INDEX

CONTENTS Page No
CHAPTER-I:
INTRODUCTION 2-35
 Outpatients and Inpatients
 Definitions of Discharge
 Discharge Planning Process
 Discharge Documentation
 Discharge Planning Policies
 Flowchart of Discharge Process
 Discharge Guiding Principles
 Review of Literature
 Research Gap
 References

CHAPTER-II:
RESEARCH METHODOLOGY AND OBJECTIVES OF THE STUDY 36-45
 Need for the Study
 Research Questions
 Objectives of the Study
 Methodology
 Research Design
 Analysis of Data

CHAPTER –III:
PROFILE OF THE ORGANIZATION 46-55

 History
 Departments
 Core Values
 Key Features

CHAPTER-IV:
DATA ANALYSIS AND INTERPRETATION 56-79

CHAPTER-V:
A SUMMARY OF FINDINGS, CONCLUSIONS AND RECOMMENDATIONS 80-83

APPENDIX – QUESTIONARE

BIBLOGRAPHY

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 CHAPTER-1

INTRODUCTION

INTRODUCTION

Communication of hospital discharge instructions between patient and provider is an

important component of hospital. “Discharge is the release of an admitted patient from the

hospital”. As per NABH, Discharge is a process by which a patient is shifted out from the hospital

with all concerned medical summaries ensuring stability.

A patient is any recipient of health care services. The patient is most often ill or injured

and in need of treatment by a physician, advanced practice registered nurse, physiotherapist,

physician assistant, psychologist, dentist, Pediatrist, veterinarian, or other health care provider.

OUTPATIENTS AND INPATIENTS

An outpatient (or out-patient) is a patient who is hospitalized for less than 24 hours. Even

if the patient will not be formally admitted with a note as an outpatient, they are still registered,

and the provider will usually give a note explaining the reason for the service, procedure, scan, or

surgery, which should include the names and titles and IDs of the participating personnel, the

patient's name and date of birth and ID and signature of informed consent, estimated pre- and

post- service time for a history and exam (before and after), any anesthesia or medications needed,

and estimated time of discharge absent any (further) complications. Treatment provided in this

fashion is called ambulatory care. Sometimes surgery is performed without the need for a formal

hospital admission or an overnight stay. This is called outpatient surgery. Outpatient surgery has

many benefits, including reducing the amount of medication prescribed and using the physician's

or surgeon's time more efficiently. More procedures are now being performed in a surgeon's

office, termed office- based surgery, rather than in a hospital-based operating room.

Outpatient surgery is suited best for healthy patients undergoing minor or intermediate

procedures (limited urologic, ophthalmologic, or ear, nose, and throat procedures and procedures

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involving the extremities).

An inpatient (or in-patient), on the other hand, is "admitted" to the hospital and stays

overnight or for an indeterminate time, usually several days or weeks, though in some extreme

cases, such as with coma or persistent vegetative state patients, stay in hospitals for

years, sometimes until death. Treatment provided in this fashion is called inpatient care. The

admission to the hospital involves the production of an admission note. The leaving of the hospital

is officially termed discharge, and involves a corresponding discharge note.

Misdiagnosis is the leading cause of medical error in outpatient facilities. Ever since the National

Institute of Medicine’s groundbreaking 1999 report, “To Err is Human”, found up to 98,000

hospital patients die from preventable medical errors in the U.S. each year, government and

privatesector efforts have focused on inpatient safety.[1] While patient safety efforts have focused

on inpatient hospital settings for more than a decade, medical errors are even more likely to

happens in a doctor’s office or outpatient clinic or center.

DISCHARGE

A patient is released from a hospital when their illness has been resolved it called

discharge of a patient in a hospital.

The discharge process is deemed to have started when the consultant formally approves

discharge and ends with the patient leaving the clinical unit. The admission and discharge

processes can act as bottlenecks in many of the hospitals and thus adversely affect the efficiency

of the hospital. It is a very important indicator of quality of care and patient satisfaction. Delay in

Discharge of the patient also increases the pressure on beds of the hospital Delay in discharge is

bad for both hospitals and the patients. It increases cost to the hospitals and is depressing to the

patients. Delayed discharge also increases the patient’s exposure to hospital acquired infections.

So, effective strategies must be in place to solve this issue. National Accreditation Board for

Hospitals and Health Care Organizations has set a standard of 180minutes for the completion of

the discharge process.

Yashoda hospital Secunderabad, has set a bench mark of 3hrs for the total time taken for

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 the discharge.Discharge to ensure that patients have the information they need to manage their

post‐ acute care. Discharge from the hospital is the point at which the patient leaves the hospital

and either returns home or is transferred to another facility such as one for rehabilitation or to a

nursing home. Discharge involves the medical instructions that the patient will need to fully

recover. Discharge planning is a service that considers the patient's needs after the hospital

stay, and may involve several different services such as visiting nursing care, physical therapy,

and home blood drawing. Discharge is a coordinated, patient - focused, transparent process that

starts either before admission or as soon after admission as appropriate. Patients, family and

careers are treated with dignity and respect, and encouraged to be actively involved in all plans

and decisions about their future care. Hospital discharge summaries serve as the primary

documents communicating a patient’s care plan to the post-hospital care team. Often, the

discharge summary is the only form of communication that accompanies the patient to the next

setting of care. High-quality discharge summaries are generally thought to be essential for

promoting patient safety during transitions

between care settings, particularly during the initial post-hospital period.

Discharge from hospital is a process and not an isolated event. It should involve the

development and implementation of a plan to facilitate the transfer of an individual from hospital

to an appropriate setting. The individuals concerned and their career(s) should be involved at all

stages and kept fully informed by regular reviews and updates of the care plan.

Definition of Discharge:

It can be defined as the processes, tools and techniques by which an episode of treatment

and/or care to a patient is formally concluded by a health professional health provider

organization or individual.

People require healthcare services from the moment they are born, and the demand for those

services varies during their life time, therefore the volume of demand is almost the size of the

human population. The complex nature of the human body and the potential ailments it might

sufferadd to the complexity of what is expected from healthcare service providers.

A healthcare system can be defined as a set of facilities and organizations that participate in
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providing services that relate to individuals' health and wellbeing. The structure and functioning of

the healthcare system is largely shaped by the country or territory it is serving.

Background

Discharge planning is critical to ensuring rapid, safe and smooth transition from hospital to

another care environment; it involves the social work functions of high risk screening, social work

assessment, counselling, bcating and arranging resources, consultation/ collaboration, patient and

family education, patient advocacy and chart documentation; it is a complex activity requiring a

wide range of clinical and organizational skills to address needs of patient, family and health care

system and to promote the optimum functioning of patients, families and support systems. Delay

factors may be internal (waiting for discharge summaries; waiting for declaration of chronicity;

transfer between nursing units; lack of documentation of discharge plan); external (lack/delay of

access to rehabilitation, convalescence, palliative care, home care resources, long term care

facility); and psychosocial (waiting for family adjustment to illness, waiting for patient function to

improve, unrealistic expectations of patient/family, social isolation of patient,

inadequate support at home, lack of concrete medical aids, transportation for treatments, financial,

family burden prevents discharge home).

Discharge planning issues can be of the following types:

Hospital system issues

Discharge date not known in advance and planning for discharge at the last minute Lack of

communication and coordination between disciplines and various departments Lack of clear

documentation of the discharge phns in the patient's medical chart Lack of clear hospital policy on

chronic status and placement options

Community resources

Inaccessibility of community resources at the appropriate time Lack of appropriate structured and

supervised resources for psychiatric patents Home care expensive and often inaccessible to

families
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Lack of palliative and long-term care resources

Patient/family issues:

Patient and family not adequately informed about the discharge date Patient and family not

adequately informed about chronic care fees Failure to include the patient and family in the

discharge planning process Families lack support and interaction with community resources

Solutions for the above issues can be of the following types: Patient/family issues:

Improve communication with patient and family concerning discharge date and planning Provide

patient and family with accurate information on chronic care status and fees of high-risk patients

within 24-48 hours of admission

Patient discharge process can be defined as 'the final step of the treatment procedure during a

patient's length of stay', and timely discharge can be defined as 'when the patent is discharged

home or transferred to an appropriate level of care as soon as they are clinically stable and fit for

discharge.

Researchers suggest that appropriate discharge processes enable the list of available beds for

admission to be kept current and accurate, and 'in addition, we can obtain useful data by accurate

registration of patients in the admission book ...' and calculating there from the admission and

discharge dates for each patient.

Complications in the discharge process and unnecessary routines causes discharge delay and

patient dissatisfaction.

The discharge process represents the final contact between the patient and the hospital health

professionals, and the outcomes of all procedures undergone by the patient are recorded at this

stage. Improving the quality of the discharge process should therefore lead to an increase in

patient satisfaction. As a resut patients are likely to return to a health centre where they have

experienced an efficient discharge process when they next seek treatment. In turn, efficiency and

productivity
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are increased at the hospital. Conversely, availble beds are a hospital's most important resource

and the length of stay in hospital is an important factor in its efficiency. The unnecessary

occupation of hospital beds and rooms and consequent low hospital bed turnover rate represent a

waste in health care resources, and result in heavy associated organizational costs. A fast

discharge process can ensure early availability of patient beds, which in turn, can reduce the

waiting time of patient admissions or even reduce the incidence of patient rejection due to

unavailability of beds.

As the counterpart to hospital admission, hospital discharge is a necessary process experienced by

each living patient. For all patients except those being transferred to a continuing care facility,

discharge is a period of transition from hospital to home that involves a transfer in responsibility

from the inpatient provider or hospitalist to the patient and primary care physician (PCP).

Prescription medications are commonly altered at this transition point, with patients asked to

discontinue some medications, switch to a new dosage schedule of others, or begin new

treatments. Self-care responsibilities also increase in number and importance, presenting new

challenges for patients and their families as they return home. Under these circumstances,

ineffective planning and coordination of care can undermine patient satisfaction, facilitate adverse

facilitate adverse events, and contribute to more frequent hospital readmissions. Poor care

coordination at the time of hospital discharge can jeopardize patient safety and result in

substandard medical care. Patientsand their caretakers are routinely ill prepared for the transition

from hospital to home. With shorter hospitalizations and high patient loads for both physicians

and nurses, discharge planning is often hurried and incomplete.

Patients and careers (attendant) are engaged with discharge planning from pre-assessment or

admission, they understand what has happened and feel valued as partners in the discharge

process, whose knowledge has been used appropriately. Plans are clearly defined and agreed with

them at every stage, including each time the estimated date of discharge is amended. Careers are
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aware of

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their right to have their needs identified and met and who to contact, so that they feel confident of

continued support in their caring role. They are given the right information and advice to help

them decide whether they can undertake or continue a caring role. Multidisciplinary health and

social care staff understand how their own role and that of others contributes to the discharge

process, sharing and receiving key information in a timely manner. Expertise is recognized and

used appropriately, practice is patient-centred and carer/family-focused, and al professions,

disciplines and agencies involved work collaboratively. Patients are assessed and services

delivered in a timely manner without unnecessary gaps or duplication of effort, ensuring care is

experienced as a coherent pathway, rather than a series of unrelated activities.

Patient and carer involvement includes good communication, involving patients and careers at all

stages of discharge planning, giving good information and ensuring patients and careers are

helped to make planning decisions and choices. Staff record all assessments, discussions, referrals

and actions relating to discharge the communication sheets alongside to aid coordination of

discharge plans. Staff expertise is recognized and used appropriately and systems enable staff to

receive timely information, understand their part in the system, develop new skills and roles, have

opportunities to work in different settings and in different ways. Staff acts in a sensitive way that

respects patients' views. They take time to involve patients in planning discharge and to explain

what different options mean for the patient. on

DISCHARGE OUT OF HOURS

It is not usual practice to discharge inpatients after 8pm without agreement from the patient and

receiving service providers. Transfers to community hospitals are usually arranged so that the

patient arrives prior to 5pm. Special consideration is given to discharge of patients at weekends

and bank holidays, such as considering availability of community-based services and transport

requirements.

Patients who attend the Emergency Department or for clinical assessment only and do not require

admission to an inpatient ward will return to their usual palce of residence without delay.

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 SIMPLE DISCHARGE - When a patient has minimal ongoing need for health or social care, the

discharge process is said to be simple, as it does not need complex planning or delivery. This

might include when the patient's level of independence is relatively unchanged, and they don't

need significantly changed support in the community, so the patient can return to their usual place

of residence. Simple discharge planning includes reviews and checks for possible changed needs.

Simple discharges might include discharge of adults, newly delivered mothers and their babies

(obstetric), children and babies (Pediatric).

COMPLEX DISCHARGE - The discharge process is said to be complex when a patient will

need support from one or more services after discharge. Discharge planning may require complex

coordination of services to enable safe discharge. The dehyed transfer of care escalation process is

followed, as well as the appropriate pathway to address the patient's specific needs.

The complex discharge planning process includes assessment of the patient's home environment,

referral to the hospital social services team for assessment of the patient and support network, a

written care plan that records health and social care needs, referral for ongoing NHS services to

monitor and, if necessary, adjust the care plan, and confirmation that services will be in place on

discharge.

Roles And Responsibilities

All professional working in the hospital will:

 Record actions, referrals, discussions, assessments etc in the patient's record. Encourage patients

to engage in the discharge process as equal partners, treating them with kindness, dignity and

respect, and taking account of their needs, wishes and rights, including the patient's right to

positive risk taking

 Work towards the patient's discharge using a whole systems' approach to the assessment,

commissioning and delivery of services.

 Work collaboratively with multidisciplinary colleagues to provide information, medication

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 equipment or specialist input, being aware of how each person's role supports the patient, and how

all parts work as a whole, to meet their needs.

 Ensure that discharge is timely, as soon as the patient no longer requires acute inpatient

investigation, treatment or therapy, and that the patient is medically fit and safe to be transferred

to another setting.

 Ensure all discharge documentation is complete and filed in the patient's record in chorological

order.

The pre-assessment or admitting nurse will:

 Start discharge planning, including assessment of risk prior to elective admission or within 24

hours of unplanned admission if possible.

 Identify what services are currently provided, note contact details, and make initial contact to

engage them in plans for supported discharge.

The ward nurse will:

 Ensure effective verbal and written hand-over of assessments and care plans. Escalate complex

issues to the ward lead and delegates to other ward staff.

 Negotiate timely and appropriate decisions, coordinate discharge plans, and act as a point of

contact for effective communication between MDT members.

 Communicate with the patient and/or carers, including discussing the initial and reviewed

estimated discharge date (EDD), provide advice and support when needed, agree transport

arrangements before discharge, and ensure carers are informed of their right to an assessment of

their own needs.

 Screen the patient for potential risks that may result in discharge delay, follow the appropriate

complex discharge pathway if risks are apparent and refer to other professions/agencies as soon as

it becomes clear they might need support.

 Work towards the EDD, doing everything possble to arrange a safe and effective discharge by

ensuring all discharge requirements are complete, and that the patient, careers or independent

advocates are involved with all decisions.

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 The ward lead (sister/ charge nurse/ midwife) will:

 Ensure their teams are aware of this procedure and that discharge planning practice complies with

it.

 a Decide the process for identifying a named nurse to coordinate discharge plans and inform ward

staff of this.

 Ensure operational systems are in place to support timely and safe discharge of medically fit

patients, and that their team work towards the EDD set by the medical team and record changes in

both the patient's electronic and paper record.

 Organize and coordinate multi-disciplinary meetings, escalate discharge concerns to the specialty

matron for support to ensure patient safety.

The specialty matron lead nurse will:

 Hold ultimate responsibility for ensuring operational systems are in place to support timely and

safe discharge of medically fit patients and that discharge is implemented in a standard way.

 Support the ward led to resolve issues at a local level and share learning across the Trust by

presenting case studies to the Nursing and Midwifery Executive Group chaired by the Director of

Nursing.

 Delegate to the ward lead, escalate operational matters to the specialty director and escalate

clinical maters to the Director of Nursing.

The director of nursing will:

 Ensure appropriate discharge clinical processes are in place to support safe discharge. Escalate

clinical concerns to the Chief Executive and delegate clinical responsibility to the Discharge

Services Matron.

The discharge services matron/ lead nurse will:

 Develop and review discharge processes, ensuring these comply with local and national guidance

and remain responsive to the changing needs of the Trust. This will include maintaining and

updating systems and tools to meet the needs of users, such as the discharge planning tool,

discharge planning leaflet or education.

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 Provide day-to-day operational leadership and management of discharge services and represent

the Trust at multi-agency discharge related meetings.

 Seek the views of patients, careers and partner organizations and promote collaborative working

with these organizations, including social services, housing, independent mental capacity

advocacy (IMCA), other hospitals, community health services, specialist nurses, care homes and

voluntary organizations.

 Receive information on adverse incidents or near misses relating to patient discharge and arrange

for these to be acted on by the appropriate clinical lead.

 Escalate unresolved operational issues to the Operations Manager, and clinical issues to the

Director of Nursing, such as matters relating to patient care, patient safety and other quality

issues.

 Delegate as appropriate to discharge services administrative and clinical staff.

 Discharge from hospital is a process and not an isolated event. It should involve the development

and implementation of a phone to facilitate the transfer of an individual from hospital to an

appropriate setting. The individuals concerned and their career(s) should be involved at all stages

and kept fully informed by regular reviews and updates of the care plan.

 Planning for hospital discharge is part of an ongoing process that should start prior to admission

for planned admissions, and as soon as possible for all other admissions. This involves building

on,or adding to any assessments undertaken prior to admission.

 Effective and timely discharge requires the availability of alterative, and appropriate, care options

to ensure that any rehabilitation, recuperation and continuing health and social care needs are

identified and met.

Implementation of Ideal Discharge Planning

 Each part of IDEAL Discharge Planning has multiple components: Include the patient and family

as full partners in the discharge planning process.

 Always include the patient and family in team meetings about discharge. Remember that

discharge is not a one-time event but a process that takes place throughout the hospital stay.

 Identify which family or friends will provide care at home and include them in conversations.

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Discuss with the patient and family five key areas to prevent problems at home.

1. Describe what life at home will be like. Include the home environment, support needed, what

the patient can or cannot eat, and activities to do or avoid.

2. Review medications. Use a reconciled medication list to discuss the purpose of each medicine,

how much to take, how to take it, and potential side effects.

3. Highlight warning signs and problems. Identify warning signs or potential problems. Write

down the name and contact information of someone to call if there is a problem.

4. Explain test results. Explain test results to the patient and family. If test results are not available

at discharge, let the patient and family know when they should get the results and identify who

they should call if they have not gotten results by that date.

5. Make follow up appointments. Offer to make follow up appointments for the patient. Make

sure that the patient and family know what follow up is needed.

DISCHARGE PLANNING

Planning for hospital discharge is part of an ongoing process that should start prior to

admission for planned admissions, and as soon as possible for all other admissions. This involves

building on, or adding to, any assessments undertaken prior to admission. Local implementation of

the single assessment process (SAP) needs to take account of this critical issue. Effective and

timely discharge requires the availability of alternative, and appropriate, care options to ensure

that any rehabilitation, recuperation and continuing health and social care needs are identified and

met. Medicare states that discharge planning is “a process used to decide what a patient needs for

a smooth move from one level of care to another.” Only a doctor can authorize a patients release

from the hospital, but the actual process of discharge planning can be completed by a social

worker,nurse, case manager, or other person. Ideally, and especially for the most complicated

medical conditions, discharge planning is done with a team approach.

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 In general, the basics of a discharge plan are:

 Evaluation of the patient by qualified personnel

 Discussion with the patient or his representative

 Planning for homecoming or transfer to another care facility

 Determining whether caregiver training or other support is needed

 Referrals to a home care agency and/or appropriate support organizations in the community

 Arranging for follow-up appointments or tests

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 The discussion needs to include the physical condition of family member both before and

after hospitalization; details of the types of care that will be needed; and whether discharge will be

to a facility or home. It also should include information on whether the patient’s condition is

likely to improve; what activities he or she might need help with; information on medications and

diet; what extra equipment might be needed, such as a wheelchair, commode, or oxygen; who will

handle meal preparation, transportation and chores; and possibly referral to home care services.

IMPORTANT OF GOOD DISCHARGE PLANNING

Effective discharge planning can decrease the chances that your relative is readmitted to

the hospital, and can also help in recovery, ensure medications are prescribed and given correctly,

and adequately prepare you to take over your loved one’s care.

Not all hospitals are successful in this. Although both the Indian Medical Association and the

NABH & JCI offer recommendations for discharge planning, there is no universally utilized

system in hospitals. Additionally, patients are released from hospitals “quicker and sicker” than in

the past, making it even more critical to arrange for good care after release.

Studies have shown that as many as 40 percent of patients over 65 had medication errors after

leaving the hospital, and 18 percent of Medicare patients discharged from a hospital are

readmitted within 30 days. This is not good for the patient, not good for the hospital, and not good

for the financing agency, whether its Medicare, private insurance, or own funds. On the other

hand, research has shown that excellent planning and good follow-up can improve patient’s health,

reduce readmissions, and decrease health care costs.

Even simple measures help immensely. Since errors with medications are frequent and

potentially dangerous, a thorough review of all medications should be an essential part of

discharge planning. Medications need to be “reconciled,” that is, the pre-hospitalization

medications compared with the post-discharge list to see that there are no duplications, omissions,

or harmful side effects. Under the best of circumstances, the discharge planner should begin

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his or her

17
 evaluation when the patient is admitted to the hospital.

The active management of admission and discharge is therefore vital to ensure that:

 Beds are available for emergency admissions

 Beds are available for elective patients, so that waiting lists are kept down

 The quality of care is high

 Patients get the care they need when they are discharged from hospital

 Beds are used efficiently.

THE GOVERNMENT’S POLICY

 Do not experience unnecessary gaps or duplication of effort understand and sign up to the care plan

 experience care as a coherent pathway, not a series of unrelated activitities believe they have been

supported and have made the right decisions about their future care for the career(s) feel valued as

partners in the discharge process.

 consider their knowledge has been used appropriately are aware of their right to have their

needs identified and met feel confident of continued support in their caring role and get support

before it becomes a problem have the right information and advice to help them in their caring

role are given a choice about undertaking a caring role

 understand what has happened and who to contact for the staff feel their expertise is

recognized and used appropriately

 Receive key information in a timely manner understand their part in the system can develop new

skills and roles have opportunities to work in different settings and in different ways work within

a system which enables them to do so effectively

 for organizations resources are used to best effect service is valued by the local community

staff feel valued which, in turn, leads to improved recruitment and retention meet targets and can

therefore concentrate on service delivery fewer complaints positive relationships with other local

providers of health and social care and housing services avoidance of blame and disputes over

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responsibility for delays.

ROLE OF CAREGIVER’S IN THE DISCHARGE PROCESS

Discharge to ensure that patients have the information they need to manage their post‐ac ute

care. The discharge staff will not be familiar with all aspects of relative’s situation. The discharge

planners should discuss with willingness and ability to provide care. It has physical, financial, or

other limitations that affect care giving capabilities. Some of the care your loved one needs might

be quite complicated. It is essential that you get any training you need in special care techniques,

such as wound, feeding tube or catheter care, procedures for a ventilator, or transferring someone

from bed to chair.

Discharge Documentation

The documentation used to plan a patient’s discharge is not purely an administrative issue. It is

the main vehicle by which all the different individuals and professionals can communicate what

plans have been made and how they are progressing, so that the care provided is co- ordinated and

managed. However, patient’s records are often fragmented, with each of the different professional

groups, such as doctors, nurses and therapists, maintaining their own records which are not

accessible to the others.

Some of those using separate documentation argue that combined documentation may mean the

creation of an additional set of records, with duplication and overlap, or that it causes access

problems when more than one member of staff requires access at the same time. These problems

will be resolved as Hospitals move towards the use of integrated electronic patient records, but in

the meantime they can be minimised by ensuring that the combined documentation is well-

designed and tested in practice. Hospitals which have adopted this approach believe that it

provides a better information source which aids multi-disciplinary working.

A few Hospitals leave the management of discharge planning to individual wards. This may be

acceptable if it reflects a conscious decision that differences between the types of patients cared

for on different wards require different approaches to planning, but this does not seem to be the

case in practice. We found wards in the same hospital with similar patients sometimes have

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different

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documentation.

This can only add to the problems of discharge planning, particularly as many

professionals work across a number of different wards. The aim should be to have a single

discharge planning process across the trust, so that everyone is clear what their responsibilities are

and how they communicate with the other professionals involved.

Hospitals should review their discharge documentation to ensure that it captures and disseminates

the information required and aids high quality multi-disciplinary discharge management.

Delayed discharge

There is no routinely available information on the level and causes of discharge delays across

Scotland, since Hospitals do not consistently measure delays nor use the same definitions. The

multi agency working group on delayed discharge is currently working towards an agreed

definitionof delayed discharge and it is expected that a definition will be agreed prior to April

1999.

A small number of Hospitals do not believe that they have a problem with delayed discharges;

these are non-teaching Hospitals with good access to community hospital beds. However, all

teaching Hospitals and most non teaching Hospitals consider delayed discharge to be a significant

problem. Figures vary depending on the time of year and how a delayed discharge is defined, but

on any given day the average number of beds occupied by patients whose discharge is delayed is

over 20 in each trust.

We also carried out ‘snapshot’ surveys at Hospitals, looking at the number of patients awaiting

discharge at a single point of time for any reason, including delays due to prescriptions, transport

and other services within the hospital. Using this definition the number of patients awaiting

discharge rises to 80 or more. It is inevitable that some patients will be waiting to be discharged at

any point in the day, but this Information can help to identify the source of problems within the

hospital which exacerbate the overall pressure on beds and may reduce the quality of patients’

experience of discharge.

Monitoring

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Good monitoring can identify patterns of delayed discharge which clarify what type of remedial

22
 action is necessary, and where. Equally, monitoring can be used to ensure that the quality of care

is high for individual patients all the way through to discharge.

A few Hospitals do not monitor discharge delays on a regular basis because they do not believe

they have a discharge problem. Apart from this small number of Hospitals, all monitor delays for

patients waiting for care to be arranged by social work departments, which they perceive to be the

most important in terms of the length of delays they account for.

For good reasons, delays while waiting for care to be arranged by social work departments tend to

be longer than those due to other causes. People are taking decisions which may affect where they

spend their lives, and funding is often scarce. However, a range of other problems can also lead to

delays, and the way in which they are monitored is very variable. Only around half of Hospitals

identify whether the

Reason for the delay is caused by the trust itself, by other NHS services or, by social work

services. All Hospitals either have already or are in the process of reaching agreements with their

 Local social work departments, covering:

 a common understanding of what constitutes a delay

 information sharing on delays

 Agreed times for assessments to be completed.

A few Hospitals and social work departments jointly monitor social work delays in Greater detail,

breaking down the process into the following stages:

 assessment process

 funding approval awaited

 awaiting funding

 Awaiting appropriate placement.

This information is important in understanding what is causing delays and how problems can be

tackled. Only half of Hospitals monitor the number of bed days ‘lost’ as well as the number of

patients; this information would allow clinicians and managers to identify which patients are

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facing

24
particular difficulties, and to target them for extra attention.

The lack of analysis of the cause of delay and information on days ‘lost’ leaves many trust

monitoring systems unable to provide the information which would be of real use in identifying

and agreeing problems, causes and action required to achieve improvements. Many Hospitals

recognize the need for improvement.

Information on shorter delays tends to be even worse. Very few Hospitals monitor delays Which

do not lead to an additional overnight stay, often referred to as ‘same day delays’, and several do

not see this as worth doing even on an ad hoc basis. Short delays of this type are often due to

waits for take home drugs to be dispensed, and for transport to be arranged. They do not result in

the loss of many bed days, but they do affect the patient’s experience of discharge. They cause

worry and inconvenience to

Patients and their families, and they can also prevent a smooth transition from hospital care to

community services.

Providing information to patients and careers

Patients and their careers also require clear and comprehensive information about follow-up

treatment and services to be provided on discharge. However, the standard of information

provided to patients varied between trusts and between specialties within trusts. In general, staff

considered that verbal communication with patients was good, although they often expressed

concern that patients might receive inconsistent messages from medical, nursing and PAM staff

where multi- disciplinary working was less developed.

Information should also be provided in writing, so that patients can refer to it in their own time.

The written information examined often omitted basic information, such as a specific, named

contact for any queries the patient might have after discharge.

Discharge policies

In addition to the high-level agreements and protocols discussed above, developed and agreed

with social work, trusts need to have their own operational policies for managing discharge.

Staff need to be involved in developing them, and the policies need to be reviewed regularly. A

25
 discharge policy should be based on the following principles:

 discharge planning should start as early as practical, if possible before admission

 The health and social needs of the patient must be considered, along with other factors which

might affect recovery, when assessing discharge requirements

 consideration of referrals to other professions should be an integral part of consultant ward rounds

 referrals should be made early to allow the other professionals time to carry out an assessment

before the patient is ready for discharge

 the consultant should involve all professionals involved in providing care on the ward or

planning to meet the needs of the patient after discharge

 a minimum discharge planning process (specified in the policy document) should be applied to

all patients

 Patients with continuing care needs or needing short term packages of care in the community will

receive a more detailed discharge planning process (specified in the policy document).

In addition, the policy should:

 require training for new and existing staff involved in discharge planning

 define the patients to whom the policy applies

 describe the discharge planning process

 clarify the responsibilities of the various staff involved in the discharge process

 set agreed timescales for action

 Specify how the quality and effectiveness of discharge planning will be monitored and maintained.

Most hospitals do have a discharge policy; however, some are only in draft, and others lack the

necessary level of detail to act as practical working documents.

Discharge (separation)

 A patient is separated at the time the hospital ceases to be responsible for the patient’s care and

the patient is discharged from hospital accommodation.

 Patients should be discharged from the inpatient ward not the hospital waiting areas, transit

lounges and discharge lounges.

26
 These are not considered hospital accommodation unless the patient is receiving care or treatment in

these areas.

The Discharge Planning Process / Process Improvement

Discharge planning is critical to ensuring rapid, safe and smooth transition from hospital to

another care environment; it involves the social work functions of high risk screening, social work

assessment, counselling, locating and arranging resources, consultation/collaboration, patient and

family education, patient advocacy and chart documentation; it is acomplex activity requiring a

wide range of clinical and organizational skills to address needs of patient, family and health care

system and to promote the optimum functioning of patients, families and support systems. Delay

factors may be internal (waiting for discharge summaries; waiting for declaration of chronicity;

transfer between nursing units; lack of documentation of discharge plan); external (lack/delay of

access to rehabilitation, convalescence, palliative care, home care resources, long term care

facility); and psychosocial (waiting for family adjustment to illness, waiting for patient function to

improve, unrealistic expectations of patient/family, social isolation of patient, inadequate support

at home, lack of concrete medical aids, transportation for treatments, financial, family burden

prevents discharge home). Respondents to a survey of interdisciplinary staff at Montreal General

Hospital identified the following discharge planning issues.

Hospital System Issues

 Discharge date not known in advance and planning for discharge at the last minute

 Lack of communication and coordination between disciplines and various departments Lack of

clear documentation of the discharge plans in the patient’s medical chart

 Lack of clear hospital policy on chronic status and placement options

Community Resources

 Inaccessibility of community resources at the appropriate time

 Lack of appropriate structured and supervised resources for psychiatric patients

 Home care expensive and often inaccessible to families

27
 Lack of palliative and long-term care resources

Patient/Family Issues

 Patient and family not adequately informed about the discharge date

 Patient and family not adequately informed about chronic care fees

 Failure to include the patient and family in the discharge

 planning process

 Families lack support and interaction with community resources

THE RESPONDENTS RECOMMENDED

Hospital system issues:

 Physicians identify discharge date upon admission and in all orders

 Daily, weekly or bi-weekly interdisciplinary rounds on all services/wards

 Summary sheet in the patient’s medical chart to document discharge planning events

 Inform staff, patient and family of clear chronic care policies and placement options

Community resources

 Liaise / develop close contacts and alliances with key community resources

 New resource development for the very ill psychiatric patient population

 Use of alternative resources in the private sector

 Improved knowledge of community resources for all disciplines

DISCHARGE PLANNING POLICIES

A performance framework to monitor discharge delays provides the means to review practice and

revise joint hospital/agency policy in a dynamic way. The policy should be readily available to

patients, caregivers, families and advocacy services in various formats and languages. The policy

should aim to: ensure the patient is treated as an individual and provided with continuity of care;

ensure acute hospital facilities are used appropriately; and identify priorities for change.

The use of a discharge risk screening tool to identify those at risk of discharge delay and a

28
discharge plan containing an estimated date of discharge. The patient is to be told of the expected

length of stay in advance for booked surgery. An audit of the discharge experiences of patients

who had elective carotid end art erectomies failed to link patients’ perception of readiness for

discharge with preparation through preadmission clinic consultations.

Post-discharge communication with GPs was found to be poor; fewer than half of the patients’

GPs reported receiving discharge summaries within two weeks of patients’ discharge.

Personal letters from surgeons were rated as more useful by GPs that were the discharge

summaries. An electronic discharge referral system is expected to replace written discharge

summaries. A subsequent draft policy of NSW Health requires critical ‘must-do’s as the minimum

discharge planning requirements for every patient.

A definition of discharge planning by an “interdisciplinary hospital-wide process that should be

available to assist patients and families in developing a feasible post hospital plan of care.”

PATIENT PARTICIPATION

In a 1999 study of patients discharged from the medical service of a NRI teaching

hospital, Up on discharge, patients assume the responsibilities previously held by the health care

team and must become familiar with their illness, medications, dosing schedule and the side

effects of their medications. Proper instruction is necessary to assure compliance with the

treatment initiated in hospital. The authors of this study recommend that a structured and extended

physician-patient discussion should occur to improve patients’ understanding of their post-

discharge instructions. The physician should determine whether the patient understands the plan.

Discharge summaries should be well-written and organized and they should provide an

easily understandable overview of the patient’s condition, symptoms to expect, medications with

instructions on how to take them, and expected side effects. Written information has been found to

enhance patient recall, e.g., of a physician’s name. Counseling by a pharmacist and

comprehensive discharge planning and instruction by nurses might also help.

Home care providers and family members should reinforce the patient’s recall of the

discharge planning information. Poor communication is likely the major cause of noncompliance

29
with the discharge treatment plan. The choice of appropriate language, allocation of sufficient

time and practicality of the discharge treatment plan should be considered by the health care team.

In an Indian study of the discharge planning conference (DPC), transcripts were analyzed

to examine how patients, relatives and healthcare professionals dealt with problems and

responsibilities within the institutional context. Patients’ rights to autonomy, integrity and

normality are emphasized in the governing national DPC procedure.

The authors describe the DPC as an institutional conversation with a special form, content,

purpose and closure consisting of a formal decision. Professionals have an agenda consisting of

questions to elicit information for decision-making. Unaware of this agenda, the patient replies to

individual questions without an understanding of the context. The participants are not on equal

ground with respect to knowledge, aims and resources, and the communication is asymmetric.

The analysis found that patients and relatives had only limited opportunity to influence decision-

making in the DPC.

The conferences were used to convey information about rules and routines to patients and

families. The healthcare professionals did not have the ability to exercise discretion. Participants

attempted to find room within the institutional frame of the conversation or to challenge it. The

authors conclude that the DPC does not actually achieve its ideological intention. They call into

question the need for, validity and efficiency of DPCs in their present form.

30
FLOW CHART OF THE DISCHARGE PROCESS

confirmation of discharge from consultant

preparation of patient case sheet and discharge summary

Preparation and Processing of Final Bill

Cash Insurance(TPA) Company

approval from the insurer & company

patient settles the bill and receives payment paid slip

Collect discharge summary and prescription

Buys the medication

DMO & Nursing staff explain discharge summary and

medication & follow-up date

DISCHARGE

31
 DISCHARGE GUIDING PRINCIPLES

 Discharge is not an isolated event but a process that starts as soon as possible and continues

throughout the hospital stay.

 Assessment for services such as healthcare, social care or housing is organised so that the patient

and/or careers understand the continuum of these services, and that they receive advice and

information to enable them to be fully involved with care planning and to make informed

decisions about their future care.

 Patients and careers are engaged with discharge planning from pre-assessment or admission, they

understand what has happened and feel valued as partners in the discharge process, whose

knowledge has been used appropriately. Plans are clearly defined and agreed with them at every

stage, including each time the estimated date of discharge is amended. Careers are aware of their

right to have their needs identified and met and who to contact, so that they feel confident of

continued support in their caring role. They are given the right information and advice to help

them decide whether they can undertake or continue a caring role.

 Effective discharge is facilitated by a ‘whole system’ approach to the patient’s care pathway,

including effective use of transitional and intermediate care services, so that acute hospital

capacity is used appropriately and individuals achieve their optimal outcome. Inpatients whose

acute episode is over are discharged as soon as they are medically stable and safe to transfer.

 Multidisciplinary health and social care staff understand how their own role and that of others

contributes to the discharge process, sharing and receiving key information in a timely manner.

Expertise is recognised and used appropriately, practice is patient-centred and career/family-

focused, and all professions, disciplines and agencies involved work collaboratively. Patients are

assessed and services delivered in a timely manner without unnecessary gaps or duplication of

effort, ensuring care is experienced as a coherent pathway, rather than a series of unrelated

activities.

 The Trust and partner health, social care, housing or voluntary agencies use their resources to best

effect to provide services valued by the local community, to meet service delivery quality targets

32
 and receive fewer complaints. Positive interagency relationships provide a system that supports

effective collaborative working, and ensures staff can access training to develop skills that support

discharge planning.

 Trust staff will underpin their practice with the principles of cooperation and understanding.

Patient and career involvement includes good communication, involving patients and careers at

all stages of discharge planning, giving good information and ensuring patients and careers are

helped to make planning decisions and choices.

 The Trust and colleagues from local health and social care organizations have agreed discharge

quality standards including collaborative, supportive working to manage all aspects of the

discharge process and ensure that discharge is facilitated at the earliest opportunity.

 Staff records all assessments, discussions, referrals and actions relating to discharge on the

discharge planning tool or communication sheets alongside to aid coordination of discharge plans.

Trust discharge services staff audit compliance with these standards twice yearly by reviewing

patient records for documented evidence of actions (see page 24). This record also provides

evidence of practice for audit.

 All staff will read and comply with the Trust discharge procedure and will access training to

familiarise themselves with Trust documents relevant to their role in discharge planning. Staff

will raise any queries about implementation with their line manager and/or Trust discharge

services staff.

 Staff are mindful of personal responsibility, professional accountability and governance issues,

including treating patients with kindness, dignity and respect, taking account of diversity and the

patient’s right to positive risk taking. They are also responsible for reporting discharge-related

issues to their line manager, and completing adverse incident reports in line with Trust policy.

 Patients are able to maximise independence, feel part of the care process, understand and sign up

to the care plan, experience care as a coherent pathway, are involved in decisions about their care,

and asked their views and preferences.

 Careers feel valued as partners in the discharge process, consider their knowledge is used

33
 appropriately, understand what has happened and who to contact, are confident of continued

support, information and advice to help them undertake or continue a caring role, and are given a

choice about this Staff expertise is recognised and used appropriately and systems enable staff to

receive timely information, understand their part in the system, develop new skills and roles, have

opportunities to work in different settings and in different ways. Staff act in a sensitive way that

respects patients’ views. They take time to involve patients and careers in planning discharge and

to explain what different options mean for the patient.

 Trust practice meets targets, reduces complaints, concentrates on service delivery, and has

positive relationships with other local providers of health, social care and housing services.

AS THE DAY OF DISCHARGE APPROACHES

 Prior to discharge

 The named nurse (or their representative) starts the discharge checklist in the discharge planning

tool as early as possible and addresses any issues. Some arrangements are signed off prior to the

day of discharge, such as arranging for outdoor clothing, food and heating to be available and

confirming the discharge address. If the patient is returning home, the nurse will suggest that a

friend or relative stays or visits regularly. Discussions might also include how the patient will

access food, drinks, and basic painkillers, such as Paracetamol or Ibuprofen.

 Arranges discharge for before midday wherever possible and arranges transfer to the discharge

lounge. Explains to patients and/or careers that they may need to rest in the discharge lounge until

medication or other services are ready, so that they do not become anxious whilst waiting.

 Records the response to referrals on the discharge planning tool or communication sheets filed

alongside. Confirms that receiving professionals are aware of the patient’s EDD and can provide

the required care. Completes a transfer of care form or letter if specific information is required

that is not in the IDS.

 Transport

 All staff encourage patients and/or careers to make their own arrangements for transport home,

34
 such as paying for a taxi themselves but offer to help make arrangements. The named nurse

explains that if they will not be collected by 11am on the day of discharge, they will need to wait

in the discharge lounge to support effective management of bed capacity. Where medical/social

circumstances indicate such need, and all alternatives have been explored, transport is offered and

booked through the discharge lounge, at least 24hrs in advance. When arranging transport, the

nurse confirms the discharge address and postcode, highlighting on the discharge planning tool if

this differs to the address on the patient’s addressograph labels.

 If the patient requires an ambulance, the nurse arranges this at least 48hrs prior to discharge and

clarifies whether a stretcher or wheelchair (sitting) is needed. The nurse ensures medication,

house keys and discharge documentation are ready for when the ambulance crew arrive on the

ward. Wards will book transport in advance and cancel it if the discharge does not go ahead.

 Medication

If medication administration will be complex, staff laisse with the receiving team prior to

discharge. The doctor or pharmacist give the patient or careers medication counselling, i.e. ensure

a clear understanding of dose, times, routes, possible side-effects, special instructions, where and

how to get further supplies and what to do if there are any problems. Possible need for help or aids

with taking medication is also considered. Instructions given are documented on the

communication sheets filed alongside the discharge planning tool.

DAY OF DISCHARGE

 When required, patients are provided with written information to complement discussions about

the nature of their illness or condition, advice about self-care, lifestyle etc. If information leaflets

are not available on the ward, patients/careers are directed to the on-site health information

Centre.

 The IDS is given to the patient or those responsible for ongoing care, such as careers or care

homes, which includes details of treatment, diagnosis, complications, outstanding medical or

social issues, medications and follow-up arrangements.

 The discharge checklist is completed to confirm that: ongoing support, such as medication

35
administration has been agreed; the patient has the required paperwork, dressings, medication,

36
 leaflets or equipment; the IDS has been clinically verified and medication provided by a

registered pharmacist; the patient, careers or care provider have a copy of the IDS.

 The discharging nurse arranges for the doctor to provide a ‘fit note’ or information for the

patient’s employer or insurance company if requested. The nurse ensures patients receive any

required specific information about their condition, gives them their Single Assessment Process

(SAP) paperwork where appropriate and checks that they have all their belongings, including any

cash or valuables.

 Files a copy of the IDS, gives a copy to the patient and arranges for a copy to be posted to the GP.

 Patient’s GP and other community staff involved

 Healthcare professionals involved in ongoing care are notified on discharge or within 24 hours.

The GP receives an electronic notification on discharge and printed IDS by post.

 In some cases the consultant dictates a formal discharge summary letter to be sent to the GP

within 5-days of discharge. If a patient is discharged to an address other than their usual

residence, the patient’s GP is informed. If the address is outside the patient’s GP practice area, the

patient is advised to register with a local GP.

DISCHARGE OUT OF HOURS

 It is not usual practice to discharge inpatients after 8pm without agreement from the

patient/careers and receiving service providers. Transfers to community hospitals are usually

arranged so that the patient arrives prior to 5pm. Special consideration is given to discharge of

patients at weekends and bank holidays, such as considering availability of community-based

services and transport requirements. The MDT responsible for discharge decisions will take

account of service availability and careers needs. Particular care is taken to ensure adequate

supportis in place.

 Patients who attend the Emergency Department or for clinical assessment only and do not

require admission to an inpatient ward will return to their usual place of residence without delay.

 Nurse-led discharge is a framework that allows patients to be discharged by nurses rather

than medical clinicians. The parameters for discharge are determined by the patient’s medical

37
team.

38
 Discharges must be arranged in advance and staff follow Trust guidelines for nurse led discharge.

 The ward contact the clinical management team for assistance booking transport, take home

medication, transfer to community hospitals or any other clinical considerations.

DISCHARGE DOCUMENTATION

 Documentation required for every patient discharged includes the planning your discharge patient

leaflet given as soon after admission as clinically appropriate and a patient copy of the IDS, which

provides information about their treatment, medication changes, future care needs, and follow up

appointments. Patients with impaired vision might require information in large print format.

Information relating to specific clinical conditions may also be provided.

 When patients with reduced mental capacity are discharged information passed to receiving teams

might include a mental capacity assessment (form A), best interest balance sheet, best interest

decision checklist (form B), a registered lasting power of attorney for health and welfare. It might

also include advocacy paperwork and records of meetings with family, carers or advocates and

SAP documentation.

 Women leaving hospital after giving birth may also require the maternity case summary,

completed and accessed via eCaMIS, and the client-held pregnancy notes given to the woman.

Parents or carers of children or young people being discharged may also require patient/parent

information documentation where applicable and open access documentation where applicable

39
 Patients transferring to district nurses, intermediate or palliative care might also require wound

care guidance and prescriber authority to administer medication.

 Patients transferring to community hospitals may also require the transfer of care (TOC) form, the

single point of access (SPoA) referral, nursing wound care guidance and prescriber authority to

administer medication, the patient’s hospital record. If transferring to an out-of-area hospital, a

copy of the current admission documentation is sent with a rewritten, signed medication

administration sheet. The medical notes are retained.

 Patients being discharged with NHS continuing healthcare (CHC) might also require the CHC

consent and checklist, social services referral, part B (checklist summary), Department of Health

CHC patient information, and a CHC care plan.

 Patients discharged with social care might also require social services referrals A, B and C, social

care assessment documentation and SAP consent. Patients needing housing support on discharge

may require social services referral, part A and the housing referral. Asylum seekers or foreign

nationals may require referral to social services and discharge information in a language other

than English.

 Patients who self-discharge will also require a self-discharge form and the IDS to be sent to the

GP within 48hrs of the patient leaving.

 Patients discharged under the managing choice protocol may also require: Factsheets 1 and 2, and

Formal Letters 1, 2 and 3.

Comparison of Average Time Taken According to Type of Discharges and NABH

Prescribed Standards

40
 s Steps in discharge Time taken according to type o discharge (in minutes-
. procedure rounded off) minutes
n
o
1 Preparation of 49 51 63 30
discharge
Summary
2 Return of unused 28 33 31 30
medicines to
Pharmacy
3 Clearance form all 78 74 75 60
departments
4 Preparation of bill 67 66 71 30
5 Bill 56 113 62 30
Total mean time in 278 337 302 180
minutes minutes minutes minutes minutes
SOURCES:

 Records from patient registrationtime

 Doctor consultation time in andout

 Admission records from date andtime

 Discharge time of the patient

The above table shows that the average time taken for each step of discharge procedure for

Individual patients (278 minutes), Insured patients (337 minutes) and Patients discharged against

medical advice (302 minutes) was markedly higher when compared with standards prescribed by

National accreditation board for Hospitals (NABH).

Longest time (113 minutes) was taken for Insurance covered patients mainly because of

delays in bill approval process. The time taken for return of unused medicines to the pharmacy

department was more or less, at par with NABH standards (30 minutes), the shortest being for

individual patients (28 minutes), which was 2 minutes lesser than the prescribed time.

41
REVIEW OF LITERATURE

This chapter is designed and aimed for presenting the review of literature for the present

study. The review of the literature plays a pivotal role in any academic writing. The literature

review helps researcher to remove limitations of the existing work or may assist to extend

prevailing study. The purpose of this chapter is to provide a comprehensive survey of the

theoretical and empirical literature on discharge process. Hence, this study is the upshot of the

earlier studies related to discharge process in hospital wise which could be found in various

national, international journals, magazines and various lead reports. The review has led the

present study to be meaningful and thought provoking and streams of literature which underpins

the central idea of this study, discharge process in Yashoda Hospital Secunderabad

.The related literature presents a strong interest on discharge process in all over of India.

The available literature and the area of research i.e., studies are:

Nagaraju (2005) defines ‘the patient discharge process as ‘the final step of the treatment

procedure during a patient’s length of stay’, and timely discharge as ‘when the patient is

discharged home or transferred to an appropriate level of care as soon as they are clinically stable

and fit for discharge’. Sources; “principles of plasma discharge and materials processing”

(Michael A.Lieberman and Allan Lichtenberg).

According to Bateni (1995),appropriate discharge processes enable the list on available beds for

admission to be kept current and accurate, and ‘[i]n addition, we can obtain useful data by

accurate registration of patients in the admission book …’ and calculating there from the

admission and discharge dates for each patient (Bateni 1995: 138)’.A study on the medical centres

of Tehran University of Medical Sciences, Iran and Shahid Beheshti has shown that in most

centrest complication the discharge process and unnecessary routines have caused discharge

delay and

42
patient dissatisfaction. Scattered information and non- integrated database systems had resulted in

increased works loads and dissatisfaction among internal and external hospital clients

(Derayeh2003).

The discharge process represents the final contact between the patient and the hospital health

professionals, and the outcomes of all procedures undergone by the patient are recorded at this

stage. Improving the quality of the discharge process should therefore lead to an increase in

patient satisfaction. As a result patients are likely to return to a health center where they have

experienced an efficient discharge process when they next seek treatment. In turn, efficiency and

productivity are increased at the hospital (Gholipor & Ghomry 2003).

Conversely, available beds are a hospital’s most important resource and the length of stay in

hospital is an important factor in its efficiency. The unnecessary occupation of hospital beds and

rooms and consequent low hospital bed turnover rate represent a waste in health care resources

,and result in heavy associated organizational costs (Porhasani 1995).

Research in the Shahid Sadoghi Hospital of Yazd has shown that the average length of

the discharge process in the morning shift for a patient leaving the hospital in the afternoon is

about six hours. The average length of then discharge process in the afternoon shift for patients

leaving the hospital in the same shift is about two hours. More than 90% of patients receive their

dischargeorder and visit by physicians before 2pm (Janfaza 2001).The delay in hospital processes

can be explained by queuing models (Ketabi 2003). A queue is described as the place where

customers wait for a server to be free. Since customers’ arrival and service times are stochastic

they sometimesexperience different waiting times, and therefore the average waiting time can be

used as a factor in the analysis of a system’s performance. The average numbers of customers

waiting in the queue,known as the average length of queue, and the percentage of busy periods for

the server, known asthe utilisation rate, are other performance factors in queuing systems. In a

sequence of workstations,the station with the longest service time creates a bottleneck in the flow

of the customers in the system.

43
RESEARCH GAP:

Research gap is an unexplored topic revealed during a literature research that has scope for

research or further exploration to identify literature gaps, you need to do a through review of

existing literature in both the broad and specific areas of your topic

 The discharge process represents the final contact between the patient and the hospital

health professionals, and the outcomes of all procedures undergone by the patient are

recorded at this stage

 Improving the quality of the discharge process should therefore lead to an increase in patient

satisfaction. As a result patients are likely to return to a health center where they have

experiencedan efficient discharge process when they next seek treatment.

 Discharge process is a crucial process in the hospital. If the discharge is late it leads to the

un satisfaction of the patients/patient attenders.

44
REFERENCES

1. Alexander Wyke, "Can Patients Drive the Future of Healthcare". Harvard Business Review,

July-August 1997, pp.146-150.

2. Curry, A. and E. Sinclair (2002) Assessing the quality of physiotherapy services Using

SERVQUAL. International Journal of Operations and Production Management, 20, 386-403.

3. Marraro, R. (2003) Investing in patient safety: An ethical and business imperative. Trustee,

56, 6, 20-23.

4. Thaper S.D., health and development, association of voluntary agencies forrural development

, New Delhi 1977

5. Ramachandrudu and VenkataRaol examine the inter-district variations inhealth services in

Andhra Pradesh. Health planning in India -A P Hpublishing corporation New Delhi 1997 pp

67-

6. Allen, A.O.: Probability, Statistics and Queueing Theory. Academic Press, London (1990)

7. Akkerman, R., Knip, M.: Reallocation of beds to reduce waiting time for cardiac surgery.

Health Care Management Science 7(2), 119–126 (2004)

8. Altinel, I.K., Ulas, E.: Simulation modeling for emergency bed require- ment planning.

Annals of Operations Research 67(1), 183–210 (1996)

9. Anthony, R.N.: Planning and control systems: a framework for analy- sis. Harvard Business

School Division of Research, Boston (1965)

10. Ashton, R., Hague, L., Brandreth, M., Worthington, D.J., Cropper, S.: A simulation-based

study of a NHS walk-in centre. Journal of the Operational Research Society 56(2), 153–161

(2005)

45
 CHAPTER – 2
RESEARCH METHODOLOGY AND OBJECTIVES OF THE STUDY

NEED FOR THE STUDY:

Discharge from Hospital has always been the topic of research and there has been

continuous striving to reduce the time of discharge. If patients are dissatisfied, it has been

observed that the major factor for their dissatisfaction is been delay in discharge process. It is the

need of an hour in today’s competitive world to achieve cent percent patient satisfaction and to

find the factors extending time in discharge process and try to rule out these factors. This made me

to take the study on patient safety to determine all the possible options to maintain the patient

safety and to improve the quality of patient safety.

RESEARCH QUESTIONS

After an extensive literature survey, the summary of the literature extracted some research

question, which needs to be addressed in the further analysis:

In this study, the researcher used qualitative research method. Qualitative research method

was developed in the social sciences to enable researchers to study social and cultural phenomena:

observe feelings, thoughts, behaviours and the belief of the mass society. Qualitative data sources

include observation and participation observation (fieldwork), interviews and questionnaires,

documents and texts, and the researcher’s impressions and reactions.

For this study, method of interview was employed. Interviewing of selected individuals is

a very important method often used by qualitative researchers. The rationale for using the

interview methods is to enable the researcher to find out what is on their mind, what they think

and how they feel about something.

The study is dealing with Patient, doctors and nurses like a human interaction and

perspectives hence it is highly encouraged to use qualitative method. It will be a more accurate
46
 finding as the interviewees are perceived to give a more honest answers and opinions through

personal interaction with the interviewer.

1. Was a tentative discharge date discussed with you during your hospitalisation?

2. Does your ward have a discharge protocol?

3. How is this discharge policy functioning?

4. What would be reasons for this (good or bad) functioning?

5. Do you think patients are satisfied with the current discharge policy?

OBJECTIVES OF THE STUDY

The present study was undertaken with the following specific objectives:

1. To study the process of discharge of patient in Yashoda hospital Secunderabad;

2. To study the roles and responsibilities of Hospital personnel in discharge process;

3. To compare the average time taken for completion of discharge process forselected discharges

with NABH standards;

4. To assess the respondents views for the discharge process of Yashoda hospital Secunderabad;

5. To offer the pragmatic suggestions to the policy makers based on the findings of the study.

METHODOLOGY

DATA COLLECTION PROCEDURE

The study is discriptive in nature and it is based on both primary and secondary data.

Primary Data:

Primary Data means data which to collect from direct sources like survey, questionnaire

and interview methods etc. The present study primary data cover the interview methods.

For find out the Yashoda hospital Secunderabad discharge process analysis the present

study focused the Patient (orthopedics), doctors (specialized) and nurses included assistant nurse

47
and head nurses on an opinion survey conducted. Naturally such as analysis involves the collection. of
primary data from the sample responses. The primary data have been collected from the sample
respondents with the help of Questionnaire specially designed for this purpose.

Secondary Data:

Secondary Data means data collected from the all ready published sources like annual

reports, printed material and reports etc.

 Annual Reports of Yashoda hospital Secunderabad discharge process for the studyperiod.

 Published and unpublished documents maintained by the Head Office of Yashoda hospital

Secunderabad.

 Paper based sources: published and unpublished dissertation works, books, periodicals and

research articles from various journals, Conference Papers, Newspapers and Magazines.

Electronic Sources: CD-ROMs, Online Databases, Internet.

RESEARCH DESIGN

Research design is the arrangement of conditions for collection and analysis of data in a

manner that aims to combine relevance to the research purpose with economy in procedure. In

fact, the research design is the conceptual structure within which research is conducted; it

constitutes the blueprint for the collection, measurement and analysis of data. As such the design

includes an outline of what the researcher will do from writing the hypothesis and its operational

implications to the final analysis ofdata.

A good design is often characterized by adjectives like flexible, appropriate, efficient,

economical and so on. Generally, the design which minimizes bias and maximizes the reliability

of the data collected and analyzed is considered a good design. The design which gives the

smallest experimental error is supposed to be the best design in many investigations. Similarly, a

design which yields maximal information and provides an opportunity for considering many

different aspects of a problem is considered most appropriate and efficient design in respect of

many research problems. Thus, the question of good design is related to the purpose or objective

of the research

48
problem and also with the nature of the problem to be studied. A design may be quite suitable in

49
 problem. One single design cannot serve the purpose of all types of study problems.

The present study confines itself, to the discharge process of Yashoda hospital Secunderabad

belonging to the health sector. The present study attempts to evaluate the discharge process of

Yashoda hospital Secunderabad, as Lead hospital inSecunderabad State. The study requires a

moderate period so as to arrive at meaningful and purposeful inferences. Hence, the period of

reference is 45 days from 12th October 2021 to 30th November 2021.

 Sampling Design

Sample design is a definite plan for obtaining a sample from a given population. It refers to

the technique or the procedure the researcher would adopt in selecting items for the sample.

Sample design may as well lay down the number of items to be included in the sample i.e., the

size of the sample. Sample design is determined before data are collected. There are many sample

designs from which student scan choose. Some designs are relatively more precise and easier to

apply than others. Students must select/prepare a sample design which should be reliable and

appropriate for this study. Sample design is determined before data are collected. The present

study sample design consists of Patient, doctors and nurses discharge process of Yashoda

Hospitals,Secunderabad

 Population of the study

A projects population is generally a large collection of individuals or objects that is the main

focus of a scientific query. It is for the benefit of the population that researches are done.

However, due to the large sizes of populations, projects often cannot test every individual in the

population because it is too expensive and time-consuming. This is the reason why study relies on

sampling techniques. The population for the study consists of the Patient (orthopedics), doctors

(specialized) and nurses included assistant nurses and head nurses in selected Yashoda hospital

Secunderabad, inSecunderabad.

Sample Frame:

A list containing all such sampling units is known as sampling frame. Thus, sampling frame
50
consists of a list of items from which the sample is to be drawn. A sampling frame includes a

51
 numerical identifier for each individual, plus other identifying information about characteristics of

the individuals, to aid in analysis and allow for division into further frames for more in-depth

analysis. The sample frame for the present study can be defined as the Yashoda hospital

Secunderabad, inSecunderabad, which are selected in study area.

 Sample Size

In order to analyze the Discharge of process, Patient (orthopedics), doctors (specialized)

and nurses included assistant nurses and head nurses in selected Yashoda hospital Secunderabad,

inSecunderabad, 435 respondents are in total population for selected from the orthopedics

department Yashoda hospital Secunderabad. 435 respondents belonged to under the Patient

(orthopedics), doctors (specialized) and nurses included assistant nurses and head nurses.

In the study has covered Yashoda hospital Secunderabad, inSecunderabad, where the

Yashoda hospital Secunderabad happened to be the Lead hospital. Identically, the number of

respondents in Yashoda hospital Secunderabad in the entire department happened to be around 60

patients, doctors 20 and nursing staff including all the department 20 has fixed the number of

sample respondents Finally, the total sample size of the study selected area 100 respondents only.

 Sampling Technique

The present study related to Random sampling technique was adopted. Random sampling

from a finite population refers to that method of sample selection which gives each possible

sample combination an equal probability of being picked up and each item in the entire population

to have an equal chance of being included in the sample. This applies to sampling without

replacement i.e., once an item is selected for the sample, it cannot appear in the sample again

(Sampling with replacement is used less frequently in which procedure the element selected for

the sample is returned to the population before the next element is selected. In such a situation the

same element could appear twice in the same sample before the second element is chosen).

The sample was collected from 100 Discharge of process, Patient (orthopedics), doctors

(specialized) and nurses included assistant nurses and head nurses in selected Yashoda hospital
52
 Secunderabad, in Secunderabad. The selected Discharge of process respondent for the data

collection where

Sample Unit

The elementary units or the group or cluster of such units may form the basis of sampling process

in which case they are called as sampling units. If the population is finite and the time frame is in

the present or past, then it is possible for the frame to be identical with the population. In most

cases theyare not identical because it is often impossible to draw a sample directly from

population.As such this frame is either constructed by the research for the purpose of this study.

Sample Unit in this study is Yashoda hospital Secunderabad discharge process. The sample

respondents includemale and females of different age groups who were positioning as the Patient

(orthopedics), doctors (specialized) and nurses included assistant nurses and head nurses in

selected Yashoda hospital Secunderabad, inSecunderabad.

ANALYSIS OF DATA

In order to study the process of Discharge the Yashoda hospital Secunderabad, the following

tools for were used to analyse the collected data.

 Simple graphs and charts with the help of MS Excel

LIMITATIONS OF THE STUDY

The following are the limitation of the present study:

 The area of study is restricted to Secunderabad state only.

 Further the study depends mainly on secondary data obtained from the records of the Yashoda

hospital Secunderabad both published and unpublished.

 Time has been the biggest constraint because of the work schedule.

53
 CHAPTER 3

PROFLE OF YASHODA HOSPITAL SECUNDERABAD

Yashoda Hospitals is a chain of hospitals based in Hyderabad, Telangana, India. It has

branches in Somajiguda, Secunderabad, and Malakpet, with another branch coming up in Hitec

City. All of its branches are NABH and NABL accredited.

It was recognised as a leading hospital for oncology in 2015 after becoming the first hospital to

achieve the milestone of treating 10,000 patients using Rapid Arc technology

History

The hospital began as a small clinic in 1989 set up by Dr G Surendar Rao. He later teamed up

with his brothers G Devender Rao and G Ravender Rao to expand operations and start Yashoda

Hospitals. The clinic was originally started in Madipally village, Warangal Dist, Telangana.

Dheeraj Gorukanti is the CEO of Yashoda Group of Hospitals. Dr Abhinav Gorukanti operates

as a director.

The group has three branches in Hyderabad at Secunderabad, Malakpet, and Somajiguda with a

combined bed capacity of 2,400. The Secunderabad branch is NABH accredited and has a

capacity of over 600 beds. It also has 3000 trained staff including doctors, nurses, and support

staff.

Departments

Yashoda Group of Hospitals offers services in the following departments:

• Neurology & Neurosurgery

• Oncology

• Cardiology and cardio-thoracic surgery

• Cardiothoracic surgery

• Nephrology and Urology

• Center for organ transplant

• Orthopaedic

• Gynaecology

• Neonatology

• Pediatric surgery

• Pulmonology & Bronchoscopy

• Dermatology, Cosmetic & plastic surgery

• Radiology & imaging sciences

• Anesthesiology

• Pediatric Cardiology

• General medicine

• General surgery

• Orthopaedics

• Ear, nose and throat (ENT)

• Gastroenterology

• Paediatrics
Key Specialities
Yashoda Hospitals has been involved in medical advancements and rare cases in neurosurgery,

cardiology, and oncology.

Neurosurgery

In 2017, it became the first hospital in India to install Intraoperative 3T MRI.The iMRI makes

brain surgeries safer, more precise, and removes the need to perform multiple surgeries. As of

2019, over 200 complex surgeries have been performed at the hospital using the technology.

Cardiology

In 2017, Yashoda Hospitals performed the first combined heart and lung transplant in the

Telugu states of Andhra Pradesh and Telangana. Doctors at Yashoda Group of hospitals

regularly perform heart transplant surgeries supported by the Jeevandan scheme.

Organ Transplants

Yashoda Hospitals also performed the first robotic transplant surgery in Andhra Pradesh and

Telangana in 2017. It performed 3 robot-assisted kidney transplants in its Secunderabad branch.

The group of hospitals distinguished itself by performing the first haplo-identical bone marrow

transplant in the region. It has been performing heart, kidney, liver, and lung transplants for a

decade (as of 2017). It has also instituted centres for organ transplants where transplants are

performed regularly by working with medical centres worldwide.

Oncology

Yashoda Group of Hospitals was recognised as a leading hospital for oncology in 2015 after

becoming the first hospital to achieve the milestone of treating 10,000 patients using RapidArc

technology. The 10,000th patient to receive treatment using RapidArc radiotherapy was a 3-

year- old girl who was cured of medulloblastoma, a malignant brain tumour.

It is equipped with the facilities to perform robotic surgeries.[23] Doctors can perform Minimally

Invasive Oncosurgery (MIOS) using this technology.

Pulmonology

The hospital performed the first lung transplantation in the Telugu states in 2012. Archana

Shedge, a 34-year-old from Pune suffering from interstitial fibrosis underwent the life-saving

surgery.

It launched the first International Conference and Live Workshop on Endobronchial

Ultrasound (EBUS) and Advanced Lung Cancer Treatments in 2019. The hospital is equipped

with advanced technology like bronchial thermoplasty, EBUS, radial EBUS, and navigational

bronchoscopy and is one of the few hospitals in the world with such facilities. Yashoda Hospitals

received international recognition in the field of Bronchoscopy, from the World Association of

Bronchology and Interventional Pulmonology (WABIP).

Yashoda Foundation

Yashoda Group of Hospitals launched Yashoda Foundation as a Corporate Social Responsibility

(CSR) initiative. Over the years, it has been actively involved in helping orphans,raising

awareness regarding diseases, and in providing experiential learning for students aspiring to be

doctors among others.

The foundation began working with orphans in 2011 and enables them to earn a livelihood. This

is done by providing free vocational courses and counselling. After the training, the youth are

given a job at Yashoda Hospitals. Currently, the foundation has recognised the needs that

orphans have beyond employment. Therefore, it has extended its work to provide holistic

support for orphans. There are four programmes run for the purpose:

1. Abhaya - offers employment training

2. Varadhi - advocacy and facilitation programme

3. Akshara - provides tuition support

In 2017, Yashoda Foundation arranged and performed the marriage for three orphaned girls that

it had been previously supporting. Mr G Ravender Rao, the group's chairman, performed the

kanyadan at the marriage ceremony.

The foundation organizes an Annual Yashoda Cancer Awareness Run on World Cancer Day,

observed on 4 February. The goal of the initiative to create awareness against cancer. In 2019,

over 7,000 people ran for the cause at Hyderabad.Yashoda Group of Hospitals also conducts

Young Doctors Camp annually, wherein students who have passed ninth grade are invited to

gain the first-hand experience of medical centres. 200 students are selected out of the applicants

each year and are given the opportunity to experience the medical profession. The group has tied

up with 40 schools, including DPS, HPS, NASR, and Geetanjali, for the cause and works with

them to recruit young, aspiring doctors for the camp.

Awards and achievements

Award Year Category

National Board of Education (NBE) Excellence in Medical

National Award 2018 Education

Heal Foundation's National Excellence in Innovative

Healthcare Foundation 2017 Hospital Administration

National Organ and Tissue Best Hospital for Organ

Transplant Organisation (NOTTO) 2017 Donation

Times Healthcare Achievers: Best Hospital: Neurology and

2017
Telugu States Neurosurgery
 Times Healthcare Achievers:
2017 Best Hospital: Oncology
Telugu States

The Week-Nielsen Best Hospital

2015 Winner
Survey

The Week-Nielsen Best Hospital

2014 Runner up
Survey

The Week-Nielsen Best Hospital

2013 Second runner up
Survey

Since three decades, Yashoda Group of Hospitals has been providing quality healthcare for the

people in their diverse medical needs. People trust us because of the strong relationships we’ve

built with them over the years.

Under astute leadership and strong management, Yashoda Group of Hospitals has evolved as a

centre of excellence in medicine providing the highest quality standards of medical treatment to

all sections of the society. Our work has always been guided by the needs of patients and

delivered by our perfectly combined revolutionary technology, best medical expertise and

advanced procedures.

We offer sophisticated diagnostic and therapeutic care in virtually every specialty and

subspecialty of medicine and surgery.

 3 independent hospitals

 3 Heart Institutes

 3 Cancer Institutes

 2400 Beds

 62 Medical specialties

 700 Specialist doctors

Constantly pushing our horizons to excellence, we are continuously seeking solutions to provide

better patient care by improving our overall facilities of hospital management and at the same

time ensuring control on the patient cost.

To provide world-class healthcare services at affordable costs, in all medical departments. With

a constant and relentless emphasis on quality, excellence in service, empathy, and respect for the

individual.

Core Values

Care

We recognize that every person is important, and hence deserves the very best care possible. We

will not be mechanical in our approach to work. We will be personal.

Courtesy

We understand that people walking through our doors are often going through a stressful time.

We will go the extra mile to help both patients and their loved ones, feel completely at ease

through courteous interactions at every stage.

Capability

Whatever be the health problem, we will be fully capable of diagnosing and treating it effectively.

Through the use of advanced technology, techniques and processes.

Character

We will be true to the trust that is placed in us. We will be faithful in following every procedure

and principle. With our primary focus on always doing what is best for the patient.

Commitment

To continuous learning. To find better methods of prevention and cure. Through undertaking,

supporting and commissioning research, in various medical and paramedical fields.

Contribution

Ensuring that we give back significantly to the society we live in through education, through

planned charity and the supporting of local initiatives for better health.

Key Features

Quality Care

Our continuous search for best practices in healthcare has lead to our superior quality and

performance. We have emerged as ‘leaders in the field’ with our rare and complex procedures,

employing most advanced technology for quick and safe treatment.

Technology

Technological superiority forms our backbone for the human medical resources to deliver

services efficiently and safely. We embrace emerging technologies that continuously advance

the capabilities of modern medicine.

Facilities

Our medical team includes skilled professionals who excel in clinical and surgical skills of

advanced procedures that benefits the patients by minimal pain and discomfort, less time in the
 hospital, faster recovery period, quicker resumption of your regular routines in life, less scarring

and elimination of many potential complications from conventional surgery.

 Surgical suites with full integration systems and cutting-edge medical equipment.

 Trauma Center with multiple trauma rooms and a dedicated CT scanner enables doctors to

identify what’s wrong with patients immediately upon their arrival.

 Intensive Care Units employ a “line of sight” approach that ensures 360 degree access to

critically ill patients.

 Surgical Observation Unit is a specialized area where patients receive additional post-operative

or post-procedural care.

 Rehabilitation Services Department provides inpatient and outpatient rehabilitation services –

physical and occupational therapy.

Team

The best team of doctors with excellent experience and expertise in all the specialties. Our team

doctors are board certified, experienced in wide range of subspecialties and passionate about

improving patient care. Large team available round the clock ( night and day even on weekends)

. Our integrated care team ensures that our patient’s physical, mental and support systems are

working together to produce a holistic outcome.

Procedures

Our medical team includes skilled professionals who excel in clinical and surgical skills of

advanced procedures that benefits the patients by minimal pain and discomfort, less time in the

hospital, faster recovery period, quicker resumption of your regular routines in life, less scarring

and elimination of many potential complications from conventional surgery.

Community service

In our efforts to contribute to the cause of medical welfare of the region, we are delivering the

quality medical care to people of the remote places through our mobile hospitals.
 CHAPTER-4

ANALYSIS AND INTERPRETATION

DATA ANALYSIS AND INTERPRETATION

A. PATIENTS:

1. Was a tentative discharge date discussed with you during your hospitalization?

S.no Opinion of No.of Percentage

the Respondents

Respondent

1 Yes 50 83.3

2 No 2 3.3

3 Don’t know/can’t 8 13.4

Say

4 TOTAL 60 100

60

50

40

30

20

10

No
Interpretation:

The Above table presents about the response of the respondents about the tentative discharge

schedule date discussed with you. It is interesting to observe data that out of total sample

respondents 50 accounting for 83.3 percent of sample respondents states YES to the statement

tentative discharge date discussed with the patients, against to the above tendency 2 accounting

for 3.3 percent of sample respondents stated No to the same statement , where as 8 accounting

for

13.4 percent o5f 9sample respondent stated Don’t know.

It can be concluded from the above analysis that majority of the sample respondents stated

YES to the statement tentative discharge date discharged with the patients.
2. Have relevant persons or attendants been informed by the hospital about your

discharge?

s Opinion of the Number of percentage

. respondents respondents
n
o
1 Yes 55 91.6
2 No 2 3.3
3 Don’t know /can’t 3 5
say
4 TOTAL 60 100

60

50

40

30

20

10

NO

Interpretation:

Presents about the response of the respondents about the relevant persons are informed

by the hospital about their discharge. It is interesting to observe data get of total sample

respondents 55 accountings for 91.6 percent of sample respondents states YES to the stated that

hospital informed about their discharge, against to the above tendency 2 accounties for 3.3

percent of sample respondents stated No . And about the same statement , where as 3

accountings for
 5 percent of sample respondent stated Don’t know.

It can be concluded from the above analysis majority of the sample respondents stated YES

to the statement institutions and hospital are informed to the patients about when their

Discharge
3. Did you receive information about you (new) medication(s) to be used after discharge?

S Opinion of respondent Number of percentage

n respondents
o
1 YES 60 100

2 No 0 0

3 Don’t know (anymore) 0 0

4 TOTAL 60 100

Interpretation

from above table it states that 60 out of 60 patients and attendants said that they have

received information of medication that to be used after their discharge

It can be concluded from the above analysis100% of the sample respondents stated YES

that they receive information about patient’s medications to be used after discharge.
4. Did you receive information about possible problems or complaints that might occur after

discharge (for example: pain, fever, wound infection)?

s opinion of Number of perecentage

. respondent respondents
n
o
1 No, not at all 50 83.3
2 Yes, but very little 3 5
3 Yes, some 2 3.3
4 Yes, certainly 3 5
5 Don’t know 2 3.3
(anymore)
6 TOTAL 60 100

receive any problem afterdischarge

No, notatall

Interpretation:

The information presented in the above table revels that No, not at all 50 of the
respondents,83.3% of total respondents are strongly agree. And 3 of respondents5% percent of

the total sampling respondents are says Yes, but very little. And 2 respondents, 3.3% of the total

sampling respondents are says Yes, some. And totally sampling respondents 3 respondents,5%

percent of total sampling respondents are says Yes, certainly. And 2 respondents,3.3% percent

of the total sample respondents are says Don’t know (anymore).

The above chart shows that majority of the respondents said that the hospital actively

discharge about possible problems or complaints that might occur after discharge (for example:

pain, fever, wound infection)59with patients during the Yashoda hospital Secunderabad
5. Were you told you can contact in case of problems or complaints after discharge?

S Opinion of Number of percentage

n respondent respondents
o
1 Yes 58 96.7
2 No 1 1.7
3 Don’t know 1 1.6
(anymore)
4 TOTAL 60 100

contact in case of problem

70

60 50
40

30

20

10

No

Interpretation:

Presents about the response of the respondents about doctors and nurses are told to the

patients that contact in case of problem after discharge. It is interesting to observe data get of total
sample respondents 58 accountings for 96.7%percent of total sample respondents states YES to

the stated that doctors told to the patients that incase of any problem after discharge contact.

And against to the above tendency 1 respondent for 1.7% percent of sample respondents stated

No. And about the same statement, whereas 1 respondent for 1.6% percent of sample

respondent stated Don’t know.

The above chart shows that majority of the respondents said yes that the hospital actively

discharges about contact in case of occurred any problems or complaints after

6. Did you receive instructions about which activities you could, or should not, do after discharge?

S Opinion of the Number of the

n respondents respondents Percentage
o
1 Yes 60 100
2 No 0 0
3 Total 60 100

60

50

40

30

20

10

NO

Interpretation:

From above table it states that 60 out of 60 respondents said that they have received

instructions about which activities could or could not after patients discharge.

It can be concluded from the above analysis100% of the sample respondents stated YES

that they receive information about patients which activities could or could not after patients

discharge.
7. Do you feel healthy and independent enough to leave the hospital?

S.no Opinion of the Number of the Percentage

respondent respondents
1 YES 55 91.7
2 NO 5 8.3
3 TOTAL 60 100

60

50

40

30

20

10

NO

Interpretation:

Above the table presents about the response of the respondents about the patients are feel

healthy and independent enough to leave the hospital. It is interesting to observe data get of total

sample respondents 55 accountings for 92% percent of sample respondents states YES to the

stated that they feel healthy and independent before leaving the hospital. Against to the above

tendency 5 accounties for 8% percent of sample respondents stated No.

The above chart shows that majority of the respondents said that the hospital actively

discharge feel healthy and independent enough to leave the hospital inpatients during the

Yashoda hospital Secunderabad.

8. Do you have a strong preference regarding where you will go after you Discharged?
s Opinion of the respondent Number of
. respondents Percentage
n
o
1 Yes 58 96.7
2 No 1 1.6
3 Don’t know (anymore) 1 1.7
4 TOTAL 60 100

70

60

50

40

30

20

10

No

Interpretation:

The information presented in the above table reveals that 58 of the total respondents 97%

respondents are strongly agree and 1 of the respondents are just to know and remaining 1 of the

respondents and 3% of the respondents of total sample are says that don’t’ know.

The above chart shows that majority of the respondents said that the hospital actively a

strong preference regarding where you will go after discharge patients during the Yashoda

hospital Secunderabad
B. DOCTORS AND NURSES

1. Does your ward have a discharge protocol?

s Opinion of the Doctors Nurses Percentage

. respondent
n
o
1 Yes 20 20 100
2 No 0 0 0
3 TOTAL 20 20 100

ward have a discharge protocol?

25

20

15

10

Interpretation:

From above table it states that 20 out of 20 doctors and nurses said that they have

discharge protocol in their wards. They done their activities during the time of discharge by the

following their protocols.

 It can be concluded from the above analysis100% of the sample respondents stated YES

that they have a discharge protocol in their wards.

The above chart shows that majority of the respondents said that the hospital actively a

strong preference regarding ward have a disc5h9arge protocol after discharge patients

during the Yashoda hospital Secunderabad

2. Do you think patients are satisfied with the current discharge policy?

s Opinion Doctors Nurses Percentage

. of the
n responden
o t
1 YES 19 18 92.5
2 No 1 2 7.5
3 TOTAL 20 20 100
Interpretation:

Above the table presents about the response of the respondents about doctors and nurses

are think that patients are satisfied with the current discharge policy. It is interesting to observe

data get of total sample respondents 19 accountings of doctors out of 20 respondent, and 18

accountings of the nurses out of 20 and totally respondents for 92.5% percent of sample

respondents states YES. Remaining of the one respondent one doctor and 2 accounts of 7.5%

nurses are said No to the statement of do you patients are satisfied with the present discharge

policy.

It can be concluded from the above analysis majority of the sample respondents stated YES

to the statement that doctors nurses are thought that patients are satisfied with the present

discharge policy.
3. There any difficult situations regarding patient discharge?

S.no Opinion of the

respondent Doctors Nurses Percentage
1 Yes 0 2 5
2 No 20 18 95
3 TOTAL 20 20 100

20
18
16
14
12

No

Interpretation:

Above the table presents about the response of the respondents about there are any

difficult situations regarding patient discharge. It is interesting to observe data get of total

sample respondents 20 out of 20 doctors are said No and 19 accounties of the nurses out of 20

are said also No, totally 95% of sample respondents are said No. Remaining 1 nurse of

respondents is said that Yes totally 5% of sample respondents are said yes to the statement of is

there any difficult situations regarding patient discharge.

It can be concluded from the above analysis majority of the sample respondents stated No to

the statement that doctors nurses are stated that there are no difficult situations regarding the

patient discharge.
 4. Do you have thought other things to say that might improve the discharge policy?

s Opinion
. of the
n responde Doctors Nurses Percentage
o nt

1 0 0 0
2 No 20 20 100
3 TOTAL 20 20 100

Interpretation:

Above the table presents about the response of the respondents doctors or nurses are

have thought other things to say that might improve the discharge policy. It is interesting to

observe data get of total sample respondents 20 out of 20 doctors and nurses both are said No

totally 100% of sample respondents are said No.

It can be concluded from the above analysis majority of the sample respondents stated No to

the statement that doctors nurses are stated that there are no other things that might.
Is any training procedure for newly hired staff for at discharge area?

Opinion of Doctors Nurses Percentage

s
. the
n respondent
o
1 Yes 19 18 92.5

2 No 1 2 7.5

3 TOTAL 20 20 100

Interpretation:

The information presented in the above table revels that 19 of the doctor respondents are

said Yes and 1 respondent are said No . And same way that 15 of nursing staff the respondents

are said Yes, remaining 5 respondents are says N. And totally 92.5% of the sample respondents

are said yes, 7.5% of respondents said No.

The above chart shows that majority of the respondents said that the hospital actively a

strong training procedure for newly hired staff for at discharge area discharge of patients during

the Yashoda hospital Secunderabad

 Is you can actively doing things to improve Patient safety?

s.no Opinion of Doctors Nurses Percentage

the
respondent
1 Yes 20 20 100
2 No 0 0 0
3 TOTAL 20 20 100

20

15

10

yes
no

doctorsnurses

Interpretation:

From above table it states that 20 out of 20 doctors and nurses said that they are actively

doing things to improve patient safety. It can be concluded from the above analysis100% of the

sample respondents stated YES that they are actively doing things to improve patient safety.

The above chart shows that majority of the respondents said that the doctors and nurses

actively a strong preference regarding to improve patient safety during the Yashoda hospital

Secunderabad And majority of the respondents said that the hospital actively a strong actively

doing things to improve Patient safety discharge during the Yashoda hospital Secunderabad.
5. Staff will freely speak up if they see something that may negatively affect?

C ha
Opinion of the Doctors Nurses Percentage

respondent

1 Yes 16 10 65

2 No 4 10 35

3 TOTAL 20 20 100

25

20

15

10

0
Yes No TOTAL

Series1Series2

Interpretation:

Above the table presents about the response of the respondents about the staff will freely

speak up if they see something that may negatively effect. The information presented in the

above table revels that 16 of the doctor respondents are said yes and 4 respondents are says no.

And same way that 10 of nursing staff the respondents says yes and 10 respondents are says no.

It is interesting to observe data get of total sample respondents 26 accountings for 65% percent

of sample respondents states YES to the stated staff will freely speak up when they see

something that may negatively affect. And remaining 14 respondents totally 35% of the sample

respondents said NO.

 6. Staff is informed about errors that happen in their units?

s Opinion of the Doctors Nurses percentage

. respondent
no s
1 Yes 18 14 80

2 No 2 6 20

3 TOTAL 20 20 100

informed about errorswhen happen in their units

staff i

YesNo

Interpretation:
The information presented in the above table revels that 18 of the doctor respondents are said yes

and 2 respondents are saying No. And same way that 14 of nursing staff the respondentsis yes and 6

respondents are saying No. And 80% of total respondents are said yes. And remaining20% of total

sample respondents said no.

 The above chart shows that majority of the respondents said that the hospital actively a strong Staff

is informed about errors that happen in their unit’s patient discharge during the Yashoda hospital

Secunderabad.
7. If staff are afraid to ask questions, when something does not seem right?

s Opinion of Doctors Nurses percentage

. the
n respondent
o s
1 3 6 22.5
2 No 17 14 77.5
3 TOTAL 20 20 100

Interpretation:

The information presented in the above table reveals that 17 of the doctor respondents are

says No and 3 respondents are says yes . And same way that 14 of nursing staff the respondents

is says No and 6 respondents are says yes. And 77.5% of total sample respondents are said no

and remaining 22.5% of total sample respondents are says yes. not

The above chart shows that majority of the respondents said that the hospital actively a

strong staff are not afraid to ask questions, when something does not seem right patients

discharge during the Yashoda hospital Secunderabad

8. Does hospital units co-ordinates well with each other?

s Opinion of the Doctors Nurses Percentage

. respondent

1 Yes 18 14 80

2 No 2 6 20

3 TOTAL 20 20 100

hospital units co-ordinate well witheach

other

No

Doctors
Interpretation:

The information presented in the above table revels that 18 of the doctor respondents are

says yes, and 2 respondents are says no. And same way that 14 of nursing staff the respondents

are says yes and 6 respondents are says no.80% of total sample respondents are said yes and

remaining 20% of total sample respondents are said no.

The above chart shows that majority of the respondents said that the hospital actively a

strong hospital units co-ordinate well with each other discharge patients during the Yashoda

hospital Secunderabad
9. Does hospital management provide a good work climate that promotes patient safety?

S.no Opinion of Doctors Nurses Percentage

the

respondent
1 Yes 20 20 100

2 No 0 0 0

3 TOTAL 20 20 100

20
18
16
14
12
10

No

Interpretation:

The information presented in the above table revels that 20 out of 20 of doctor

respondents are says yes. And same way that 20 out of 20 nursing staff the respondents are says

yes .100% of the total respondents are says yes. They said that Yashoda hospital Secunderabad

management provided good work climate that promotes patient safety.

7
 The above chart shows that majority of the respondents said that the hospital

management provide a good work climate that promotes patient safety discharge patients during

the Yashoda hospital Secunderabad

7
 CHAPTER-5

A SUMMARY OF FINDINGS, SUGGESTIONS AND CONCLUSION

5.1 SUMMARY

This study was conducted in patient care and safety departments of AN EVALUATION

OF DISCHARGE PROCESS OF YASHODA HOSPITAL SECUNDERABAD. A

performance framework to monitor discharge delays provides the means to review practice and

revise joint hospital/agency policy in a dynamic way. The policy should be readily available to

patients, caregivers, families and advocacy services in various formats and languages. The

policy should aim to: ensure the patient is treated as an individual and provided with continuity

of care; ensure acute hospital facilities are used appropriately; and identify priorities for change.

FINDINGS

 It is found from analysis 83.3% of respondent stated positive ness to the statement that tentative

discharge date discussed with patient. Whereas nearly 16.7% respondent expressed negative.

 It is found from analysis 91% of relevant persons are informed by the hospital and remaining

9% of relevant persons or attendants of patients have not been informed by hospital about their

discharge.

 It is found from analysis 83.2% of respondent expressed positive ness to the statement about the

proper medication which is related to existing infection and pain after discharge. And other

16.8% of persons are expressed negatively.

 According to analysis 3% of the patients are said that they don’t know to whom they have to

contact and complaint after their discharge. And remaining 97% of the patients are said that

doctors and nurses are told to them if any case of problem or complaints contact them even in
8
the

8
 time of after discharge.

 From this study fought that 92%(staff) said that patients are satisfied with the current discharge

policy. And remaining 8% of the patients are not feel better and healthy.

 Doctors and nurses totally 35% of respondents are said that they will not freely speak up with

patient if they see something that may negatively affect. And remaining of the 65% staff are

said that they will freely speak up if they seen something that may negatively affect.

 Doctors 20% of total sample respondents are said that they have not informed about some errors

that happens in their units . And nurses informed 100% of respondents are informed about their

errors in their units.

 It finds that there are sometimes mistakes in the billing which result in over estimates. This the

patient resists and then corrections were made.

 It observes that the Patients bargain at the billing counter at the time of bill settlement, this leads

a lot of time consumption and chaos at the billing counter. The 3rd step takes far too more time

than it should ideally be happen.

 It observed that in some cases hospital staff does not coordinating with the other.78% of staff

said that they will not afraid of questions when something does not seem right. remaining 22%

of the staff peoples are said they are afraid of some questions.

SUGGESTIONS

 Doctors and nurses are discussed with the patients about their discharge dates. But 3.3% of the

total sampling respondents are said that doctors and nurses are can’t discussed about their

discharge. So at the time of the hospitalization doctors or nurses and other staff members are

must have discussed with patient about their discharge date.

 Management can advised to the management staff and doctors & nurses to provide clear

8
 information to patients about to whom they have contact after discharge incase of problem. But

3.4% of total sampling respondents said that they are not give any information about whom they

contact incase of problem after discharge.

 7.5% of the total sampling respondents are given that the patients and attenders are not satisfied

with the present discharge policy. Because there was delay of billing process and insurance

approval.

 8%of the doctors and nurses of total sampling respondents given information that in this hospital

have no training procedure for newly hired staff because they give more preference to

experienced candidates.

 35% of the total respondents said that Doctors and nurses are advised to speak up freely with the

ly
patient that may negative ffect on the patients.

 Doctors and nurses 20% of total respondents said that staff members either doctors or nurses

can’t informed about their errors. So management suggested to informing about their errors with

in their unites.

 22.5% of the total respondents said that staff members are afraid to ask questions, when

something does not seem right. So management suggest that whether they did right or wrong

theyfreely speak up because patient safety is a veryimportant.

 20% of the total respondents said that staff members are can’t co-ordinating between each other.

So management suggest that staff members should improve co-ordination in staff and between

the doctors and nurses.

CONCLUSION

The discharge process is deemed to have started when the consultant formally approves

discharge and ends with the patient leaving the clinical unit. The admission and discharge

8
processes can act as bottlenecks in many of the hospitals and thus adversely affect the efficiency

of the hospital. It is a very important indicator of quality of care and patient satisfaction. Delay

in Discharge of the patient also increases the pressure on beds of the hospital Delay in

dischargeis bad for both hospitals and the patients. It increases cost to the hospitals and is

depressing to the patients.

I would take great privilege to thank all the departments of Yashoda hospital

Secunderabad for giving such an opportunity for allowing and supporting to complete this

project.

8
 APPENDIX
QUESTIONARE

Analysis of Patient Discharge process survey in YASHODA HOSPITAL SECUNDERABAD

Patient\staff- Demographic data

Patient\staff name: Age: Sex: Reg.no: Mobile no: Address:

Email ID:

............................................................................................................................................

ATIENTS:

1. Was a tentative discharge date discussed with you during your hospitalization?

a) Yes b) No c) don’t know (any more) ()

2. Have relevant persons or institutions (for example: general practitioner, nursing home,

rehabilitation center) been informed by the hospital about your discharge?

a) Yes b) No c) don’t know (any more) ()

3. Did you receive information about you (new) medication(s) to be used after discharge?

a) Yes b) No c) don’t know (any more) ()

4. Did you receive information about possible problems or complaints that might occur after

discharge (for example: pain, fever, wound infection)?

a) Yes b) No c) don’t know (any more) ()

5. Were you told you can contact in case of problems or complaints after discharge?

a) No, not at all b) yes, but very little c) yes, some d) yes certainly e) don’t know ( )

6. Did you receive instructions about which activities you could, or should not, do after discharge?

a) Yes b) No c) don’t know (any more) ()

7. Do you feel healthy and independent enough to leave the hospital?

8
 a) No, not at all b) yes, but very little c) yes, some d) yes certainly e) don’t know ( )

8. Do you have a strong preference regarding where you will go after you Discharged?

a) Yes b) No c) don’t know (any more) ()

B. DOCTORS AND NURSES

2. Does your ward have a discharge protocol?

a) Yes b) No ()

3. Do you think patients are satisfied with the current discharge policy?

a) Yes b) No ()

4. Are any difficult situations regarding patient discharge?

a) Yes b) No ()

5. Do you have thought other things to say that might improve the discharge policy?

a) Yes b) No ()

6. Is any training procedure for newly hired staff for at discharge area?

a) Yes b) No ()

7. Is you can actively doing things to improve Patient safety?

a) Yes b) No ()

8. Staff will freely speak up if they see something that many negatively affect?

9. Staff is informed about errors that happen in their units?

a) Yes b) No ()

10. If staff are afraid to ask questions, when something does not seem right?

a) Yes b) No ()

11. Does hospital units co-ordinates well with each other?

a) Yes b) No ()

12. Does hospital management provide a good work climate that promotes patient safety?
8
 a) Yes b) No ()

13. Comments: If any suggestion for improving for discharge

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

8
BIBLOGRAPHY

BOOKS:

1. Alexander Wyke, "Can Patients Drive the Future of Healthcare". Harvard Business Review,

July-August 1997, pp.146-150.

2. Curry, A. and E. Sinclair (2002) Assessing the quality of physiotherapy services Using

SERVQUAL. International Journal of Operations and Production Management, 20, 386-403.

3. Marraro, R. (2003) Investing in patient safety: An ethical and business imperative. Trustee,

56, 6, 20-23.

4. Thaper S.D., health and development, association of voluntary agencies forrural development

, New Delhi 1977

5. Ramachandrudu and VenkataRaol examine the inter-district variations inhealth services in

Andhra Pradesh. Health planning in India -A P Hpublishing corporation New Delhi 1997 pp

67-

6. Allen, A.O.: Probability, Statistics and Queueing Theory. Academic Press, London (1990)

7. Akkerman, R., Knip, M.: Reallocation of beds to reduce waiting time for cardiac surgery.

Health Care Management Science 7(2), 119–126 (2004)

8. Altinel, I.K., Ulas, E.: Simulation modeling for emergency bed require- ment planning.

Annals of Operations Research 67(1), 183–210 (1996)

9. Anthony, R.N.: Planning and control systems: a framework for analy- sis. Harvard Business

School Division of Research, Boston (1965)

8
10. Ashton, R., Hague, L., Brandreth, M., Worthington, D.J., Cropper, S.: A simulation-based

8
 study of a NHS walk-in centre. Journal of the Operational Research Society 56(2), 153–161

(2005)

REPORTS:

 Patient discharge reports on 2018-19.

 NABH guideline manuals

WEB:

 Www.Yashoda hospital Secunderabad.com

 https://www.uptodate.com/contents/hospital-discharge-and-readmission

 https://www.england.nhs.uk/blog/amit-arora/

 http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted

 https://www.bgs.org.uk/resources/deconditioning-awareness

PUBLICATIONS:
Publications taken from the following;

 Journal of improving patient discharge process

 Journal of national standard for patient discharge summary information

 Journal of hospital discharge and patient

 Journal of hospital discharge and community support

 Journal of the discharge process – from a patient perspective

 Journal of comparative assessment of discharge procedure of tertiary hospitals with

respect to guideline of NABH

 Journal of IAEA safety related publications

 Journal of Policy and operating mode

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9