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 Table of Contents  
Year : 2016  |  Volume : 3  |  Issue : 1  |  Page : 39-42

Identifying discharge process factors causing an increased length of stay

Department of Hospital Administration, Symbiosis Institute of Health Sciences, Pune, Maharashtra, India

Date of Web Publication4-Aug-2016

Correspondence Address:
Anil Parameshwar Pandit
Symbiosis Institute of Health Sciences, Pune - 411 004, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-1880.187767

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Introduction: The purpose of continuous quality improvement programs is to improve health care by identifying problems, implementing and monitoring corrective action, and studying its effectiveness.
Aim: The present study aims to find out the present length of stay (LOS) of inpatients at a superspeciality hospital.
Objectives: 1. To study the existing system of discharge process of patients, 2. to find out the reasons for the delays, 3. To recommend suitable suggestions to reduce length of stay.
Mehodology and Results: By considering the LOS of 128 random patients, 32 from each ward A, B, C, and D. The average LOS (ALOS) was found to be 5.69. Factors have been identified by studying the delays through time and motion study in the discharge process.
Recommendations: Recommendations have been made for appropriate changes to be considered to reduce ALOS and bring it to 5.0 so that proper resource utilization occurs, and at the same time, there is an improvement in bed turnover rate and thereby in bed occupancy rates.

Keywords: Average length of stay, patient experience, quality, resource utilization

How to cite this article:
Kulkarni M, Pandit AP, Singh P. Identifying discharge process factors causing an increased length of stay. J Nat Accred Board Hosp Healthcare Providers 2016;3:39-42

How to cite this URL:
Kulkarni M, Pandit AP, Singh P. Identifying discharge process factors causing an increased length of stay. J Nat Accred Board Hosp Healthcare Providers [serial online] 2016 [cited 2021 Apr 11];3:39-42. Available from: http://www.nabh.ind.in/text.asp?2016/3/1/39/187767

  Introduction Top

A fundamental measure used in health services research is the mean length of stay (LOS) for a defined set of patients in a specific institution. In many cases, this average LOS (ALOS) is used to compare different health facilities or changes within a single facility and plays a central role in the evaluation of resource utilization. Annexure 4 of NABH guidelines captures 64 quality indicators; ALOS is one among them. [1] The continuous quality improvement (CQI) 4c lists bed occupancy rate and ALOS. LOS is a term used to measure the duration of a single episode of hospitalization. Inpatient days are calculated by subtracting the day of admission from the day of discharge. ALOS is computed by dividing the total number of inpatient hospital days, in the hospital, counted from the date of admission to the date of discharge by the total number of discharges (including deaths) in the hospital during a given year. A hospital day (or bed-day or inpatient day) is a day, during which a person admitted as an in-patient is confined to a bed and stays overnight in a hospital. [2]

Literature review

While the overall goal of CQI programs is universal, there are a variety of ways to conduct CQI studies. No particular method or format for these studies has been stipulated; there are many online resources for CQI methodologies, including the popular Plan-Do-Study-Act model. [3] CQI is a tool for improving the quality of services provided by organizations. CQI refers to have a systematic approach to collecting and reviewing data or information to identify opportunities to improve the operations of an organization with the end result of delivering better services to customers or clients. [4]

Although many studies on improving admission outcomes for chronic obstructive pulmonary disease (COPD) patients and improving efficiency tended to focus on reducing the duration of inpatient care, [5],[6] no optimum LOS has been consistently described. International trends in COPD-related hospitalization have shown that although the ALOS has decreased since 1972, admissions rates have increased in patients aged 45 years or older. [7] This has led some to suggest that efforts to cut down the duration of inpatient episodes may result in a "revolving door" phenomenon. [8]

LOS is an important measure of resource utilization, and naturally, there are several systems for modeling and predicting LOS. [9],[10],[11],[12] Specifically, the study of LOS outliers is essential for the management and financing of hospitals. The reimbursement of outliers is important either to protect patients that can be more expensive or to protect hospitals from losses with uncommon cases. LOS can in part explain hospital costs as there is a strong, no perfect, correlation between LOS and hospital costs. [13],[14] A study in two public Spanish hospitals revealed that 4.8% of the total patient discharges represent 15.4% of the total LOS and 17.9% of the total hospital costs. [15]


The study was conducted with an aim to identify discharge process factors causing an increased LOS.


  1. To study the current discharge process in a tertiary care hospital
  2. To recommend steps to cut down ALOS.

  Methodology Top

The research methodology adopted for the study is observatory and retrospective. The process flow was studied both for admissions and discharge of inpatients. Time and motion study of the discharge process was done to trace the areas of improvement. For ALOS, 128 samples were taken at a random from four wards. Time and motion study was done after the process mapping for the discharge of private patients, panel patients, and those through TPAs. The process of Plan-Do-Check-Act is followed to address the issues of delays in the discharge of patients.

Observation and analysis

The analysis of collected data through critical care units proves that the ALOS of patients at the hospital is 5.69, [Figure 1], which agrees with the hypothesis. Further, the actions consuming maximum time and delays for the discharge of patients were also checked. When checking the reasons of discharge, 66.4% of the patients were found medically fit for discharge, others had other reasons such as delays in cashless process, miscommunication, mismatch, discharge against medical advice, or other factors for a longer stay at hospital [Table 1].
Figure 1: Length of stay of patients in various wards

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Table 1: ALOS at different wards A-D

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The unnecessary stay of a patient in the hospital causes the unavailability of the bed to the other patients. This is very commonly observed in a situation in the hospital that patients do not get bed and so are kept in casualty for few hours or are shifted or referred to other sister hospitals.

The process flow of admission and discharge has been studied and the identified reasons of delay can be intervened to improve the LOS of patients at hospitals.

The recommendation of proper consultation with the patient regarding nonextension of the stay in hospital after doctor has advised him/her for discharge plays an important role. He/she must be convinced that he/she can go home because he/she is physically fit to go and there should not be a feeling that he/she was forced to go home even after he/she was requiring more care.

Miscommunication among the staff is also one of the important reasons for the more ALOS. For example, the doctor during his/her morning round examines the patient and asks the resident to follow-up with him/her in the afternoon regarding the condition of the patient so that he/she can decide upon discharging the patient. During the afternoon, the duties of the resident doctors change, and if there is no proper communication between the three, the discharge gets postponed. In addition, the incomplete information filled in by one resident, who may not be there during the discharge, causes a delay in the discharge process. The patient should be given the tentative discharge date in advance. Though it is not possible to say about the discharge well before in all the cases, the approximate recovery time for particular surgery can be informed to the patient. If not very early, the date of discharge should be informed to the patient a day before his discharge so that he/she can overcome his/her personal problems and shift out of the hospital on the required time and the day. The patient should be given the tentative discharge date in advance. Though it is not possible to say about the discharge well before in all the cases, the approximate recovery time for particular surgery can be informed to the patient. If not very early, the date of discharge should be informed to the patient a day before his discharge so that he/she can overcome his/her personal problems and shift out of the hospital on the required time and the day. The patient should be given the tentative discharge date in advance.

  Conclusion Top

It has been observed during the study that there is a difference in the LOS patients. The reasons can be varied. The condition of the patient and illness and stage of illness at which he has been brought to the hospital are vital.

The reasons are broadly of two types - controllable and uncontrollable. The controllable reasons should be controlled so that there will be a minor difference in the ALOS. The problematic areas which can be controlled and improved are:

  1. Proper process flow
  2. Proper communication
  3. Ease of cashless process
  4. Timely reports
  5. Prior intimation about patients' discharge.

Managing LOS is one of the most vexing challenges for any hospital. Though patients do need minimum stays for recovery and monitoring, LOS is sometimes too long because patients are forced to wait for varying reasons. As a result, patients suffer and hospitals incur a revenue loss of "denied days."


This study was conducted for a period of 3 months only and was confined to four general wards, i.e., wards A-D of a single superspeciality hospital.

Future avenues

Quality improvement is a continuous process and LOS is an integral part of it. The LOS can be studied about specific diseases, mode of treatment, process flow, variation in nurse-patient ratio, and illness in specific genders or age factors. Standardization of LOS can be done to understand the lacuna in the process. Furthermore, geographical locations can be seen as one of the reasons for increased LOS. Effective management of patient flow and process flow combined with timely communication can lead to better management of ALOS along with quality service delivery at hospitals.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Quality Indicators for ICU. (n.d.). Available from: http://www.bibme.org/apa/journal-citation/new. [Last accessed on 2015 May 25].  Back to cited text no. 1
European Community Health Indicators Monitoring. (n.d.). Available from: http://www.healthindicators.eu/healthindicators/object_document/o6136n29138.html. [Last accessed on 2015 Jun 01].  Back to cited text no. 2
NCCHC′s Standards for Health Services and Correctional Health Care: Guidelines for the Management of an Adequate Delivery System. Available from: http://www.ncchc.org/spotlight-on-the-standards-24-1. [Last accessed on 2015 Jun 20].  Back to cited text no. 3
Pushparajah S, McClellan R, Henry A, Kuitert LM. Use of a chronic disease management programme in COPD to reduce hospital admissions. Chron Respir Dis 2006;3:187-93.  Back to cited text no. 5
Utens CM, Goossens LM, Smeenk FW, van Schayck OC, van Litsenburg W, Janssen A, et al. Effectiveness and cost-effectiveness of early assisted discharge for chronic obstructive pulmonary disease exacerbations: The design of a randomised controlled trial. BMC Public Health 2010;10:618.  Back to cited text no. 6
Säynäjäkangas O, Kinnunen T, Tuuponen T, Keistinen T. Length of stay and interval to readmission in emergency hospital treatment of COPD. Age Ageing 2004;33:567-70.  Back to cited text no. 7
Agboado G, Peters J, Donkin L. Factors influencing the length of hospital stay among patients resident in Blackpool admitted with COPD: A cross-sectional study. BMJ Open 2012;2. pii: e000869.  Back to cited text no. 8
Abe T, Toyabe S, Cao P, Kurashima S, Akazawa K. Development of a simulation program for estimating hospital incomes under the prospective payment system. Comput Methods Programs Biomed 2005;80:271-6.  Back to cited text no. 9
Kraft MR, Desouza KC, Androwich I. Data Mining in Healthcare Information Systems: Case Study of a Veterans′ Administration Spinal Cord Injury Population. IEEE Computer Society, In: Proceedings of the 36 th Hawaii International Conference on System Sciences, 6-9 January, 2003, Hawaii; 2003.  Back to cited text no. 10
Marshall A, Vasilakis C, El-Darzi E. Length of stay-based patient flow models: Recent developments and future directions. Health Care Manag Sci 2005;8:213-20.  Back to cited text no. 11
Ng SK, McLachlan GJ, Lee AH. An incremental EM-based learning approach for on-line prediction of hospital resource utilization. Artif Intell Med 2006;36:257-67.  Back to cited text no. 12
Cots F, Elvira D, Castells X, Sáez M. Relevance of outlier cases in case mix systems and evaluation of trimming methods. Health Care Manag Sci 2003;6:27-35.  Back to cited text no. 13
Polverejan E, Gardiner JC, Bradley CJ, Holmes-Rovner M, Rovner D. Estimating mean hospital cost as a function of length of stay and patient characteristics. Health Econ 2003;12:935-47.  Back to cited text no. 14
Freitas A, Silva-Costa T, Lopes F, Garcia-Lema I, Teixeira-Pinto A, Brazdil P, et al. Factors influencing hospital high length of stay outliers. BMC Health Serv Res 2012;12:265.  Back to cited text no. 15


  [Figure 1]

  [Table 1]

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