Average Time of Discharge: Why a Hospital is Not a Hilton

Do you get as annoyed as I do about being pressured on your “Time of Discharge?” I just received my monthly report, and we’re in The Doghouse again: our average TOD – 3:28 pm – is hours after “check-out time.”

But when did we turn into the Holiday Inn?

Let’s start by appreciating where this comes from. Many hospitals, including mine, tend to run full – given the huge fixed costs of operating a modern hospital, being full is probably the only way you can be profitable, just like the airlines. Queuing theory (don’t tell me you’ve forgotten your queuing theory!) tells us that, when you’re full, you should look for fundamental choke points and do your best to relieve them. There are PhDs working for McDonald’s whose lives are dedicated to figuring out how to avoid lines at lunchtime rush hour, and others working in aviation who model the best ways to load passengers onto planes (latest answer courtesy of a Fermi Lab astrophysicist: start in the back and load every third row, back to front, sequentially).  

The main stenosis in hospitals occurs in the early afternoon: the morning’s OR cases are finishing, the ED is heating up, the clinics are sending over elective and urgent admissions, the respiratory therapists have done their weaning and “liberated” a few patients from vents… and everybody needs a floor bed. Now! But they’re all taken, since nobody’s gone home yet.

Gridlock. Bad for business.

How do you fix this? About a decade ago, some smart consultant (I can’t figure out who, but he or she must have had a terrific PowerPoint slide making this point since every hospital I know of picked up on it) came up with the solution: let’s measure and report the time of discharge by service, shining the holy light of transparency on service chiefs like me to get them cracking. And since everybody likes Goals, how about we set a guideline – “The Discharge Time on 5 South is 11 am” – and post it in every room and nurse’s station. Then it won’t be a shocker to the family when we try to hustle grandma into the wheelchair and roll her out of her room before noon.

This all seems fine so far, particularly if I’m the COO or CFO. But from what I’ve seen visiting scores of hospitals in the U.S., achieving an 11 am discharge time, at least on medical services, is all-but-impossible. (If your hospital has met this goal, particularly on a medical service, I’d love to hear about it.) Why is this so hard?, naturally ask the C-Suite Folks, who see “good business” being turned away because sluggish physicians aren’t getting with the discharge-time program.

Because a Hospital is not a Hilton. If I have 14 patients on my service, my mornings are spent running around seeing them all, waiting for their labs, checking in with consultants, talking to family members and primary care physicians, and more. I’m also prioritizing my work – though the hospital undoubtedly wants me to see potentially discharge-able patients first, that violates the first rule of triage: see my sickest patients first. Until the cloning thing gets a bit more advanced, I can’t do both.

In other words, the morning of discharge is an amazingly active time – whereas, at the Hilton, I just have to get up, pack my bag, finish my brunch, read my USA Today, and I’m A La Casa. Moreover, the Hilton might hit me up for an extra $225 if I don’t get out on time.

All of this makes the hotel analogy fundamentally flawed.

For certain patients, of course, the morning may not be quite so active, and an 11 am checkout might be quite do-able. On surgical services, for example, discharge might hinge simply on whether Mrs. Jones has bowel sounds and kept down her breakfast; on medicine, on whether Mr. Diaz can walk or is no longer confused. But these patients, who can leave by 11, are the outliers.

In fact, with lengths of stay as short as they are now, the morning of discharge is not just active, it is hyperactive. So when I am pressured to “improve” my time of discharge, I usually respond, “If you’d like, I can move the average discharge time up to 8 am. It’ll just be one day later than I had planned.” CFOs don’t like to hear that.

Which brings me to my final plea: I believe it should be illegal to report Time of Discharge without also – in the same document – reporting adjusted average length of stay (or LOS against appropriate benchmarks). Time of discharge and ALOS are inextricably linked. The service that has a long length of stay AND a late discharge time might really have a problem. But the service with a short length of stay and a late discharge time is probably doing very good work, and harassing it over its TOD is annoying and counterproductive.

Can any good come out of the focus on time of discharge? Sure. Late discharges sometimes truly do highlight systems problems that need fixin’ – the teaching service that should be restructured so that the attending “card flips” with the housestaff to identify potential discharges before teaching rounds; the lab that needs to get its morning blood work out by 9 am, not 10:30; the social work/case management enterprise that needs streamlining. In such cases, the average discharge time can be a useful metric for QI projects that map out the mornings and shave some minutes here and there. And preparing patients and families the night before for a potential discharge makes good sense.

But just pressuring docs with a flawed and all-but-irrelevant hotel analogy – particularly when the data are presented without also considering performance on overall length of stay – is just plain silly.

17 Responses to “Average Time of Discharge: Why a Hospital is Not a Hilton”

  1. kirsten March 26, 2008 at 1:45 pm #

    My brother-in-law was in the hospital for only 1 full day after inexplicably fainting. at 8 am the next morning the nurses said he was ready to go, he signed almost all the discharge papers and was told he only had to see the neurologist before he could walk out. The neurologist showed up at 4:30pm! I understand his schedule is quite hefty and the hospital can not dictate who he sees first so is there a solution? And as you said, they put him through a battery of tests in only 1 day…. that should be reported.

  2. totoxm March 26, 2008 at 2:52 pm #

    I enjoy your blog and what you contribute to health care quality through your work.

    While I do not disagree with your stance here, I feel compelled to point out an issue that I see repeated throughout medicine. Schedules, systems, and processess that exist for the convenience of the doctor, the nurse, the techs, or the hospitals; instead of a schedule that is driven by the intent to provide patient-centered, customer friendly care. I see repeatedly the situation where the patient is just a cog in the wheel – instead of the hub. I think it is at the heart of many of the issues in medicine that end up negatively impacting everyone.

  3. pprescot March 27, 2008 at 12:37 am #

    totoxm: did you not read the whole post? Make rounds at 6 AM. Order labs, get OK results at 11 AM. Meet the discharge deadline?

    Etc Etc Etc.

    The patient IS the cog. And the poorly designed “gears” are the hospital services. But the blame, of course, falls on the MD.

    Expect the administrative MBA trained pygmies to get the point? Maybe, in a hundred years.

  4. menoalittle March 27, 2008 at 2:13 am #

    Bob,

    Interesting. Have you been called to the C-Suite yet? It is inconceivable that a patient is safe when the hyperactivity is focused on a deadline for getting the patient out of the hospital, unless it was a soft admission not needing to be hospitalized in the first place and the patient enjoyed breakfast in bed. Most hospitals have vacant beds that are not staffed based on business decisions by the same C-Suite Folks who see patients as customers and whose mantra places profits before patients. This is a distinctly different approach from the warm and fuzzy hospital mission statements appearing on the glossy annual reports would have everyone believe.

    BTW, if you ever deploy the care altering CPOE devices that have been coming to UCSF “next year for the past five years” (your January 27, 2008 post), the TOD and ALOS will not improve and will likely go south. Then what?

    Best regards and continue these articulate posts,

    Menoalittle

  5. josh March 27, 2008 at 9:15 pm #

    Most pediatric programs handle this by discharging the patient the next day. I know that’s pretty bogus but if a patient is ready Thursday evening, he usually gets sent home Friday morning. At least the housestaff have time to fill out the paperwork!

  6. vanillablue March 27, 2008 at 10:01 pm #

    totoxm: I’d argue that discharging a patient later in the day usually is providing patient-centered care. It allows for more time for discharge planning, is usually more convenient for families to pick up the patient, and is overall less “rushed” for the patient. Arbitrarily stating that patients should be discharged by a fixed time is not patient-centered at all.

    • Loquascious March 26, 2014 at 5:58 pm #

      Usually a discharge before noon is planned the afternoon before and is more relaxed. Discharging a patient a 5 PM is usually rushed and harried. Patients get home as pharmacies close, physicians offices close, and case workers and social workers go home for the evening. Overall suboptimal.

  7. DZA March 27, 2008 at 10:59 pm #

    “In fact, with lengths of stay as short as they are now, the morning of discharge is not just active, it is hyperactive. So when I am pressured to “improve” my time of discharge, I usually respond, “If you’d like, I can move the average discharge time up to 8 am. It’ll just be one day later than I had planned.” CFOs don’t like to hear that.”

    Precisely my response to case management. The D/C well enough to have gone home this morning, I already sent home yesterday evening…

    /love your stuff

  8. totoxm April 1, 2008 at 3:45 am #

    I guess I wasn’t clear. It just seems to me (having been a patient, and more importantly having had children in the hospital several times) that the whole system is screwy. Dr. Wachter is of course making the point from the physician’s perspective. I have to say however that I detect an undercurrent of physician convenience at the heart of his comments – that’s what I was responding to. I am probably wrong about Dr. Wachter, but I have seen too often the very same type of behavior he is accusing the hospital admin of doing on the part of physicians themselves. It is all to easy to blame “MBA trained pygmies”, but I have seen as bad or worse behavior from physicians in terms of doing things out of concern for their own convenience or precious time, rather than what the patient needs.
    Here is what I’m really talking about: why do we have a situation where it is doctors vs. admin? The whole thing is wacked.

  9. chris johnson April 8, 2008 at 1:26 am #

    From my perspective as a pediatrician, the paradigm makes even less sense because length of stay is so short with children. They get sick fast, they get well fast. So a good share of the time we don’t even know they might be ready to go home until after we round on them. Then there’s the dismissal paperwork (which gets more burdonsome by the year), etc., etc. We’re lucky to get them out by 3 pm. As you’ve pointed out, of course, we could go back to the old way — dismiss them the next morning.

  10. Dede April 8, 2008 at 3:37 am #

    totoxm,
    you are right about the whole system is wacked.
    I don’t know about you, but if I need to get my car fixed, I’ll have to make an appointment and leave it to them to repair when they have time to repair ,and I pay what they ask for.
    Now the doctors work whenever are needed because the sick bodies can wait until you have convenient time to work, so we do nights, we work 20 hours a day sometimes when it gets crazy,we get paid whatever the insurance company willing to cover or not at all, a lot of times it’s not like we don’t want to make your stay more pleasant, we just have to go and see 20 more really sick people and give them the best care we could deliver as well. Otherwise, the patient relations will find you, nurses will be paging you, other families are angry, worst of all….. ,if you missed any thing or you are too slow to see a very sick patient-you get sued!
    Unfortunately, hospital is not hilton after all, please bear with us, we are here to help you and your family to get better, we are doing the best we can in this wacked system.

  11. menoalittle April 10, 2008 at 5:39 am #

    Bob,

    Speaking of Hiltons and hospitals, I decided to  research  executive compensation of both.  In the year 2006, Hilton’s CEO, Stephen Bollenbach, received one million dollars in salary, a $137,830 bonus, and stock and option awards totaling $8,720,247. Hilton’s President and COO, Matthew Hart, received $850,000 in salary, no bonus, and stock and option awards totaling $1,985,788.

    In contrast, a  table from the April 4, 2008 “Wall Street Journal”, that is not reproducible in its original form here, lists salaries of “some of the best paid  nonprofit hospital CEOs” for the same year, 2006:

                                                                                     total comp in $millions

    Gary Mecklenburg (Northwestern Memorial Hospita)            16.4

    Floyd Loop           (Cleveland Clinic)                                     7.5

    Mark Neaman      (Evanston Northwestern Healthcare)          5.4

    Lloyd Dean          (Catholic Healthcare West)                        5.3

    Philip Incarnati     (McLaren Health Care Corp.)                     5.2

    Joseph Trunfio     (AHS Hospital Corp.)                                 5.0

    Alan Brass           (Promedica)                                             4.1

    Herbert Pardes    (New York-Presbyterian)                            3.5

    Jeffrey Romoff     (UPMC)*                                                  3.3

    Douglas French    (Ascension Health)                                   3.3

       *   a subject of a Wachter’s World post

    Would you rather run a hospital or the Hilton?  Perhaps, the CEOs  really think they are operating the Hilton?

    Best regards,

    Menoalittle

  12. Quality Nurse May 15, 2008 at 2:14 pm #

    This was a very interesting blog, and I feel compelled to share some of my own thoughts. I understand the doctors’ position, they are very busy and require triaging their patients; the sickest should come first. However, administration focuses on the bottom line, after all, forced to make the most from less and less, administration must focus its attention on maximizing reimbursement. Most contracts will state that hospitals are paid on the day of admission, but not on the day of discharge. Therefore, keeping a patient longer through the day keeps a potential bed occupied by a non-paying patient.
    It may be unfortunate that this is what it has come to, but it is the state of affairs. The 11 am discharge time seems universal, but it is just a number. I believe that the primary focus is that discharges are timely and administration would appreciate a sincere effort to expedite these discharges.
    What this blog points out is the disconnect of physicians and administration. Both pushing their own agendas, and both are valid. Neither seem to want to sit down together and attempt to look at the process in place and suggest how it could be changed or improved. Too many times I have seen MD’s say that they didn’t care what happens to the hospital, they will still get paid. And on the other side, MD’s have to be responsible for treating their patients how they see fit; we seem to have quite a conundrum.
    In another post, Dr. Provonost was mentioned and appears highly regarded. In the past he spearheaded a PI process in the ICU’s aimed at improving communication among the healthcare staff, while involving the patient and family. This project, Transformation in the ICU, successfully improved communication by changing the way things are done. There was a better understanding by the whole team of the plan of care and what had to be done and seen by the attending physician to achieve a safe discharge. The project ended with a decrease in LOS, improved safety and quality, etc. Please research this project from Johns Hopkins.
    Perhaps through the proper use of physician extenders, and a well-communicated plan, discharges could be achieved without the attending physician to actually need to see the patient. This may be seen as rude or unprofessional, but so is keeping a patient sitting in a hospital bed just to wait for the attending to come and say goodbye.

  13. Bobpaule May 20, 2008 at 9:45 pm #

    I have the exceptional privilege of working for a 200 bed community non-profit hospital, still out of the reach of the degrading symbiosis (commensalism may be the more appropriate term here) between large HMOs and our greedy politicians. Doctors here have a real say in decision making.

    As a result fixed discharge times were eliminated 10 years ago, and sometimes patients spend the next night just because there is no one to pick them up.

  14. tongen November 4, 2008 at 9:59 pm #

    Hospital or Hilton

    As you accurately point out, signs like “Discharge Time: 11 AM” seem pointless and, frankly, insulting. “My patients aren’t going anywhere until I say so.” is sometimes heard in the doctor’s lounge. Another popular one, “It’s all about money!”

    Hospitals across the country are struggling to make ends meet. Now, more than ever in these very tough financial times. Investment income is way down and charity/unreimbursed care has exploded coincident with the unemployment rate. The federal deficit is at an all time high, and medicare is running out of money faster than the politicians can spend it. The US Healthcare system is, by far, one of the most expensive in the world yet is unable to brag that it delivers quality to match.

    So how does this effect hospitalists. Well, for starters, you better start caring about your hospitals bottom line or you will be out of a job. This doesn’t mean you have to sacrifice patient care, it means we all have to trim the waste and fat. For the most part, administrators have no desire in pushing sick old grandma out of the hospital too early.

    Let’s agree to define”too early” as it pertains to a clinical endpoint.

    It’s bad for business in many ways. It leads to a bad community reputation resulting in fewer patients. It may result in a higher readmission rate, which will be frowned upon by CMS. Now if your hospital is pretty full most of the time then this is also a bad thing for patients and care because the longer Mrs. Smith sits in her hospital bed (on the day she is clinically ready for discharge) then the longer another patient waits somewhere else and the more likely Mrs. Smith will suffer a hospital-related infection or injury. So given all the downsides to “hanging out” in the hospital why is it so hard to discharge patients in the morning?

    It is often because of poor planning. One of the most common questions asked by patients and family upon admission is, “How long will I be in the hospital?” The truth is that we really suck at answering this question because we are afraid to give them an estimate and then be wrong. But it can be done. Studies have shown that the accuracy of the physician’s best guess at this is not the driving point. It is the fact that the physician is more likely to be driving toward a discharge goal if they are indeed answering this question.

    Another reason may be that nurses are reluctant to process a discharge in an efficient manner because it will mean that they might end up with another admission before there shift ends.

    If we physicians can communicate discharge goals/plans at a time earlier than the day of discharge, then patients and families can prepare and don’t suffer from failed expectations, so patient satisfaction improves. Then nurses, colleagues, social workers, and care coordinators can work toward with the patient and family with the same goal in mind. If the patient’s clinical condition changes then goals and plans can be adjusted accordingly. Most hosptitals don’t need EVERYONE discharged by 11AM. In fact this would overwhelm the capabilities of many hospitals. Ask your hospital to graph discharge across time of day and you will likely see what most US hospitals see…a big bump right before the evening shift starts.

    We ran some statistics at my health system and discovered:
    1. If every patient in system was discharged 1 hour earlier it would save the organization $3 million in the course of a year.
    2. Patients admitted on a Tuesday have a LOS that is 0.22 days less than if admitted on a Friday.
    3. Patients discharged on a Thursday have a LOS that is 0.77 days less than if discharged on a Monday.

    Three million dollars for one hour! Imagine the savings if that was applied across all hospitalized patients in the USA. Think of the possibilities and that’s just for one hour, now imagine it was 6-8 hours.

    As physicians we have an obligation to improve on this. We need to get over any “control issues” we may have. We need to help set appropriate care and length of stay expectations for patients and staff alike. We need to cut out the fat and waste in our practices and work flows and we will begin to make a difference.

    Scott Tongen, MD

    • Mt Doc March 27, 2014 at 5:17 pm #

      It’s great that 1 hour of earlier discharge would save money. However, I have found I cannot meet the discharge time and have basically given up paying attention to it. I am a hospitalist and get to the hospital an hour before my day shift because I get more work done in the early morning than in the next 4 hours, when I get paged every ten minutes. The first people I see are the sickest – those in the ICU usually take priority followed by people on the floor having problems. Then I see the new admissions who came in the night before. Next I see the patients ready to be discharged, unless I get interrupted by another admission that morning or a patient deteriorating. Then I see the stabler patients who are not ready for discharge. Since the number of ICU patients, the number of unstable patients, and the number of new admissions varies from day to day, the time that I can see the patients ready for discharge varies from day to day. My feeling is that I’ll see then as soon as I can but I will not put an unstable patient at risk to get a stable one out the door sooner. Like most hospitalists, I have no desire to have a service size larger than I need to and no desire to delay discharges. My day runs a lot smoother if I have a lighter patient load. I also try to get as much of the discharge paperwork done as possible one day early.

      There are ways around this if the hospital would feel it important enough. I could be teamed up with a nurse practitioner whose job it would be to discharge the patients who were ready while I attended to those who were unstable, for instance. With the current situation, however, I feel that railing at hospitalists for not getting discharges done at an arbitrary time is just another stick to beat the doctors with over something they have little control over.

  15. Online Checking Account January 11, 2010 at 7:12 pm #

    Perhaps through the proper use of physician extenders, and a well-communicated plan, discharges could be achieved without the attending physician to actually need to see the patient.

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