Table 2.
Fishbone for discharge phase crosswalk. Abbreviations: advanced practice nurse (APN); multi-disciplinary rounds (MDRs); Meridian Health (MH); social worker (SW); assistant nurse manager (ANM); care transition center (CTC); prescription (Rx).
| Obstacle | Potential Solutions |
|---|---|
| Discharge Planning Delays | |
| Failure to identify discharges until day of discharge | MDR |
| Placement Issues | |
| Patients on 1:1 observation not accepted | None |
| MH facilities do not accept PD patients | Work to change policy |
| Delay in initiation of facility search | MDR/APNs |
| Lack of SW support on weekends | Increase SW resources on weekends |
| Delays in authorization | Have facilities accept patients pending authorization |
| Failure of facilities to accept patients after hours | Have standard set of rules for all participating facilities |
| Transport Delays: Alert | Have alternative provider available |
| Transport Delays: LogistiCare | None |
| Nursing Delays | |
| Misaligned incentives | Create incentives for nurses to discharge early |
| Passive alert system | Discharge board |
| Meds to beds | Should not be an obstacle (can deliver to CTC or lounge) |
| Competing nursing priorities | ANM to assist |
| Lack of ownership of process | Nurse manager or designee to “own” process |
| Internal transportation issues | Rapid discharge team |
| Clinical Delays | |
| Delayed physician discharge order | Hold hospitalists, faculty, residents accountable |
| APN deployment | |
| Med Rec and Rx issues | Increase use of hospitalists/APNs |