between Delay Between Between For Jr Dr Delay Time for Time taken Summary completion Between Draft file correction between Making the for Making Dispatch & of the Consultants completes reaching of the Draft start of draft of the final Patient summary & order for and Jr Dr the DPD & draft & Summary walking out File discharge & Starts Start of Corrected of the Dispatch Case file Correction. Draft case file Hospital received at DPD

Ishikawa Diagram and Control Impact Matrix Then fish bone diagram (root cause analysis) and the control impact matrix helped to prioritize the cause and highlight what was within the control of the hospitals’ management and determine what is going to impact in a big way. See Fig: control Impact Matrix. So from the above mentioned chart and the matrix we can see that things that like,  Responsibility of the shifting nurse ● Communication between floor in-charges & DPD ● 4-6 Attitude(visiting Hours) ● Nurse and patient relative communication Are within the control of the management and it would be easy to change. The causes which was least could be changed was  Attitude of the staff ● TPA Process ● Patient related factors

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0:14


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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE Impact Medium

High ●

In our control

Low

Responsibility of the shifting nurse ● Communication Between Floor incharges & DPD ● 4-6 Attitude(visiting Hours ● Nurse and patient relative Communication

Reports of Cath and other procedures ● Revision of the Prices ● Photographs & formalities of Govt Insurances ● Diabetic Education

Attitude of the staff

● ●

Pharmacy returns of medicine process

Control

Out of Control

TPA Process Patient related factors

Patient To meet Dr. Devi Prasad Shetty

Key Responsibility Areas of the Staffs Stake Holders Involved in the Process of discharge In Cardiology Consultants Jr Doctors Nurse

Key Responsibilities In discharge Process          

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Decision about discharge of the Process Final Signature for the summary Correction of the Draft Proofreading & final Signature of the final Summary Discharge communication to the Patient Relatives Preparing the Case file for Sending to the DPD Sending the Billing Sheet to the Inpatient Billing Collection of the reports that are pending & investigations which are required before discharge. Preparing the file for the Patient and a another file for the MRD Explaining the Discharge Summary to the Patient & Patient relative


Shifting Nurse

INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE  Shifting the Patient for Cath lab  Shifting the patient for Other investigations like Echo, X-ray etc  Shifting the patient from SDCCU and ward  Taking the samples from ward to the lab, which cannot be sent through Pneumatic system  Taking the Case files from ward to the DPD & return of the summary to the ward

Data Processors

  

Floor Coordinator

    

Patient & Patient Relative

 

Drafting the summary & final summary Communicating with the Consultants and Jr Doctors for correction and authorization of the summary Communicating with the Ward nurse & Floor Coordinators Communicating with the Corporate Cell for Insurance Establishing a rapport with the patient and the patient relative Coordinating with the Data processors, nurses, and patient and patient relative. To look for the reasons for the delay and communicate to the patient and patient relatives. To control the process and look for the reason for delay and try to resolve it. Paying the bill and displaying to the Allocated nurse for discharge Understanding the discharge Summary(Medications, and Review)

Key Responsibility Areas of Stakeholders From the above chart if closely study the shifting nurse profile then for a single nurse of a ward of bed strength more 40 and every day average 15 patients getting discharge from the same ward; she has too much workload. She had to bring the files from the floor and also back to the ward. This was her least priority work, as she had other responsibility mentioned in the chart. The other responsibilities used to take huge precious time as she/he had to go up and down the hospital many a times. As an example there may be a patient at the ward who had to be shifted for CT/MRI scan, then that patient would be shifted with the help this shifting nurse. Hence the other pending responsibilities would be remain pending, like discharge summary. Discharge summary was not her priority. Hence most of the time, it was found that the summary even after it was made authorized by the consultant, it was lying idle at the data processing department. The floor coordinators were not coordinating regarding this matter was another observation.

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Improve For improvement of the process, I have given some recommendation based on the analysis and also keeping in view, that it can be made operational. While formulating the recommendations the cost of implementation, and how much the recommendation would impact the process was considered as well. Recommendation

1. Summary Dispatch And Patient Walking Out Of The Hospital  Nursing staff/coordinator of the respective floors has to inform the patient relatives or attendants immediately once Doctors decides for discharge. And also another repeat communication can be provided to the patient relatives once the discharge summary and the billing is ready. So if the patient relatives come to the ward, they can clear the bill and as well take part in the patient education given by the dietician, rehabilitation specialists(physiotherapist and yoga therapist), and also diabetic counseling. This would again be followed by nurses’ education about the medications and explanation of the discharge summary.  Process should be flexible so that the patient’s relative or attendant has to be allowed to come inside the ward for completing discharge formalities.  Dedicated manpower should be deployed for issuing the discharge files to the data processing department and collecting the discharge summaries and cath procedure reports as soon as it is ready.  For diabetic patient, counseling from diabetology department if possible may be done in advance (parallel to the discharge summary process).  Corporate patients like Kalaignar Insurance Scheme and Vajpayee Arogya the photographs should be taken immediately after the procedure (SDCCU for cath patients)  Billing should be done parallel to the discharge summary process, and then time can be saved. Pre-requisites like the cath report, the returning of the medication and indenting the medications against the patients’ bill has to be completed.

2. Gap between the data processing department and respective floors once the summary is ready and duly signed by the consultants  Information should be passed on from the data processing department to the nurses or coordinator of the respective floors once the summary is duly signed.  The files which are signed by the consultant should not be encouraged to accumulate. 25


INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE  One person in respective floors should be held responsible for the follow up of discharge process; single point of contact has to be implemented, so that the process will be fast and easier. Hence the coordinator was given the responsibility of follow-up. 3. Ordering for discharge by the consultants and files reaching the data processing department:  Nurses have to prioritize the patient for discharge expect for the sick patients. A discharge desk was instituted at the 6th floor for the facilitation of the patient after my suggestion. The discharge desk was having experienced nursing staff for facilitation of the discharge patient and she would do the nursing education and also coordinate with the other educators. 4. Sr. residents or junior doctors’ correction of the draft copy of discharge summary  Draft copy of the discharge summary (if ready) should be placed at the top in the files by the nurse so that when consultants comes for round can correct the summary, so no need to wait for the residents to proofread twice. ( this protocol should be made mandatory)  For observation patients getting discharge, if the Junior resident can write the following sub headings:  Diagnosis,  The course in the hospital and  Medications on discharge in a consultant sheet it will be easy for preparation of discharge summary.

5. Delay in the data processing department  Files have to be prepared on the priority basis based on wards.  First in, first out (FIFO) process should be followed.  Lack of communication is observed in the data processing department in which the work is not shared properly and leads to delay in preparing discharge summaries. Long term recommendations

 Time line for discharge should be implemented, i.e., 4pm Or  Two time line slots also can be implemented like 12pm and 4pm  Control mechanism to be created for checking Average time for discharge of a patient

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

Control Discharge checklist forms have to be introduced at the hospital to track the time taken for every discharge. This checklist was structured on the same lines as used in this project. Every month during the weekly meeting the results of the data have to be presented before the Chief Operating Officer. The procedure for collection of data should be same as before (every time the case files changes hand had to be entered into the checklist) and to be reported to the Manager in-charge of the process. But this is having a challenge that is the person entering the time in the checklist may be biased. So suggestion was given that the same pattern of time entry should be incorporated in the HIS so the problem of biasing may be avoided. There would be special provision in the HIS that, the concerned managers or the GM administration and the COO may randomly check the control chart. And try to look for the patients who have gone out of control and track the same in search of the cause of the delay.

Discussion The commitment of the top management was critical to the improvement of the process of discharge in the six sigma tool application. Further reduction in the average time can be brought if the medical fraternity was also made aware about the consequences of delayed discharge. Raising awareness among medical fraternity about the reason for reducing time taken for the discharge. Their cooperation from them would surely be positive.

Conclusion In my project I have used DMAIC as an approach to streamline the discharge process in the hospitals Cardiology department patient. Several tools are involved in the study like process mapping, pareto chart, time line chart, statistical process control charts, fish and bone diagram (Ishikawa diagram), control impact matrices and as well trying to understand the KRA’s of the stakeholders in the process to look for the causes for delay. We found that significant reduction in the average discharge time from 7 hours 51 minutes to 6 hours 28 minutes which was 17.62% decrease. The time for correction of the draft is 2hours 38 minutes by the Junior Doctors and the Consultants. Once the discharge summary is handed to the ward the patient took 2 hours 14 minutes to walk out the ward and leave the hospital, this process has to be probed for continuous improvement. The major difference that bought; the files that were lying down idle for 2 hours 14 minutes. After a dedicated manpower was deployed for carrying the files from the Data Processing department to the ward, the work was done in 14 minutes, hence there was on an average 89% reduction. Also there were changes in the subprocess where after the consultant has ordered for discharge and file reaching the data processing department also reduced to 30% from the pre implementation study. The success in this approach seems to be related to the data driven six sigma methodologies. The success in this study also was due to the involvement of the top management commitment to improve the process of discharge and creating an atmosphere for change to be taken as a right spirit.

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INSTITUTE OF HEALTH MANAGEMENT RESEARCH BANGALORE

References 1. X. Zu et al The evolving theory of quality management: The role of Six sigma. Journal of operations management 26(2008) Pg 630-650 2. Theodore T. Allen, Shih-Hsien Tseng, Kerry Swanson, Mary Ann McClay: Improving the Hospitals discharge process with six sigma methods. Quality Engineering, 22 :1, 13-20 3. Mary Ann McClay. Hospitals get serious about Operations: Process Reengineering McKinsey, 74-85 4. David Anthony, VK Chetty, Anand Kartha, Kathleen McKenna,Maria Rizzo DePaoli, Brian Jack . Re-engineering the Hospital Discharge: An Example of a Multifaceted Process Evaluation. 5. Angello Pellicone and Maude Martocci. Faster Turn Around Time March 2006. www.asq.org 6. Chuck DeBusk,GE Healthcare; Kate Bombach, St. John Health. Improving the discharge process. GE Healthcare. 7. Health Board Executive. Admission and discharge guidelines. Health strategy Implementation 8. Chuck DeBusk and Art Rangel Jr. Creating a lean six sigma Hospital discharge process. An six sigma Case study. GE health care performance solutions

9. Sigma Breakthrough Technologies, IncŠ.Improving the inpatient discharge cycle time and patient satisfaction. Sbtionline.com 10. Institute for health care improvement, Š 2005 Cambridge, Massachusetts. www.ihi.org 11. Brandon Carrus, Stephen Corbett, Deepak Khandelwal; McKinsey Qaurterly. A hospital wide strategy for fixing emergency-department overcrowding. 12. Gerard C. Niemeijer, MSc, Albert Trip, PhD, Kees T. B. Ahaus, PhD, Ronald J. M. M. Does, PhD,and Klaus W. Wendt, MD, Ph. Quality in trauma care: Improving the discharge procedure of patients by means of lean six sigma. Journal of Trauma;69(614-619)

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