Discharging patients from the hospital is a critical aspect of health care delivery. It is a time of transition where one group of care givers stops treating the patient and another group starts. The most frequent type of transition occurs when patients go from hospital to home, happening nearly 40 million times each year in the U.S.. Studies show that about 20 percent of discharged patients have an adverse event – a preventable emergency department visit or re-admission – within 30 days following hospitalization. The discharge process is so important that a cottage industry is emerging around it. Some consultants, software products, best practices, training, and research studies focus just on discharging patients.
To use S.I.T., we start by listing the components of the service (process):
- Issue the Discharge Order
- Schedule follow-up appointments with next care givers
- Develop medication plan
- Identify post discharge services (nursing, rehabilitation, etc)
- Develop written discharge plan
- Review diagnosis with patient
- Review tests and procedures that were performed
- Review written discharge plan
- Confirm patients understanding of the plan
- Wheelchair the patient out of hospital
To apply S.I.T., we use each of the five templates to one or more of these components to create a “virtual product,” a hypothetical solution for a yet-to-be-identified problem. We then work backwards from this “solution” and match it up to potential problems that it solves or benefits that it delivers. This is classic “SOLUTION-TO-PROBLEM” innovation.
1. SUBTRACTION: Remove the Discharge Order. This is a great way to start off using a structured innovation method, especially in the group workshop setting, because it creates a sense of anxiety and ambiguity. The Subtraction template is particularly good at breaking fixedness, those static frames of how we think the world works. After all, how can you have a Hospital Discharge Process without the Discharge Order? Using Function-Follows-Form, imagine the potential benefits of removing this first step. For example, instead of starting the discharge process upon written doctor’s orders, now the process starts the minute you arrive in the hospital. Instead of “Hospital Admissions,” the patient enters the hospital with the intent of discharge. At arrival, the pre-conditions for leaving the hospital are developed, so that the patient can leave when those conditions are met.
2. MULTIPLICATION: To use Multiplication, we make a copy (or copies) of a process step and change it in some way. Let’s make copies of Step 9, confirm the patients understanding of the discharge plan. We multiply that and change it: the patient confirms their understanding when they arrive home. Perhaps the patient has to go to a web site that tests understanding of the discharge process. The potential benefit is more compliance with the discharge plan and reduced complications.
3. TASK UNIFICATION: This template requires us to take a step in the process and assign it an additional task or job. Let’s take Step 2 – scheduling follow-up appointments with the patients family doctor (and other care givers). The additional job is to require the family caregiver to issue the Discharge Order. In other words, it is now the family doctor who determines when the patient leaves the hospital, not the hospital doctors. Benefits? Perhaps this could shift the risk of complications to the “receiving” doctors and away from the hospital. This might encourage the family doctor to be involved earlier in the hospital stay so they are better able to make the right decisions.
4. DIVISION: This template works in three ways: dividing a step physically, functionally, or preserving division – dividing while preserving the characteristics of the whole unit. For this exercise, let’s divide Step 3, The Medication Plan. Perhaps the hospital develops the medication plan using only generic drugs forms. The determination of using generic versus name brand drugs is “divided” out for later determination by the family doctor.
5. ATTRIBUTE DEPENDENCY: This template is the odd one in that it uses attributes of the situation instead of components. The idea is to create (or break) dependencies between attributes to create the “virtual product.” Normally, we would create a full matrix of attributes, both internal and external to the situation, a tool described in other LAB’s. Here is one example of how this would work for the hospital discharge process. We create a dependency between: patient’s understanding of the Discharge Plan and reimbursement by the patient’s insurance company. The more they understand it, the more hospital charges are reimbursed. Benefit? This could encourage more compliance with the plan and reduce re-admissions.
As with all businesses, hospitals will survive and thrive with a sustained commitment to innovation. Leading hospitals such as The Mayo Clinic and others are doing just that to transform health care from a political debate to real change.