Workgroups from SGH and CGH recently improved their respective discharge processes in a bid to ease the perennial hospital problem of insufficient beds. Both showed that commitment, constant communication and coordination among stakeholders of the projects -- doctors, nurses, administrators, allied health professionals, patients and their next-of-kin alike – were crucial in bringing about a successful outcome.

Strategy Work Group (Integrated Operations), Singapore General Hospital
If patients are to be able to recover and leave hospital as soon as possible, discharge planning must start as promptly as at the time of admission.

Under SGH’s improved discharge protocol, some members of the team like therapists, who might typically be brought in later in the care process, are involved much earlier. Starting physical and occupational therapy early helps patients to start moving and recover faster.

The team meets every day, with nurses and allied health professionals providing doctors with updates of their patients’ conditions. These daily huddles not only keep these doctors in the loop about the state of their patients’ health, but also allow them to intervene quickly should patients not show any improvement or take a turn for the worse. Those who are advancing well, meanwhile, are prepped for early discharge.

Patients are our focus
Efficient discharge of patients has benefits for both them and their families, as well as for the hospital. For the former, time and money are saved as they stay fewer days in hospital. For the latter, more beds are freed up for other patients.

“Our healthcare professionals are always on the lookout to improve things for our patients. The early discharge process is an embodiment of the collaborative effort that our staff put in to enhance patient care,” said Professor Ruban Poopalalingam, Chairman, Division of Anaesthesiology and Perioperative Medicine, and co-lead, Strategy Workgroup for Integrated Ops.

All hands on board
Everyone with a stake in the patient’s recovery is fully committed and on board with the care plan. For instance, pharmacists have switched to e-prescription to help expedite the discharge process. E-prescriptions, which do away with paper and faxed prescriptions, reduce prescribing and dispensing errors, as well as the time taken to execute a prescription.

Once the team agrees that a patient is ready to be discharged, the process can be quickly put into action. Because of the daily meetings, the team already has a fair idea of which of their patients might be ready to go home. Administrative and other discharge procedures are prepared well in advance. Indeed, most times, the paperwork is ready even before the doctor gives the go-ahead for the patient to be discharged.

With the paperwork and prescription ready, all that is left is for the patient to be transferred to the discharge lounge to wait to be picked up. Because patients can be discharged as early as 10am, family members no longer have to take a full day to fetch patients home. In the past, patients had to wait for their doctors to see them during their ward rounds before they are told if they could go home. Settling their bills and having their discharge processed take further time. Patients, as a result, might be able to leave only in the afternoon, meaning they incur the cost of another day of bed charges.

The percentage of patients discharged before 1130am improved for the wards which introduced the new protocol. For example, for one ward, the percentage improved from an average of 25% to 37%. Cost and time saved aside, more importantly, “shorter hospital stays allow patients to recover faster,”

- Senior Nurse Manager Hartini Osman, Singapore General Hospital

Strategy Workgroup (Integrated Operations), Changi General Hospital
As with the SGH experience, strong team work, commitment and coordination were the key elements behind CGH’s project to improve patient discharge home or transfer to community hospitals.  

To facilitate patient transfers, CGH established its Coordinating Tower (CT) which “acts as the liaison between the wards and the community hospitals and nursing homes, eliminating the need for ward nurses to spend time coordinating with external partners for their patients’ transfer”
- Ms Tan Meifen, Assistant Director of Inpatient Operations, Changi General Hospital

“It took a few months to ensure that the process is smooth but we worked closely together with nursing colleagues to make it happen,” added Ms Tan, who oversaw the set-up of the Coordinating Tower.

As a result of these changes, overall wait time for admission to the community hospital has reduced from 7 days to 1 day (pre-approved list concept), saving a total of over 3300 bed days a year.

CT has also facilitated another decongestion project with our CGH team and Agency of Integrated Care (AIC), known as the residential referral team (RRT), whose main outcome is to look at the reduction of turnaround time for nursing home placements. The team has achieved a reduction from 72 calendar days to 29 calendar days, saving a total of 10277 bed days in 2018* . The team recently won the SingHealth Quality Service Award (SHQSA) under “Service Initiative” in 2019.

Reduced Wait Time
To ensure that patients don’t stay longer than necessary in hospital, putting them at risk of contracting other diseases, another team led by Sister Carol Tan checks the wards for patients who might be ready to go home. They then assess these patients, and if they are found to be ready for early discharge, they are transferred to the discharge lounge. Modeled pretty much like airport VIP passenger waiting lounges, the room has amenities such as snacks, beverages and even hot bento lunches for patients waiting for their loved ones to fetch them home. The team won the SHQSA under “Service Initiative” for the year of 2018.

Mr Chong Wei Yan, who became the 20,000th patient to use the lounge, said: “I am happy that the discharge lounge helps to reduce the waiting time for patients at A&E who need to be admitted.”

* data from 1 Jan 2018 to 31 Aug 2018

This story is brought to you by Strategy Retreat Group 6 - Integrated Operations.