You receive your daily assignment and see that it includes a patient discharge. Do you think “Wow, I am so fortunate to be the person today who provides this family with a smooth transition from the NICU to home” or “Ugh, I have a discharge today”?

In our large, Level IV NICU that serves a population that is both high risk and low socioeconomic status resulting in several barriers to discharge, many nurses would answer with a resounding “Ugh.” This response is due to the stress, frustration, and even dread associated with all the moving parts of a NICU discharge. To address these feelings, our NICU team applied the Lean hospital approach to our discharge process.

How did we do apply the lean hospital approach to our discharge process?

Step 1: We reviewed the idea of standard work.

A multidisciplinary team from the NICU formed and participated in a Kaizen (Japanese term for continuous improvement) event focused on the discharge process. The team acknowledged the three elements of standard work: task time, inventory, and work sequence. The team also acknowledged the shared goal of identifying and documenting a “best way” or standard work for our discharge process. This new standard would provide a foundation for process stability and continuous improvement.

Step 2: We defined the current practice.

The team met at the Gemba (Japanese term for where the work occurs) and interviewed stakeholders; mapped out the current process; and highlighted inefficiencies in the discharge process, including: communication issues, a silo mentality of caregivers, batching of tasks, repetition of tasks or rework, and common barriers.

Step 3: We identified our best way and future standard work for our discharge process.

The multidisciplinary team defined the three elements of standardized work as follows:

  • Task time: 5-10 minutes
  • Inventory: We revised an existing discharge checklist in the EMR in order to standardize documentation.
  • Work sequence:
    • During a weekly conference, NICU multidisciplinary team discusses and identifies patients appropriate for discharge within 14 days.
    • Case Manager flags these patients in the EMR so a best practice advisory (BPA) for the discharge checklist tool will fire once per shift for those health care workers entering the patient chart.
    • All health care providers receiving the BPA for the discharge checklist must update and acknowledge the checklist.
    • Using the discharge checklist, patients predicted to be discharged within the week will be discussed in a huddle format at the end of patient rounds. Outstanding task will be assigned with expected completion date noted.

Using the Lean hospital approach helped to identify and eliminate discharge process inefficiencies, thereby improving workflow and providing more time for purposeful patient care. Furthermore, applying the lean hospital approach helped to define a new best way or standard work for our discharge process.  After all, don’t we all want more time to do our best work?

Holly Rene

Holly Rene is a neonatal nurse practitioner. She received her BSN from the University of Wisconsin-Madison and her Masters of Science in Nursing from Rush University. Her training continues at the University of Chicago Comer Childrens’ Hospital.

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