NUR 530 Module 5 Project One Example

Project One: A Systems Analysis of Late Discharges on 6 South

[Student Name]

Southern New Hampshire University

NUR 530: Systems Leadership and Collaborative Practice

Project One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Project One: A Systems Analysis of Late Discharges on 6 South

Milestone One described 6 South as a capable medical unit where every department handles a slice of each discharge and none is accountable for all of it. This project analyzes that process in depth. It sets out the baseline measures, reports an audit of delayed discharges, ranks their causes and follows the largest back to its structural roots. The analysis shows that two-thirds of late discharges trace to three causes, and that all three arise from a single structural gap: teams settle who is going home only on the morning of departure, too late for any department to prepare. The project closes by confirming the aim and the measures that Project Two will use.

Scope

The analysis covers the discharge of adult medical patients from 6 South, from the day before an expected discharge to the moment the room is clean and assigned. It includes the unit's nurses, both hospitalist teams, the unit pharmacist, case management and social work, therapy, transport and environmental services. Admissions, the emergency department and outside facilities are treated as forces acting on the process rather than parts of it, so the analysis considers their effects but does not propose changes to their internal work.

Baseline Measures

Table 1 lists the baseline measures drawn from the electronic record for the three months reviewed in Milestone One.

Table 1

Baseline Measures for Discharge on 6 South, Three Months

Note. Composite unit data.

The unit's discharge-before-noon rate is close to the 7% reported on two medical units at an academic medical center before a structured improvement effort there (Wertheimer et al., 2014). Length of stay is included for context rather than as a target, since team-based ward interventions have rarely shortened it (Pannick et al., 2015). Readmission serves as the balancing measure: an earlier discharge that sends patients home unprepared would show up there first.

Audit of Delayed Discharges

For four weeks, charge nurses recorded the main reason for every discharge that left the unit after two in the afternoon, using a one-page form with fixed categories and a space for comments. Sixty delayed discharges were recorded. Table 2 ranks their primary causes.

Table 2

Pareto Table of Primary Causes for 60 Delayed Discharges

Note. Composite audit data, four weeks. Delayed means leaving the unit after 14:00.

Three causes account for 68% of delays. Ranking causes by frequency helps a team aim improvement on the few causes that produce most of a problem (Langley et al., 2009). The comments on the forms, however, showed that the categories overlap. In fourteen of the eighteen facility delays, the referral had been sent on the morning of discharge. Of the twelve ride delays, the family had been told of the discharge that same day in ten. The categories describe where each discharge got stuck, but most of them share an earlier cause.

Asking Why

Following the largest category back one step at a time makes the link explicit. The patient waited for a facility because the facility had not accepted the referral. The facility had not accepted because the referral arrived that morning and its admissions nurse reviews referrals after lunch. The referral arrived that morning because the case manager learned of the discharge at morning rounds. The case manager learned then because the team decides who will leave on the day itself. The team decides on the day itself because no forum exists for agreeing on tomorrow's discharges the afternoon before, and no role is responsible for sharing that forecast.

The same chain, with different links, explains the ride delays and the late orders. It also explains why the earlier fixes faded. Asking nurses to teach sooner did not move the facility's review or the family's drive, and asking hospitalists to round on discharges first moved one step while every other department kept its old timing.

Structural Causes

Four structural problems emerge. First, there is no next-day forecast: the unit does not identify likely discharges the afternoon before, so every department starts late. Second, the handoffs run in sequence; each department waits for the one before it, although reconciliation, teaching, referrals and ride planning could begin in parallel once a discharge is expected. Third, the process has no owner, and the charge nurse's informal list carries no authority. Fourth, measures are misaligned: pharmacy is judged on turnaround for new orders, case management on avoidable days and hospitalists on the care of their sickest patients, and none is credited for preparing a discharge a day early.

These causes fit what complexity science predicts about health care organizations, where outcomes arise from interactions among agents following local rules rather than from any single decision (Plsek & Greenhalgh, 2001). They also explain why the harm falls unevenly. Delayed discharge burdens the frailest patients most, through lost mobility and hospital-acquired complications, and places staff under pressure that strains working relationships (Rojas-García et al., 2018).

What a Nurse Leader Can Change

Two of the structural causes sit largely within the influence of a unit nurse leader. The forecast and the owner can be created on 6 South with the cooperation of the hospitalist teams and case management, without new staff. The sequence of handoffs can be partly changed by agreement, for example by having the pharmacist begin reconciliation for patients on the forecast list. The fourth cause, misaligned measures, needs the support of department directors and senior leaders, which Project Two will address in a stakeholder plan. Discharge planning that begins earlier in a stay is supported by evidence: structured discharge planning for medical inpatients modestly shortened stays and lowered readmissions in a Cochrane review of 33 trials (Gonçalves-Bradley et al., 2022).

Confirmed Aim and Measures

The analysis supports the draft aim from Milestone One. Within six months, 25% of patients discharged from 6 South will be off the unit by noon, up from 9%. That percentage, charted monthly, is the outcome measure. The process measures track how many discharges were named on the previous afternoon's forecast, as a proportion of all discharges, and the median time from order to departure. Balancing measures are the 30-day readmission rate, which should not rise above its baseline of 15.8%, and staff overtime on the day shift. Boarding time for medicine admissions will be tracked as a downstream measure, with the understanding that many factors outside the unit influence it.

Conclusion

The delays audited on 6 South are not a collection of unrelated events. Three causes account for two-thirds of them, and all three arise from the same structural gap: no one forecasts discharges the afternoon before, so every department begins its part on the day itself. Project Two will design a change that creates the forecast, gives it an owner, moves handoffs into parallel and seeks the senior support needed to align each discipline's measures with the shared goal.

References

Gonçalves-Bradley, D. C., Lannin, N. A., Clemson, L., Cameron, I. D., & Shepperd, S. (2022). Discharge planning from hospital. Cochrane Database of Systematic Reviews, 2022(2), Article CD000313. https://doi.org/10.1002/14651858.CD000313.pub6

Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.

Pannick, S., Davis, R., Ashrafian, H., Byrne, B. E., Beveridge, I., Athanasiou, T., Wachter, R. M., & Sevdalis, N. (2015). Effects of interdisciplinary team care interventions on general medical wards: A systematic review. JAMA Internal Medicine, 175(8), 1288-1298. https://doi.org/10.1001/jamainternmed.2015.2421

Plsek, P. E., & Greenhalgh, T. (2001). The challenge of complexity in health care. BMJ, 323(7313), 625-628. https://doi.org/10.1136/bmj.323.7313.625

Rojas-García, A., Turner, S., Pizzo, E., Hudson, E., Thomas, J., & Raine, R. (2018). Impact and experiences of delayed discharge: A mixed-studies systematic review. Health Expectations, 21(1), 41-56. https://doi.org/10.1111/hex.12619

Wertheimer, B., Jacobs, R. E. A., Bailey, M., Holstein, S., Chatfield, S., Ohta, B., Horrocks, A., & Hochman, K. (2014). Discharge before noon: An achievable hospital goal. Journal of Hospital Medicine, 9(4), 210-214. https://doi.org/10.1002/jhm.2154