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Barriers to Earlier Hospital Discharge: What Matters Most?
“Every system is perfectly designed to get the results it gets.”
—W. Edwards Deming inspired quote1
The timing of patient discharge represents a Gordian knot in hospital operations. Moving the time of discharge to earlier in the day is a complex challenge that defies replicable solutions and is often a barrier to optimal throughput and patient experience. In this issue of the Journal of Hospital Medicine, Zoucha et al. identify that discharge orders are frequently delayed due to physicians caring for other patients, heterogeneity in physician rounding styles, and other intrinsic factors such as census size, rounding style, and teaching versus nonteaching services.2 Some of these factors and their negative impact are consistent with the effect of higher hospitalist workload (census) when increasing length of stay that was identified by Elliott et al.3 Others, such as rounding style and balancing teaching and education, are a part of many hospitalist service operations. Other intrinsic factors identified by the authors include awaiting consultant recommendations, care completion by social workers, procedures, labs, radiology, therapy services, and home oxygen.
The authors, however, recognize hospitalist behaviors and hospital operations as intrinsic factors. This is significant because intrinsic factors are theoretically under the control of the hospital’s physicians, administration, and support services. They lend themselves to continuous improvement, re-engineering, and change management. They are a direct result of the people, processes, structure, and supporting information technology (IT).
The findings of this study contrast with the perceived dominance of extrinsic factors such as awaiting a ride, insurance authorization issues, or placement as the cause for discharge delays. Anecdotally, physicians and nurses in organizations often identify such extrinsic factors as causes of discharge delays before they call out intrinsic factors.
Frequently, the first reaction to managing complex intrinsic constraints is to add resources and complexity. Continuous improvement often reveals the culprit is poor design and waste found throughout the system. Zoucha et al. refer to LEAN successes by others4 as an example of how to approach these complex intrinsic issues. Increasing early discharge with improvement in length of stay and reducing or maintaining the readmission rate has been achieved using the Institute for Healthcare Improvement Model for Improvement,5 the Red/Yellow/Green Discharge Tool within the electronic medical record,6 and a comprehensive management plan.7 These examples were often accomplished through improving the deployment of existing resources and reducing wasted activity. New predictive tools using supervised machine learning can help identify appropriate patients for discharge earlier in the day.8 This approach is built on the concepts of “efficiency and communication as components of quality healthcare delivery.”6
Perhaps a practical reductionist approach is to start with the end in mind, and ask the question “what matters most?” Three key times occur in each discharge and the authors capture two of these: the discharge order time and discharge time. Not captured is the time the patient and family are told they are being discharged. It is against this backdrop that we can look at four perspectives: caregiver, organization, community, and the patient and family. “What matters most?” depends on the perspective of each one of the parties involved.
From the perspective of the caregivers (physicians and residents), the conclusions support prioritizing rounding on patients ready to discharge, lowering team census, and restructuring teaching rounds to drive earlier discharges. But only 7% of encounters prioritized patients ready for discharge first. Seventy-six percent prioritized sickest patients first (33%), room-by-room (27%), and newest patients (16%).2 The authors emphasize that such an approach needs to be balanced against the needs of the entire team census to ensure optimal care for all patients. Team and individual hospitalist census and processes must be optimized to improve the efficiency and effectiveness of the work. For teaching services, the goal is to accomplish effective teaching while maintaining or improving throughput. When
Healthcare is delivered by teams. As we look at supporting and structuring our hospitalist teams’ inpatient rounding we need to include the contributions of advanced practice professionals, pharmacists, nurses, care managers, social workers, and others. Achieving a team focus on a goal can be supported by number-by-time (n-by-T) target initiatives, which have been used successfully.10,11 Team-based solutions must be developed to address these complex issues and in recognition of the need to distribute this responsibility across the system, not just depending on physician changes to ensure optimal outcomes.
The perspectives of organization and community have the common goals of delivering healthcare value (outcomes, quality, safety, and sustainability) and ensuring access. To achieve these, it is important to separate the discharge curve (by shifting these patients’ time of discharge to the left) from the arrival curve, which is more fixed. The organization and community benefit from reduced cost of care, improved value delivery, and better access to services. For hospitals and health systems facing high occupancy, this becomes important for access and serving the community, especially during the peak hours for admissions and discharges.
Against this backdrop is the most important perspective, which is that of the patients and families. What matters most to them? When does their clock start? For patients and families, we believe that their expectations begin when the physician or APP says, “you are doing well and we can get you home today.” In the current study, the median time to discharge from the discharge order for four of the five hospitals was about three hours.2 It is reasonable to assume the time interval is on the order of four to six hours or more for many patients. Is this acceptable? We have little data to answer this question directly, and while the Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) survey asks select questions regarding the effectiveness of discharge information, it is silent on matters of discharge timeliness and expectations. While on the administrative side we often use readmission rates as a proxy for a safe and “effective” discharge, in reality, we lack meaningful patient-reported outcome measures to assess our effectiveness, which is a necessity for performance improvement.
The opportunities for improvement suggested by this study include restructuring rounding to prioritize discharges, managing census per provider, and rethinking resident education to accommodate both education and service. The authors’ approach includes identifying ways to improve the efficiency of the work through other team members (such as pharmacy techs for medication reconciliation) and balancing ancillary services support for all inpatient care and the outpatients they serve. Alternatively, tying incentives to the goal could be a convenient leadership response. The 2016 Society of Hospital Medicine State of Hospital Medicine Report notes that more than half (54%) of nonacademic hospitalist groups that treat adults have an incentive tied to early morning discharge orders or times. We believe that by keeping the patients and families at the center of this discussion, we are more likely to accomplish the goal of improved safety, efficiency, effectiveness, and patient experience.
The literature supports discharge delays as an international challenge with research on the topic in healthcare systems across the world.12 This may be related to an aging population, improvements, and access to advanced healthcare, and the challenges of occupancy and capacity mismatches in many healthcare systems worldwide. The authors have identified important intrinsic factors for these throughput and discharge delays. The results beg the question, are we willing to do the redesign and behavior change in our delivery of healthcare and healthcare education to achieve a more optimized system of care delivery?
A now-retired Cleveland Clinic performance improvement engineer frequently referenced W. Edwards Deming on “what makes the biggest difference in improving internal service quality?” He distilled this to two axioms based on Deming’s work: reducing cycle time and reducing defects. Both must be accomplished from the customer’s (patient’s) perspective without tradeoffs between the two. Cycle time is the time to accomplish a completed process or action, such as patient discharge or LOS. Defects are all the waste or “impossible” challenges that contribute to the feeling of resignation that lead to people dismissing the possibility of improvement, stating “it is what it is.” The challenge in the service of our patients and families, organizations, and communities is to move this dialog forward to “it is what we make it.”13
When we tell the patient and family they are being discharged it should happen safely, efficiently, predictably, and with empathy. From the perspective of clinicians, it should be as easy as possible to consistently do the right thing and do the work to which they have dedicated themselves. For communities and organizations struggling with access, improving throughput is vital.
Disclosures
Neither author has any conflicts to disclose. There are no external funding sources for this manuscript.
1. Institute for Healthcare Improvement. Available at: http://www.ihi.org/communities/blogs/origin-of-every-system-is-perfectly-designed-quote. Accessed August 2, 2018.
2. Zoucha J, Hull M, Keniston A, et al. Barriers to Early Hospital Discharge: A Cross Sectional Study at Five Academic Hospitals. J Hosp Med. 2018;13(12):816-822. doi: 10.12788/jhm.3074. PubMed
3. Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786. doi: 10.1001/jamainternmed.2014.300. PubMed
4. Beck MJ, Okerblom D, Kumar A, Bandyopadhyay S, Scalzi LV. Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion. Hosp Pract. 2016;44(5):252-259. doi: 10.1080/21548331.2016.1254559. PubMed
5. Patel H, Morduchowicz S, Mourad M. Using a Systematic Framework of Interventions to Improve Early Discharges. Jt Comm J Qual Patient Saf. 2017;43(4):189-196. doi: 10.1016/j.jcjq.2016.12.003. PubMed
6. Mathews KS, Corso P, Bacon S, Jenq GY. Using the Red/Yellow/Green Discharge Tool to Improve the Timeliness of Hospital Discharges. Jt Comm J Qual Patient Saf. 2014;40(6). doi:10.1016/s1553-7250(14)40033-3. PubMed
7. Wertheimer B, Jacobs REA, Bailey M, et al. Discharge before noon: An achievable hospital goal. J Hosp Med. 2014;9(4):210-214. doi: 10.1002/jhm.2154. PubMed
8. Barnes S, Hamrock E, Toerper M, Siddiqui S, Levin S. Real-time prediction of inpatient length of stay for discharge prioritization. J Am Med Inform Assoc. 2015;23(e1). doi: 10.1093/jamia/ocv106. PubMed
9. Wachter RM. Hospitalist Workload. JAMA Intern Med. 2014;174(5):794. doi:1 0.1001/jamainternmed.2014.18. PubMed
10. Parikh PJ, Ballester N, Ramsey K, Kong N, Pook N. The n-by-T Target Discharge Strategy for Inpatient Units. Med Decis Making. 2017;37(5):534-543. doi:10.1177/0272989x17691735. PubMed
11. Kane M, Weinacker A, Arthofer R, et al. A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon. J Nurs Adm. 2016; 46(12):630-635.doi: 10.1097/NNA.0000000000000418 PubMed
12. Rojas-García A, Turner S, Pizzo E, Hudson E, Thomas J, Raine R. Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expect. 2017;21(1):41-56. doi: 10.1111/hex.12619. PubMed
13. Emmelhainz L. Achieving Excellence: Some Last Thoughts. Lecture presented: Health System Leadership at Cleveland Clinic Akron General; May 16, 2018; Akron, OH. PubMed
“Every system is perfectly designed to get the results it gets.”
—W. Edwards Deming inspired quote1
The timing of patient discharge represents a Gordian knot in hospital operations. Moving the time of discharge to earlier in the day is a complex challenge that defies replicable solutions and is often a barrier to optimal throughput and patient experience. In this issue of the Journal of Hospital Medicine, Zoucha et al. identify that discharge orders are frequently delayed due to physicians caring for other patients, heterogeneity in physician rounding styles, and other intrinsic factors such as census size, rounding style, and teaching versus nonteaching services.2 Some of these factors and their negative impact are consistent with the effect of higher hospitalist workload (census) when increasing length of stay that was identified by Elliott et al.3 Others, such as rounding style and balancing teaching and education, are a part of many hospitalist service operations. Other intrinsic factors identified by the authors include awaiting consultant recommendations, care completion by social workers, procedures, labs, radiology, therapy services, and home oxygen.
The authors, however, recognize hospitalist behaviors and hospital operations as intrinsic factors. This is significant because intrinsic factors are theoretically under the control of the hospital’s physicians, administration, and support services. They lend themselves to continuous improvement, re-engineering, and change management. They are a direct result of the people, processes, structure, and supporting information technology (IT).
The findings of this study contrast with the perceived dominance of extrinsic factors such as awaiting a ride, insurance authorization issues, or placement as the cause for discharge delays. Anecdotally, physicians and nurses in organizations often identify such extrinsic factors as causes of discharge delays before they call out intrinsic factors.
Frequently, the first reaction to managing complex intrinsic constraints is to add resources and complexity. Continuous improvement often reveals the culprit is poor design and waste found throughout the system. Zoucha et al. refer to LEAN successes by others4 as an example of how to approach these complex intrinsic issues. Increasing early discharge with improvement in length of stay and reducing or maintaining the readmission rate has been achieved using the Institute for Healthcare Improvement Model for Improvement,5 the Red/Yellow/Green Discharge Tool within the electronic medical record,6 and a comprehensive management plan.7 These examples were often accomplished through improving the deployment of existing resources and reducing wasted activity. New predictive tools using supervised machine learning can help identify appropriate patients for discharge earlier in the day.8 This approach is built on the concepts of “efficiency and communication as components of quality healthcare delivery.”6
Perhaps a practical reductionist approach is to start with the end in mind, and ask the question “what matters most?” Three key times occur in each discharge and the authors capture two of these: the discharge order time and discharge time. Not captured is the time the patient and family are told they are being discharged. It is against this backdrop that we can look at four perspectives: caregiver, organization, community, and the patient and family. “What matters most?” depends on the perspective of each one of the parties involved.
From the perspective of the caregivers (physicians and residents), the conclusions support prioritizing rounding on patients ready to discharge, lowering team census, and restructuring teaching rounds to drive earlier discharges. But only 7% of encounters prioritized patients ready for discharge first. Seventy-six percent prioritized sickest patients first (33%), room-by-room (27%), and newest patients (16%).2 The authors emphasize that such an approach needs to be balanced against the needs of the entire team census to ensure optimal care for all patients. Team and individual hospitalist census and processes must be optimized to improve the efficiency and effectiveness of the work. For teaching services, the goal is to accomplish effective teaching while maintaining or improving throughput. When
Healthcare is delivered by teams. As we look at supporting and structuring our hospitalist teams’ inpatient rounding we need to include the contributions of advanced practice professionals, pharmacists, nurses, care managers, social workers, and others. Achieving a team focus on a goal can be supported by number-by-time (n-by-T) target initiatives, which have been used successfully.10,11 Team-based solutions must be developed to address these complex issues and in recognition of the need to distribute this responsibility across the system, not just depending on physician changes to ensure optimal outcomes.
The perspectives of organization and community have the common goals of delivering healthcare value (outcomes, quality, safety, and sustainability) and ensuring access. To achieve these, it is important to separate the discharge curve (by shifting these patients’ time of discharge to the left) from the arrival curve, which is more fixed. The organization and community benefit from reduced cost of care, improved value delivery, and better access to services. For hospitals and health systems facing high occupancy, this becomes important for access and serving the community, especially during the peak hours for admissions and discharges.
Against this backdrop is the most important perspective, which is that of the patients and families. What matters most to them? When does their clock start? For patients and families, we believe that their expectations begin when the physician or APP says, “you are doing well and we can get you home today.” In the current study, the median time to discharge from the discharge order for four of the five hospitals was about three hours.2 It is reasonable to assume the time interval is on the order of four to six hours or more for many patients. Is this acceptable? We have little data to answer this question directly, and while the Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) survey asks select questions regarding the effectiveness of discharge information, it is silent on matters of discharge timeliness and expectations. While on the administrative side we often use readmission rates as a proxy for a safe and “effective” discharge, in reality, we lack meaningful patient-reported outcome measures to assess our effectiveness, which is a necessity for performance improvement.
The opportunities for improvement suggested by this study include restructuring rounding to prioritize discharges, managing census per provider, and rethinking resident education to accommodate both education and service. The authors’ approach includes identifying ways to improve the efficiency of the work through other team members (such as pharmacy techs for medication reconciliation) and balancing ancillary services support for all inpatient care and the outpatients they serve. Alternatively, tying incentives to the goal could be a convenient leadership response. The 2016 Society of Hospital Medicine State of Hospital Medicine Report notes that more than half (54%) of nonacademic hospitalist groups that treat adults have an incentive tied to early morning discharge orders or times. We believe that by keeping the patients and families at the center of this discussion, we are more likely to accomplish the goal of improved safety, efficiency, effectiveness, and patient experience.
The literature supports discharge delays as an international challenge with research on the topic in healthcare systems across the world.12 This may be related to an aging population, improvements, and access to advanced healthcare, and the challenges of occupancy and capacity mismatches in many healthcare systems worldwide. The authors have identified important intrinsic factors for these throughput and discharge delays. The results beg the question, are we willing to do the redesign and behavior change in our delivery of healthcare and healthcare education to achieve a more optimized system of care delivery?
A now-retired Cleveland Clinic performance improvement engineer frequently referenced W. Edwards Deming on “what makes the biggest difference in improving internal service quality?” He distilled this to two axioms based on Deming’s work: reducing cycle time and reducing defects. Both must be accomplished from the customer’s (patient’s) perspective without tradeoffs between the two. Cycle time is the time to accomplish a completed process or action, such as patient discharge or LOS. Defects are all the waste or “impossible” challenges that contribute to the feeling of resignation that lead to people dismissing the possibility of improvement, stating “it is what it is.” The challenge in the service of our patients and families, organizations, and communities is to move this dialog forward to “it is what we make it.”13
When we tell the patient and family they are being discharged it should happen safely, efficiently, predictably, and with empathy. From the perspective of clinicians, it should be as easy as possible to consistently do the right thing and do the work to which they have dedicated themselves. For communities and organizations struggling with access, improving throughput is vital.
Disclosures
Neither author has any conflicts to disclose. There are no external funding sources for this manuscript.
“Every system is perfectly designed to get the results it gets.”
—W. Edwards Deming inspired quote1
The timing of patient discharge represents a Gordian knot in hospital operations. Moving the time of discharge to earlier in the day is a complex challenge that defies replicable solutions and is often a barrier to optimal throughput and patient experience. In this issue of the Journal of Hospital Medicine, Zoucha et al. identify that discharge orders are frequently delayed due to physicians caring for other patients, heterogeneity in physician rounding styles, and other intrinsic factors such as census size, rounding style, and teaching versus nonteaching services.2 Some of these factors and their negative impact are consistent with the effect of higher hospitalist workload (census) when increasing length of stay that was identified by Elliott et al.3 Others, such as rounding style and balancing teaching and education, are a part of many hospitalist service operations. Other intrinsic factors identified by the authors include awaiting consultant recommendations, care completion by social workers, procedures, labs, radiology, therapy services, and home oxygen.
The authors, however, recognize hospitalist behaviors and hospital operations as intrinsic factors. This is significant because intrinsic factors are theoretically under the control of the hospital’s physicians, administration, and support services. They lend themselves to continuous improvement, re-engineering, and change management. They are a direct result of the people, processes, structure, and supporting information technology (IT).
The findings of this study contrast with the perceived dominance of extrinsic factors such as awaiting a ride, insurance authorization issues, or placement as the cause for discharge delays. Anecdotally, physicians and nurses in organizations often identify such extrinsic factors as causes of discharge delays before they call out intrinsic factors.
Frequently, the first reaction to managing complex intrinsic constraints is to add resources and complexity. Continuous improvement often reveals the culprit is poor design and waste found throughout the system. Zoucha et al. refer to LEAN successes by others4 as an example of how to approach these complex intrinsic issues. Increasing early discharge with improvement in length of stay and reducing or maintaining the readmission rate has been achieved using the Institute for Healthcare Improvement Model for Improvement,5 the Red/Yellow/Green Discharge Tool within the electronic medical record,6 and a comprehensive management plan.7 These examples were often accomplished through improving the deployment of existing resources and reducing wasted activity. New predictive tools using supervised machine learning can help identify appropriate patients for discharge earlier in the day.8 This approach is built on the concepts of “efficiency and communication as components of quality healthcare delivery.”6
Perhaps a practical reductionist approach is to start with the end in mind, and ask the question “what matters most?” Three key times occur in each discharge and the authors capture two of these: the discharge order time and discharge time. Not captured is the time the patient and family are told they are being discharged. It is against this backdrop that we can look at four perspectives: caregiver, organization, community, and the patient and family. “What matters most?” depends on the perspective of each one of the parties involved.
From the perspective of the caregivers (physicians and residents), the conclusions support prioritizing rounding on patients ready to discharge, lowering team census, and restructuring teaching rounds to drive earlier discharges. But only 7% of encounters prioritized patients ready for discharge first. Seventy-six percent prioritized sickest patients first (33%), room-by-room (27%), and newest patients (16%).2 The authors emphasize that such an approach needs to be balanced against the needs of the entire team census to ensure optimal care for all patients. Team and individual hospitalist census and processes must be optimized to improve the efficiency and effectiveness of the work. For teaching services, the goal is to accomplish effective teaching while maintaining or improving throughput. When
Healthcare is delivered by teams. As we look at supporting and structuring our hospitalist teams’ inpatient rounding we need to include the contributions of advanced practice professionals, pharmacists, nurses, care managers, social workers, and others. Achieving a team focus on a goal can be supported by number-by-time (n-by-T) target initiatives, which have been used successfully.10,11 Team-based solutions must be developed to address these complex issues and in recognition of the need to distribute this responsibility across the system, not just depending on physician changes to ensure optimal outcomes.
The perspectives of organization and community have the common goals of delivering healthcare value (outcomes, quality, safety, and sustainability) and ensuring access. To achieve these, it is important to separate the discharge curve (by shifting these patients’ time of discharge to the left) from the arrival curve, which is more fixed. The organization and community benefit from reduced cost of care, improved value delivery, and better access to services. For hospitals and health systems facing high occupancy, this becomes important for access and serving the community, especially during the peak hours for admissions and discharges.
Against this backdrop is the most important perspective, which is that of the patients and families. What matters most to them? When does their clock start? For patients and families, we believe that their expectations begin when the physician or APP says, “you are doing well and we can get you home today.” In the current study, the median time to discharge from the discharge order for four of the five hospitals was about three hours.2 It is reasonable to assume the time interval is on the order of four to six hours or more for many patients. Is this acceptable? We have little data to answer this question directly, and while the Hospital Consumers Assessment of Healthcare Providers and Systems (HCAHPS) survey asks select questions regarding the effectiveness of discharge information, it is silent on matters of discharge timeliness and expectations. While on the administrative side we often use readmission rates as a proxy for a safe and “effective” discharge, in reality, we lack meaningful patient-reported outcome measures to assess our effectiveness, which is a necessity for performance improvement.
The opportunities for improvement suggested by this study include restructuring rounding to prioritize discharges, managing census per provider, and rethinking resident education to accommodate both education and service. The authors’ approach includes identifying ways to improve the efficiency of the work through other team members (such as pharmacy techs for medication reconciliation) and balancing ancillary services support for all inpatient care and the outpatients they serve. Alternatively, tying incentives to the goal could be a convenient leadership response. The 2016 Society of Hospital Medicine State of Hospital Medicine Report notes that more than half (54%) of nonacademic hospitalist groups that treat adults have an incentive tied to early morning discharge orders or times. We believe that by keeping the patients and families at the center of this discussion, we are more likely to accomplish the goal of improved safety, efficiency, effectiveness, and patient experience.
The literature supports discharge delays as an international challenge with research on the topic in healthcare systems across the world.12 This may be related to an aging population, improvements, and access to advanced healthcare, and the challenges of occupancy and capacity mismatches in many healthcare systems worldwide. The authors have identified important intrinsic factors for these throughput and discharge delays. The results beg the question, are we willing to do the redesign and behavior change in our delivery of healthcare and healthcare education to achieve a more optimized system of care delivery?
A now-retired Cleveland Clinic performance improvement engineer frequently referenced W. Edwards Deming on “what makes the biggest difference in improving internal service quality?” He distilled this to two axioms based on Deming’s work: reducing cycle time and reducing defects. Both must be accomplished from the customer’s (patient’s) perspective without tradeoffs between the two. Cycle time is the time to accomplish a completed process or action, such as patient discharge or LOS. Defects are all the waste or “impossible” challenges that contribute to the feeling of resignation that lead to people dismissing the possibility of improvement, stating “it is what it is.” The challenge in the service of our patients and families, organizations, and communities is to move this dialog forward to “it is what we make it.”13
When we tell the patient and family they are being discharged it should happen safely, efficiently, predictably, and with empathy. From the perspective of clinicians, it should be as easy as possible to consistently do the right thing and do the work to which they have dedicated themselves. For communities and organizations struggling with access, improving throughput is vital.
Disclosures
Neither author has any conflicts to disclose. There are no external funding sources for this manuscript.
1. Institute for Healthcare Improvement. Available at: http://www.ihi.org/communities/blogs/origin-of-every-system-is-perfectly-designed-quote. Accessed August 2, 2018.
2. Zoucha J, Hull M, Keniston A, et al. Barriers to Early Hospital Discharge: A Cross Sectional Study at Five Academic Hospitals. J Hosp Med. 2018;13(12):816-822. doi: 10.12788/jhm.3074. PubMed
3. Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786. doi: 10.1001/jamainternmed.2014.300. PubMed
4. Beck MJ, Okerblom D, Kumar A, Bandyopadhyay S, Scalzi LV. Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion. Hosp Pract. 2016;44(5):252-259. doi: 10.1080/21548331.2016.1254559. PubMed
5. Patel H, Morduchowicz S, Mourad M. Using a Systematic Framework of Interventions to Improve Early Discharges. Jt Comm J Qual Patient Saf. 2017;43(4):189-196. doi: 10.1016/j.jcjq.2016.12.003. PubMed
6. Mathews KS, Corso P, Bacon S, Jenq GY. Using the Red/Yellow/Green Discharge Tool to Improve the Timeliness of Hospital Discharges. Jt Comm J Qual Patient Saf. 2014;40(6). doi:10.1016/s1553-7250(14)40033-3. PubMed
7. Wertheimer B, Jacobs REA, Bailey M, et al. Discharge before noon: An achievable hospital goal. J Hosp Med. 2014;9(4):210-214. doi: 10.1002/jhm.2154. PubMed
8. Barnes S, Hamrock E, Toerper M, Siddiqui S, Levin S. Real-time prediction of inpatient length of stay for discharge prioritization. J Am Med Inform Assoc. 2015;23(e1). doi: 10.1093/jamia/ocv106. PubMed
9. Wachter RM. Hospitalist Workload. JAMA Intern Med. 2014;174(5):794. doi:1 0.1001/jamainternmed.2014.18. PubMed
10. Parikh PJ, Ballester N, Ramsey K, Kong N, Pook N. The n-by-T Target Discharge Strategy for Inpatient Units. Med Decis Making. 2017;37(5):534-543. doi:10.1177/0272989x17691735. PubMed
11. Kane M, Weinacker A, Arthofer R, et al. A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon. J Nurs Adm. 2016; 46(12):630-635.doi: 10.1097/NNA.0000000000000418 PubMed
12. Rojas-García A, Turner S, Pizzo E, Hudson E, Thomas J, Raine R. Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expect. 2017;21(1):41-56. doi: 10.1111/hex.12619. PubMed
13. Emmelhainz L. Achieving Excellence: Some Last Thoughts. Lecture presented: Health System Leadership at Cleveland Clinic Akron General; May 16, 2018; Akron, OH. PubMed
1. Institute for Healthcare Improvement. Available at: http://www.ihi.org/communities/blogs/origin-of-every-system-is-perfectly-designed-quote. Accessed August 2, 2018.
2. Zoucha J, Hull M, Keniston A, et al. Barriers to Early Hospital Discharge: A Cross Sectional Study at Five Academic Hospitals. J Hosp Med. 2018;13(12):816-822. doi: 10.12788/jhm.3074. PubMed
3. Elliott DJ, Young RS, Brice J, Aguiar R, Kolm P. Effect of Hospitalist Workload on the Quality and Efficiency of Care. JAMA Intern Med. 2014;174(5):786. doi: 10.1001/jamainternmed.2014.300. PubMed
4. Beck MJ, Okerblom D, Kumar A, Bandyopadhyay S, Scalzi LV. Lean intervention improves patient discharge times, improves emergency department throughput and reduces congestion. Hosp Pract. 2016;44(5):252-259. doi: 10.1080/21548331.2016.1254559. PubMed
5. Patel H, Morduchowicz S, Mourad M. Using a Systematic Framework of Interventions to Improve Early Discharges. Jt Comm J Qual Patient Saf. 2017;43(4):189-196. doi: 10.1016/j.jcjq.2016.12.003. PubMed
6. Mathews KS, Corso P, Bacon S, Jenq GY. Using the Red/Yellow/Green Discharge Tool to Improve the Timeliness of Hospital Discharges. Jt Comm J Qual Patient Saf. 2014;40(6). doi:10.1016/s1553-7250(14)40033-3. PubMed
7. Wertheimer B, Jacobs REA, Bailey M, et al. Discharge before noon: An achievable hospital goal. J Hosp Med. 2014;9(4):210-214. doi: 10.1002/jhm.2154. PubMed
8. Barnes S, Hamrock E, Toerper M, Siddiqui S, Levin S. Real-time prediction of inpatient length of stay for discharge prioritization. J Am Med Inform Assoc. 2015;23(e1). doi: 10.1093/jamia/ocv106. PubMed
9. Wachter RM. Hospitalist Workload. JAMA Intern Med. 2014;174(5):794. doi:1 0.1001/jamainternmed.2014.18. PubMed
10. Parikh PJ, Ballester N, Ramsey K, Kong N, Pook N. The n-by-T Target Discharge Strategy for Inpatient Units. Med Decis Making. 2017;37(5):534-543. doi:10.1177/0272989x17691735. PubMed
11. Kane M, Weinacker A, Arthofer R, et al. A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon. J Nurs Adm. 2016; 46(12):630-635.doi: 10.1097/NNA.0000000000000418 PubMed
12. Rojas-García A, Turner S, Pizzo E, Hudson E, Thomas J, Raine R. Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expect. 2017;21(1):41-56. doi: 10.1111/hex.12619. PubMed
13. Emmelhainz L. Achieving Excellence: Some Last Thoughts. Lecture presented: Health System Leadership at Cleveland Clinic Akron General; May 16, 2018; Akron, OH. PubMed
© 2018 Society of Hospital Medicine
Hospitalists Recall 9/11
Flashbulb Memories are memories for the circumstances in which one first learned of a very surprising and consequential (or emotionally arousing) event. Hearing the news that President John Kennedy had been shot is the prototype case. Almost everyone can remember, with an almost perceptual clarity, where he was when he heard, what he was doing at the time, who told him, what was the immediate aftermath, how he felt about it, and also one or more totally idiosyncratic and often trivial concomitants.1
In personal terms, all Americans are connected by recollections of the experience. 97% can remember exactly where they were or what they were doing the moment they heard about the attacks. (Pew Research survey, September 5, 2002)
The classic flashbulb memories of our parents' generation, who were young adults in the 1960s, were the assassinations of Martin Luther King and President John Kennedy. In the same way, the 9/11 attacks seem destined to endure as our generation's flashbulb memory, with the Space Shuttle Challenger explosion a distant second for those of us on the far side of age 40. Few of us are likely to ever forget the grief, anger, and confusion of September 11, 2001 and the days that followed, and it seems appropriate 10 years later to remember those who died that day, and to reflect on the lessons we learnedor should have. As hospitalists, we are at least somewhat familiar with the tragic and senseless loss of life that day, as the terrorist attacks were in a sense a reflection, writ large, of the unexpected and inexplicable deaths we have all been a part of: the healthy young woman exsanguinating from DIC in the immediate postpartum period, the preschool teacher rapidly succumbing to pneumococcal meningitis, the young adult dying of acute leukemia or necrotizing fasciitis.
On September 11, 2001, one of us (B.J.H.) was 2 years out of residency and in private practice near San Francisco.
For most of us on the West coast, 9/11 began while we slept. By the time I had awoken, showered, and coffeed, both planes had already hit the towers, and I only found out in the course of routinely turning on the television for a minute before leaving for work. Sometimes we forget that in those first minutes and hours, the news was contradictory and confused. Television and Internet couldn't keep up with the facts. And then within minutes, the towers fell. My first thought was that I was seeing tens of thousands of people die. Nine years earlier I had worked in the building adjacent to the World Trade Center and I knew the swarms of commuters moving through every morning. That the casualties were so much fewer is still miraculous to me.
I did go to work that morning, to a hospital full of colleagues with identical shocked looks. That dayand for the fog of days afterwardevery television in every room was on, showing planes hitting the towers over and over, different cameras, different angles; long crowds of people walking home to New Jersey out of the smoke; the faces of doomed firefighters in the stairwell, taken by survivors as they came down and the rescuers went up. Several thousand miles away, it was impossible to believe that it was all real and happening. Who could have ever imagined such a thing? I cannot believe that 9/11 didn't transform every American, regardless of background. What landmark would be next? Who in their right mind would work in the Sears Tower or Empire State Building after 9/11? I obsessed about bombings of the Golden Gate Bridge: the deck collapsing, my car plunging into the bay. For 6 months, I changed my commute times to avoid backed‐up, rush‐hour traffic. The events of 9/11 changed my beliefs and how I looked at things around me that I had always trusted.
For the other of us (J.C.P.), the news came in a patient's room during rounds.
My patient and I watched in disbelief while, as a reporter talked about the tragedy of a passenger jet crashing into one of the twin towers moments before, the second attack occurred. We both immediately knew beyond any doubt that this was a terrorist attack, although that fact seemed to take longer to register with the reporter. The rest of that morning is a blur, though I do recall attempting to see patients and teach through a haze of disbelief and disquiet. I eventually made it to my office and sat down, only to have my officemate burst in breathlessly and say, They just bombed the Pentagon! The receipt of that factually altered piece of information caused me to wonder just how horrific the day would prove to be when it was all over, and convinced me that life in the U.S. would never again be the same. The unfolding story over the next several days held my attention as no other public event during my lifetime has, and my wife and I spent evenings glued to the television that week. A benefit concert with an all‐star lineup of pop musicians was organized and held within days of the attacks, and I remember watching Paul Simon perform Bridge Over Troubled Water and thinking that it would have been more honest, though probably too dark, if he had chosen American Tune instead:
And I don't know a soul who's not been battered
I don't know a friend who feels at ease
I don't know a dream that's not been shattered
Or driven to its knees
But it's all right, it's all right
We've lived so well so long .
In a real sense it is surprising, even shocking, that there has not been a major domestic terrorism attack during the intervening decade, particularly given our multicultural, open society, but for me as for many of us, the next occurrence is a matter of when and hownot if. I've flown countless times since, but still never go to or through an airport, particularly in major cities, without thinking about the possibility of a terror strike, and I never walk through my former home of Washington, D.C. without thoughts of what if?
What lessons should we take away from the 9/11 tragedy a decade later, and indeed from our work with our patients? Certainly that mass casualties and disaster preparedness are an unfortunate fact of life in the 21st century, and that hospitalists have a responsibility to engage with our institutions in preparing for these eventualities. Possibly that life is uncertain and, at best, goes by much more quickly than any of us could have imagined when we embarked on our medical training. In the end, that our lives are measured primarily not by the number of years we live, but by how we live them, and the lives that we touch along the way.
Once a year, we pause to remember the nearly 3000 individuals who lost their lives on 9/11. As hospitalists, we practice a profession that demands a great deal from us and encourages workaholism; perhaps the 10th anniversary of those heinous acts should make each of us, as we remember the lives touched most directly by the attacks on the World Trade Center, the Pentagon, and United Flight 93, also pause to consider our work‐life balance, and to ensure that we are reserving sufficient quality time for our families and friends, as well as for activities that renew and enrich us.
- ,.Flashbulb memories.Cognition.1977;5(1):73–99.
Flashbulb Memories are memories for the circumstances in which one first learned of a very surprising and consequential (or emotionally arousing) event. Hearing the news that President John Kennedy had been shot is the prototype case. Almost everyone can remember, with an almost perceptual clarity, where he was when he heard, what he was doing at the time, who told him, what was the immediate aftermath, how he felt about it, and also one or more totally idiosyncratic and often trivial concomitants.1
In personal terms, all Americans are connected by recollections of the experience. 97% can remember exactly where they were or what they were doing the moment they heard about the attacks. (Pew Research survey, September 5, 2002)
The classic flashbulb memories of our parents' generation, who were young adults in the 1960s, were the assassinations of Martin Luther King and President John Kennedy. In the same way, the 9/11 attacks seem destined to endure as our generation's flashbulb memory, with the Space Shuttle Challenger explosion a distant second for those of us on the far side of age 40. Few of us are likely to ever forget the grief, anger, and confusion of September 11, 2001 and the days that followed, and it seems appropriate 10 years later to remember those who died that day, and to reflect on the lessons we learnedor should have. As hospitalists, we are at least somewhat familiar with the tragic and senseless loss of life that day, as the terrorist attacks were in a sense a reflection, writ large, of the unexpected and inexplicable deaths we have all been a part of: the healthy young woman exsanguinating from DIC in the immediate postpartum period, the preschool teacher rapidly succumbing to pneumococcal meningitis, the young adult dying of acute leukemia or necrotizing fasciitis.
On September 11, 2001, one of us (B.J.H.) was 2 years out of residency and in private practice near San Francisco.
For most of us on the West coast, 9/11 began while we slept. By the time I had awoken, showered, and coffeed, both planes had already hit the towers, and I only found out in the course of routinely turning on the television for a minute before leaving for work. Sometimes we forget that in those first minutes and hours, the news was contradictory and confused. Television and Internet couldn't keep up with the facts. And then within minutes, the towers fell. My first thought was that I was seeing tens of thousands of people die. Nine years earlier I had worked in the building adjacent to the World Trade Center and I knew the swarms of commuters moving through every morning. That the casualties were so much fewer is still miraculous to me.
I did go to work that morning, to a hospital full of colleagues with identical shocked looks. That dayand for the fog of days afterwardevery television in every room was on, showing planes hitting the towers over and over, different cameras, different angles; long crowds of people walking home to New Jersey out of the smoke; the faces of doomed firefighters in the stairwell, taken by survivors as they came down and the rescuers went up. Several thousand miles away, it was impossible to believe that it was all real and happening. Who could have ever imagined such a thing? I cannot believe that 9/11 didn't transform every American, regardless of background. What landmark would be next? Who in their right mind would work in the Sears Tower or Empire State Building after 9/11? I obsessed about bombings of the Golden Gate Bridge: the deck collapsing, my car plunging into the bay. For 6 months, I changed my commute times to avoid backed‐up, rush‐hour traffic. The events of 9/11 changed my beliefs and how I looked at things around me that I had always trusted.
For the other of us (J.C.P.), the news came in a patient's room during rounds.
My patient and I watched in disbelief while, as a reporter talked about the tragedy of a passenger jet crashing into one of the twin towers moments before, the second attack occurred. We both immediately knew beyond any doubt that this was a terrorist attack, although that fact seemed to take longer to register with the reporter. The rest of that morning is a blur, though I do recall attempting to see patients and teach through a haze of disbelief and disquiet. I eventually made it to my office and sat down, only to have my officemate burst in breathlessly and say, They just bombed the Pentagon! The receipt of that factually altered piece of information caused me to wonder just how horrific the day would prove to be when it was all over, and convinced me that life in the U.S. would never again be the same. The unfolding story over the next several days held my attention as no other public event during my lifetime has, and my wife and I spent evenings glued to the television that week. A benefit concert with an all‐star lineup of pop musicians was organized and held within days of the attacks, and I remember watching Paul Simon perform Bridge Over Troubled Water and thinking that it would have been more honest, though probably too dark, if he had chosen American Tune instead:
And I don't know a soul who's not been battered
I don't know a friend who feels at ease
I don't know a dream that's not been shattered
Or driven to its knees
But it's all right, it's all right
We've lived so well so long .
In a real sense it is surprising, even shocking, that there has not been a major domestic terrorism attack during the intervening decade, particularly given our multicultural, open society, but for me as for many of us, the next occurrence is a matter of when and hownot if. I've flown countless times since, but still never go to or through an airport, particularly in major cities, without thinking about the possibility of a terror strike, and I never walk through my former home of Washington, D.C. without thoughts of what if?
What lessons should we take away from the 9/11 tragedy a decade later, and indeed from our work with our patients? Certainly that mass casualties and disaster preparedness are an unfortunate fact of life in the 21st century, and that hospitalists have a responsibility to engage with our institutions in preparing for these eventualities. Possibly that life is uncertain and, at best, goes by much more quickly than any of us could have imagined when we embarked on our medical training. In the end, that our lives are measured primarily not by the number of years we live, but by how we live them, and the lives that we touch along the way.
Once a year, we pause to remember the nearly 3000 individuals who lost their lives on 9/11. As hospitalists, we practice a profession that demands a great deal from us and encourages workaholism; perhaps the 10th anniversary of those heinous acts should make each of us, as we remember the lives touched most directly by the attacks on the World Trade Center, the Pentagon, and United Flight 93, also pause to consider our work‐life balance, and to ensure that we are reserving sufficient quality time for our families and friends, as well as for activities that renew and enrich us.
Flashbulb Memories are memories for the circumstances in which one first learned of a very surprising and consequential (or emotionally arousing) event. Hearing the news that President John Kennedy had been shot is the prototype case. Almost everyone can remember, with an almost perceptual clarity, where he was when he heard, what he was doing at the time, who told him, what was the immediate aftermath, how he felt about it, and also one or more totally idiosyncratic and often trivial concomitants.1
In personal terms, all Americans are connected by recollections of the experience. 97% can remember exactly where they were or what they were doing the moment they heard about the attacks. (Pew Research survey, September 5, 2002)
The classic flashbulb memories of our parents' generation, who were young adults in the 1960s, were the assassinations of Martin Luther King and President John Kennedy. In the same way, the 9/11 attacks seem destined to endure as our generation's flashbulb memory, with the Space Shuttle Challenger explosion a distant second for those of us on the far side of age 40. Few of us are likely to ever forget the grief, anger, and confusion of September 11, 2001 and the days that followed, and it seems appropriate 10 years later to remember those who died that day, and to reflect on the lessons we learnedor should have. As hospitalists, we are at least somewhat familiar with the tragic and senseless loss of life that day, as the terrorist attacks were in a sense a reflection, writ large, of the unexpected and inexplicable deaths we have all been a part of: the healthy young woman exsanguinating from DIC in the immediate postpartum period, the preschool teacher rapidly succumbing to pneumococcal meningitis, the young adult dying of acute leukemia or necrotizing fasciitis.
On September 11, 2001, one of us (B.J.H.) was 2 years out of residency and in private practice near San Francisco.
For most of us on the West coast, 9/11 began while we slept. By the time I had awoken, showered, and coffeed, both planes had already hit the towers, and I only found out in the course of routinely turning on the television for a minute before leaving for work. Sometimes we forget that in those first minutes and hours, the news was contradictory and confused. Television and Internet couldn't keep up with the facts. And then within minutes, the towers fell. My first thought was that I was seeing tens of thousands of people die. Nine years earlier I had worked in the building adjacent to the World Trade Center and I knew the swarms of commuters moving through every morning. That the casualties were so much fewer is still miraculous to me.
I did go to work that morning, to a hospital full of colleagues with identical shocked looks. That dayand for the fog of days afterwardevery television in every room was on, showing planes hitting the towers over and over, different cameras, different angles; long crowds of people walking home to New Jersey out of the smoke; the faces of doomed firefighters in the stairwell, taken by survivors as they came down and the rescuers went up. Several thousand miles away, it was impossible to believe that it was all real and happening. Who could have ever imagined such a thing? I cannot believe that 9/11 didn't transform every American, regardless of background. What landmark would be next? Who in their right mind would work in the Sears Tower or Empire State Building after 9/11? I obsessed about bombings of the Golden Gate Bridge: the deck collapsing, my car plunging into the bay. For 6 months, I changed my commute times to avoid backed‐up, rush‐hour traffic. The events of 9/11 changed my beliefs and how I looked at things around me that I had always trusted.
For the other of us (J.C.P.), the news came in a patient's room during rounds.
My patient and I watched in disbelief while, as a reporter talked about the tragedy of a passenger jet crashing into one of the twin towers moments before, the second attack occurred. We both immediately knew beyond any doubt that this was a terrorist attack, although that fact seemed to take longer to register with the reporter. The rest of that morning is a blur, though I do recall attempting to see patients and teach through a haze of disbelief and disquiet. I eventually made it to my office and sat down, only to have my officemate burst in breathlessly and say, They just bombed the Pentagon! The receipt of that factually altered piece of information caused me to wonder just how horrific the day would prove to be when it was all over, and convinced me that life in the U.S. would never again be the same. The unfolding story over the next several days held my attention as no other public event during my lifetime has, and my wife and I spent evenings glued to the television that week. A benefit concert with an all‐star lineup of pop musicians was organized and held within days of the attacks, and I remember watching Paul Simon perform Bridge Over Troubled Water and thinking that it would have been more honest, though probably too dark, if he had chosen American Tune instead:
And I don't know a soul who's not been battered
I don't know a friend who feels at ease
I don't know a dream that's not been shattered
Or driven to its knees
But it's all right, it's all right
We've lived so well so long .
In a real sense it is surprising, even shocking, that there has not been a major domestic terrorism attack during the intervening decade, particularly given our multicultural, open society, but for me as for many of us, the next occurrence is a matter of when and hownot if. I've flown countless times since, but still never go to or through an airport, particularly in major cities, without thinking about the possibility of a terror strike, and I never walk through my former home of Washington, D.C. without thoughts of what if?
What lessons should we take away from the 9/11 tragedy a decade later, and indeed from our work with our patients? Certainly that mass casualties and disaster preparedness are an unfortunate fact of life in the 21st century, and that hospitalists have a responsibility to engage with our institutions in preparing for these eventualities. Possibly that life is uncertain and, at best, goes by much more quickly than any of us could have imagined when we embarked on our medical training. In the end, that our lives are measured primarily not by the number of years we live, but by how we live them, and the lives that we touch along the way.
Once a year, we pause to remember the nearly 3000 individuals who lost their lives on 9/11. As hospitalists, we practice a profession that demands a great deal from us and encourages workaholism; perhaps the 10th anniversary of those heinous acts should make each of us, as we remember the lives touched most directly by the attacks on the World Trade Center, the Pentagon, and United Flight 93, also pause to consider our work‐life balance, and to ensure that we are reserving sufficient quality time for our families and friends, as well as for activities that renew and enrich us.
- ,.Flashbulb memories.Cognition.1977;5(1):73–99.
- ,.Flashbulb memories.Cognition.1977;5(1):73–99.