A Lean Six Sigma Quality Improvement Project Improves Timeliness of Discharge from the Hospital.

BACKGROUND: Hospital overcrowding has become a widespread problem, with constrained bed capacity and admission bottlenecks having far-reaching negative impacts on quality and safety. Focus on timing of discharge may be the least disruptive and most effective way to address constrained bed capacity, yet there may be significant institution-specific barriers to implementation. METHODS: With the creation of a "Value Team," a 627-bed, tertiary care academic medical center embarked on a quality improvement (QI) project using Lean Six Sigma process improvement methodology. After defining the problems around timeliness of discharge, the team went through the steps in the Define, Measure, Analyze, Improve, Control (DMAIC) framework. Interventions, which were implemented on the basis of an in-depth analysis of barriers to the discharge process, included geographic cohorts of internal medicine physicians on specific hospital units and multidisciplinary huddles one day before anticipated discharge. RESULTS: After accounting for the concurrent trends in the control group, the percentage of discharge orders released by 10:00 a.m. increased by 21.3 points (p < 0.001; adjusted odds ratio [OR] = 2.62; 95% confidence interval [CI] = 1.91-3.59), and the percentage of patients discharged by noon increased by 7.5 points (p = 0.001; adjusted OR = 1.70; 95% CI 1.15-2.51). There were no significant changes in the 30-day readmission rate or length of stay. CONCLUSION: A QI program shaped by Lean Six Sigma principles and reinforced by clinician huddles and geographic cohorting was associated with earlier posting of discharge orders and physical discharge by noon.

Improving the utilisation of medication-assisted treatment for alcohol use disorder at discharge.

Alcohol use disorder is a constellation of symptoms and behaviours related to dependence and abuse. It is present in 11.0% of US adults and is a leading cause of death and healthcare expenditures in the USA. Medication-assisted treatment (MAT) is medication to reduce cravings, decrease rewards or limit withdrawal symptoms in combination with behavioural therapy.A review of all patients with an alcohol-related condition admitted to internal medicine teams at an academic medical centre over a 7-month period (N=583) identified that only 1.4% (n=8) were discharged with an MAT prescription. Quality improvement methods were used to increase the proportion of patients discharged with an MAT prescription.Implementing educational interventions and embedding a recommendation for MAT into the order sets used to treat alcohol withdrawal increased the percentage of patients with an alcohol-related condition that were discharged with an MAT prescription to 11.2%.MAT remains an underused intervention for the treatment of alcohol use disorder. However, combining educational and structural interventions, including just-in-time teaching, can successfully increase the percentage of patients who receive an MAT prescription.