How much do operational processes affect hospital inpatient
Hannah Wong1,2,3, Robert C. Wu4,5, George Tomlinson4,6, Michael Caesar3,4,
Howard Abrams4,5,7, Michael W. Carter1,2, Dante Morra4,5
1Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, ON, Canada
2Centre for Research in Health Care Engineering, University of Toronto, Toronto, ON, Canada
3Shared Information Management Services, University Health Network, Toronto, ON, Canada
4Centre for Innovation in Complex Care, Toronto General Hospital, University Health Network, Toronto, ON, Canada
5Department of Medicine, University of Toronto, Toronto, ON, Canada
6Department of Public Health Sciences, University of Toronto, Toronto, ON, Canada
7Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
Address correspondence to Dante Morra, Email: firstname.lastname@example.org
Background The objective of this study is to determine the effect of day of the week, holiday, team admission and rotation schedules, individual
attending physicians and their length of coverage on daily team discharge rates.
Methods We conducted a retrospective analysis of the General Internal Medicine (GIM) inpatient service at our institution for years 2005 and
2006, which included 5088 patients under GIM care.
Results Weekend discharge rate was more than 50% lower compared with reference rates whereas Friday rates were 24% higher. Holiday
Monday discharge rates were 65% lower than regular Mondays, with an increase in pre-holiday discharge rates. Teams that were on-call or that
were on call the next day had 15% higher discharge rates compared with reference whereas teams that were post-call had 20% lower rates.
Individual attending physicians and length of attending coverage contributed small variations in discharge rates. Resident scheduling was not a
significant predictor of discharge rates.
Conclusions Day of the week and holidays followed by team organization and scheduling are significant predictors of daily variation in discharge
rates. Introducing greater holiday and weekend capacity as well as reorganizing internal processes such as admitting and attending schedules may
potentially optimize discharge rates.
Keywords day of the week, discharge rate, holiday, operational efficiency, scheduling
Improving patient flow in acute care hospitals is an impor-
tant issue in hospital management and research. Improved
patient flow can decrease wait times for care, ease
Emergency Department (ED) congestion, and increase the
effective capacities of the ICU and inpatient units.1–4One
way to improve patient flow is to remove variation in pro-
cesses along the care pathway that can block or delay flow.5
One process in particular—patient discharge—has received
critical attention because variation and delays in this process
create ‘bottlenecks’ that ultimately delay most care pathways,
especially new admissions from the ED.6,7
Although the decision to discharge an individual patient
from hospital should predominately be a clinical decision,
there may be non-clinical factors that influence decision-
making. These may include patient and family preferences,8
physician practice preferences,9internal hospital inefficien-
cies,10post-acute care bed capacity11and healthcare finan-
Hannah Wong, PhD Candidate
Robert C. Wu, Assistant Professor
George Tomlinson, Associate Professor
Michael Caesar, Director of Information Management
Howard Abrams, Associate Professor
Michael W. Carter, Professor
Dante Morra, Assistant Professor
# The Author 2009, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved
Journal of Public Health | Vol. 31, No. 4, pp. 546–553 | doi:10.1093/pubmed/fdp044 | Advance Access Publication 22 May 2009
by guest on February 2, 2016
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OPERATIONAL PROCESSES THAT AFFECT DISCHARGE RATES
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