Friday December 22nd 2006: >>

“There’s a popular notion that patients don’t like short length of stay,” says Paul Alexander Clark, senior knowledge manager for Press Ganey Associates in South Bend, Ind. Press Ganey develops patient satisfaction surveys for hospitals.

On the contrary, Clark says reducing length of stay and increasing patient satisfaction are not conflicting goals.

Based on data from its patient satisfaction surveys, Clark says patients who have longer hospital stays (after controlling for diagnosis and severity of illness) actually are significantly less satisfied than patients with shorter stays.

“Ultimately, what it comes down to is that patients want to feel ready to leave. There’s no market demand for hospital visits,” Clark explains.

Four elements important to patient satisfaction

Clark says Press Ganey research has determined that four elements of the discharge process measure patient satisfaction with the process.

The following four elements also strongly correlate with overall patient satisfaction regarding the hospital’s care:

• Patient’s personal readiness—Do the patient and family feel that they have the appropriate understanding, confidence, and capacity to leave the hospital?
• Speed—Is the process of getting the patient home or to another care setting efficient?
• Instruction—Do the patients and family know what to do after the patient is discharged?
• Coordination of arrangements—How well were arrangements made and communicated for accessing home care services, medical equipment, rehabilitation care, and other postdischarge health services?

Last year, more than two million patients admitted at 1600 hospitals completed Press Ganey patient satisfaction surveys, which include four questions about the discharge process, Clark says.

Patients experience discharge as a distinct episode in their hospital care, but it also colors their perceptions of the entire hospitalization.

Readiness for discharge

Patients may be dissatisfied with the discharge process if the hospital’s discharge procedures are not patient-centered; physicians, nurses, and specialists provide conflicting information about when the patient will go home; there are no customer service procedures around the patient’s leaving; and there is a bed shortage in the hospital.

Hospitalists, nurses, and other providers should be careful about the language they use as they prepare the patient for discharge, Clark says. The language patients hear influences how they perceive their discharge.

“If you say, ‘Medicare won’t pay, so you have to leave’ or ‘Insurance doesn’t cover you for more than three days,’ patients feel that they are being kicked out before it’s medically appropriate,” Clark explains.

It’s important to eliminate these phrases and instead communicate confidence that the patient is ready to go home, he says. Giving the patient and family a contact sheet with staff phone numbers is a simple, but surprisingly underused, way to reassure the patient that he or she is ready to go home but can get help if needed.

To avoid sending conflicting messages about the discharge, hospitalists and nurses can use whiteboards, which are already in many patient rooms but are inconsistently used, Clark says. The expected date of discharge should be written on the board so that hospitalists and nurses are not giving the patient different dates.

Often, discharge plans are developed only for patients with complex medical and psychosocial issues, but Clark says one hospital that set out to improve its patient satisfaction with the discharge process set a goal of writing a discharge plan for 100% of its patients.

Having a staff member take 15 minutes to sit down with the patient and his or her family to write a discharge plan can make the patient feel ready to leave the hospital at the appointed time, Clark says. Customer service practices that convey appreciation and best wishes can also help the patient feel ready to leave the hospital, he adds.

Speed of discharge process

Although a patient does not want to feel rushed into leaving the hospital, once the decision to discharge has been made and communicated, the patient wants the process to move quickly.

It is important to educate the patient and family about what needs to occur before the patient can leave the hospital so that he or she can appreciate all of the steps in the process, Clark explains.

The patient may even place greater value on the services that are given if he or she knows that the staff must obtain results from the lab, receive final discharge orders, and wait for information about medical equipment before discharging the patient.

Many hospitals try to adhere to a universal time for discharge, but recently some hospitals are scheduling discharge times to stagger the workload, Clark says. Time slots are assigned to patients so that pharmacy, lab, housekeeping, and patient transport are not under one deadline.

In the recently published HCPro report “Patient Satisfaction and the Discharge Process,” Clark recommends taking the following steps to implement scheduled discharge times:

• Establish appointment slots for each day based on the average number of patients discharged from a unit per day
• Adjust the number of slots based on the day of the week and the unit (e.g., internal medicine units may have fewer slots on Saturday and Sunday, but critical care may have more slots)
• Assign slots as soon as possible, but at least 24 hours in advance; elective surgery patients can be assigned a discharge time at preadmission
• Display a schedule of all discharges at the nurses’ and physicians’ workstations
• Schedule only one patient per slot
• Schedule transfers exactly as you would schedule discharges
• Track the percentage of patients discharged within 30 minutes of their discharge appointment time

Another best practice, says Clark, is daily rounding by case managers, facilitators, or social workers.

These practitioners should review patients’ needs prior to discharge and update patients and families on the status of all that needs to be done before discharge procedures. At admission, always ask “who will be taking you home at discharge?”

Instructions

In general, physicians and nurses tend to underestimate how much information patients need at discharge. Staff may give important instructions once, but as in all learning, Clark says, studies show that repetition and reinforcement are needed for patients and families to take in all of the information.

Healthcare professionals may perceive such repetition as excessive, but patients and families find it helpful and reassuring to hear information repeated, according to Clark.

Telling patients what they can expect during the course of an illness, operation, or hospital stay also helps reduce their fear and anxiety. Although hospital procedures are familiar to healthcare professionals, they are foreign and confusing to patients.

Some hospitals have patient education nurses who specialize in different areas of medicine so that “every nurse doesn’t need to know everything about every illness,” Clark says. Obtaining feedback from former patients or focus groups can help evaluate the effectiveness of patient education materials.

Remember that meeting patients’ information needs throughout the hospitalization does not necessarily mean that they will be satisfied with the discharge instructions for care at home, because they see discharge as a distinct episode, according to Clark.

Coordination of arrangements

One of the most effective ways that a hospital can boost patient satisfaction is to make a phone call to the patient within 48 hours of discharge.

Largely underutilized, postdischarge phone calls build loyalty to the facility and the physicians, says Clark. Some hospitals have even done postdischarge calls as a tactic to help give their patient satisfaction scores a boost.

Much of healthcare is reactive and geared toward putting out fires, Clark notes.

With postdischarge phone calls, hospitals are proactively developing and ensuring relationships with their patients by checking on their progress and clarifying their instructions, if needed.

For patients who require postacute services, Clark says it is good practice to address patients’ and families’ anxieties concerning the transition to a new level of care and make a phone call to the nurse at the acute-care facility. If a nurse at the next care facility is expecting your patient and is well-informed about his or her issues, this will reflect well on your hospital and smooth the way for your patient. The nurse is likely to tell the patient that you called, he says.

The quality of the facility will also be a reflection on your services, he notes. “By arranging for or recommending a health service, you stand behind the quality of that service,” Clark writes in Patient Satisfaction and the Discharge Process. “To use a marketing term, this is called ‘commingling of brands.’ ”