2. Figure 4.1b – Discharge Order Process
Start
Patient ready
to be discharged?
Physician documents
patient ready for
discharge paper chart
Physician informs patient
that he or she will be
discharged that day
Physician rounds
Continue
treatment
Physician places patient
chart in “New Order”rack
in front of Unit Secretary
Unit Secretary enters
orders and
schedules follow-ups
Unit Secretary
schedules
appointments with
Support Services
Unit Secretary prints out
appointment sheets
Unit Secretary signs chart
and places chart on
“Completed” Rack
Nurses verify appointments,
verify discharge instructions,
complete Medication
Reconciliation Form and tube
down prescriptions
Support Services
Round
Nurse educate patient of discharge
instructions and physically prepare
patient for discharge
Unit Secretary or nurse calls
for patient transport ticket
Transport or volunteer
escorts patient
Patient discharged
End
Yes
No
3. Figure 4.2a – Problems within the discharge order process
Start
Patient ready
to be discharged?
Physician documents
patient ready for
discharge paper chart
Physician inform patient
that he or she will be
discharged that day
Physician rounds
Continue
treatment
Physician place patient
chart in “New Order” rack
in front of Unit Secretary
Unit Secretary enters
orders and
schedules follow-ups
Unit Secretary
schedules
appointments with
Support Services
Unit Secretary prints out
appointment sheets
Unit Secretary signs chart
and places chart on
“Completed” Rack
Nurses verify appointments,
verify discharge instructions,
complete Medication
Reconciliation Form and tube
down prescriptions
Support Services
Round
Nurse educate patient of discharge
instructions and physically prepare
patient for discharge
Unit Secretary or nurse calls
for patient transport ticket
Transport or volunteer
escorts patient
Patient discharged
End
Yes
No
A
C
D
E
F
G
B
Start data
collecting
End data
collecting
4. Figure 4.2b – Explanations of problems in Figure 4.1a
C
D
E
F
G
B
A
· Physicians tell patients unrealistic discharge times
· Orders written at the end rounds rather than after each patient
· Rounding teams deliver orders at the end of rounds rather than after each patient
Other Overall Problems:
· Discharge orders from night shift aren’t completed
· Charts are lying all around and not in designated areas
· No outer indication on patient chart that the patient is ready for discharge
· Unit secretary experiences many interruptions (attending to patients, answering numerous phone calls that
someone with no training could answer, ordering equipment, and other tasks that are others’ job
· Unit secretaries can’t read physician handwriting
· Patient orders are not signed by physician
· Prescription orders not given dosage amounts and/or are not signed
· Unit secretary unable to schedule appointments because unaware if patient is following up at this hospital or
with an outside physician
· Delayed receipt of discharge orders prevent appointments from being made
· Physicians simply state “requries labs” and do not clarify which ones
· Orders are not relayed as discharges to support services
· Many different windows to enter in the various parts of discharge instructions
· Medications must be typed in rather than simply being selected
· Medication form not always filled out
· Anticipated discharge time not indicated on green sheet when prescriptions are sent down
· Patient families are not aware of discharge so nurse has to wait until family arrives to educate
· Nurses cannot educate families on proper equipment use because equipment has not arrived
· Transport sends someone not qualified to walk the patient out
· Not enough volunteers
· Volunteers leave at 1:00PM and most discharges are occurring after that time
5. Figure 4.3a – Value Stream
Figure 4.3b – Time Value Breakdown of the Discharge Process
Value Added
(minutes)
Non-value Added
(minutes)
Total Discharge
Time (minutes)
Process Times (within scope) 40
Process Times (out of scope) 81
Queue Times (within scope) 124
Queue Times (out of scope) 84
Totals 121 208 329
Percent 0.367781155 0.632218845
Figure 4.3c – Time Distribution
Tell
patient
about
discharge
Physician
writes
order
Order
Dropped
Off
Unit
Secretary
Enters
Order
Patient
Checks
Out/
Discharged
Process
Time:
0:10
Process
Time:
0:13Queue
Time:
0:58
Queue
Time:
0:21
Process
Time:
0:01 Queue
Time:
0:45
Process
Time:
0:14
Queue
Time:
2:45
Process
Time:
0:02
