OK, So You Know Your Demand To Get Into Your Hospital ... But Do You Know Your Demand To Get Out?

We now realise that it is difficult for a Medical patient to get out of hospital once they have been admitted. You are more likely to be moved to another ward when you are approaching a medically fit status (which we all know extends LoS) rather than remain on the same ward and be discharged when you are declared medically fit.

Talking recently to a senior nurse, who was unfortunate enough to have spent 3 spells in hospital over the last few years, she went on to explain that on each occasion this is exactly what had happened to her and that on each occasion her LoS was extended by an additional 3 days after she had become medically fit. It is hard to get out, she exclaimed, unless you discharge yourself. The main difference is that most patients (and their families) don’t actually know when they are medically fit. They have to wait for someone to tell them that it’s okay for them to go home. Some, obviously, whilst undergoing this protracted process contract hospital acquired infections which extends their LoS even further putting even more pressure on the entire system and the staff.

We have visited many hospitals where demand information is difficult to obtain. Some of the more enlightened hospitals, however, can now provide patient ‘demand to get in’ from their Emergency Department or via GP referral (some even by the hour and by the day of the week). We tend to have this annoying habit of saying “but I can’t see it” when factual, real time, data is not readily available and accessible. Our observation is that whilst organisations may know their demand to get in, they very rarely know their ‘demand to get out’, the demand for discharge. We just simply cannot “see it”.

In light of this, we have run several experiments in several hospitals where we employed a simple visual management technique to enable us see this demand to get out. To our astonishment (and to that of the organisations themselves) it turns out that it is absolutely normal to find that, at any given time (except over the Christmas period maybe) between 25% and 30% of beds on medical wards are occupied by patients who are medically fit for safe discharge, but they are still in the hospital. The demand to get out.

This 30% does not consist solely of DToC patients (bearing in mind that different organisations use different operational definitions to describe DToC patients), it also include many patients who are simply medically fit for a simple discharge but are still occupying a bed on the ward.

These same organisations freely admit that medical demand to get in is actually very predictable. Likewise, from our experiments we can confirm that demand to get out is equally predictable by the day and by specialty.

All this is good news because it means that due to this predictability, we can actually, for the first time, schedule discharges of unscheduled care patients.

For some time now many hospitals have attempted, without success to introduce discharges earlier in the day the ‘early bird’ or golden patient’ as some call it.

Seeing demand to get out, again for the first time, enables small numbers of discharges to be ‘drip fed’ throughout the day (which is all that is actually needed to cope with in-coming demand) as opposed to the usual large quantity, at the wrong time of the day (late afternoon and early evening) and the resultant chaos and stress that this causes.

To enable our experiments to unearth these medically fit patients we obviously rely heavily on the accuracy and honesty of the information provided by the ward staff. I’ve heard many nurses and managers declare that it’s far easier to retain a patient than to go through the process of discharging a patient and admitting the next one (unless the patient is an unpleasant individual – they like to hang on to nice, compliant, patients). It is human nature after all to avoid hard work if at all possible.

Some organisations have even gone so far as to announce to staff that it is a disciplinary offence not to declare medically fit patients. There is another side to this coin however. One senior nurse recently reported to us that her mother had been admitted into the hospital where she works. When this senior nurse went to the ward to find out her mothers medical status, she received one set of responses. However, upon explaining that the patient was actually her mother, she received a totally different set of responses. Reflecting on this, her hypothesis was that when she made the initial enquiry, the ward staff thought she was wearing her ‘management hat’ and was going to force them to do something with this patient that they did not believe would be in the best interest of the patient (maybe transfer her to another ward - off template as some organisations call it). It may be, she continued, that in an effort to create space for incoming demand, management were influencing, adversely, the behaviour of the ward staff.

We have witnessed this ‘cat and mouse’ game, with opposing agendas, all but disappear once this highly pressurised, highly charged and emotional environment is replaced with a transparent and stable process in which, through seeing and understanding this genuine demand to get out, discharges for un-scheduled care patients are being scheduled.