DISSERTATION REPORT

AT
YASHODA SUPERSPECIALITY HOSPITAL AND CANCER
INSTITUTE, GHAZIABAD.

STUDY OF DISCHARGE AND ANALYSE THE GAPS AND

SCOPE OF OPERATIONAL IMPROVEMENTS IN
DISCHARGE PROCESS AT YASHODA HOSPITAL,
GHAZIABAD.

BY
DR. KASHISH MOHAN (PT)
PG/21/140

UNDER THE GUIDANCE OF

MRS NAGMA KHAN
DR PANKAJ TALREJA

PGDM (Hospital & Health Management)

2021-23

INTERNATIONAL INSTITUTE OF HEALTH

MANAGEMENT AND RESEARCH, NEW DELHI

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 The certificate is awarded to

Dr. Kashish Mohan (PT)

In recognition of having completed her Dissertation in the Operations Department.

And successfully completed her project on

To study the process of discharge and analyze the gaps and scope of operational
improvement in the discharge process at Yashoda Superspeciality Hospital and
Cancer Institute.

16th January 2023- 31st May 2023

AT

Yashoda Superspeciality Hospital and Cancer Institute, Ghaziabad.

Comments:

………………………………………………………………………………………………

……….………………………………………………………………………………………

……………….

MRS. NAGMA KHAN

SENIOR MANAGER,

YASHODA SUPERSPECIALITY HOSPITAL AND CANCER INSTITUTE,

GHAZIABAD.

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 TO WHOMSOEVER IT MAY CONCERN

This is to certify that Dr. Kashish Mohan (PT) student of PGDM (Hospital and Health
Management) from International Institue of Health Management Research, New Delhi has
undergone internship at Yashoda Superspeciality Hospital and Cancer Institute from 16th
January 2023 to 31st May 2023.

The candidate has successfully carried out the study designed to her during dissertation
and her approach to the study has been sincere and analytical.

The internship is in fulfilment of the course requirements. We wish her all the success in
all her future endeavours.

Dr. Sumesh Kumar Dr. Pankaj Talreja

Associate Dean, Academic and Student Affairs, Controller of Examination,

IIHMR, DELHI. IIHMR, DELHI.

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4|Page
 CERTIFICATE FROM DISSERTATION ADVISORY COMMITTEE

This is to certify that Dr. Kashish Mohan (PT), a graduate student of PGDM (Hospital and
Health Management) has worked under the guidance and supervision. She is submitting her
dissertation titled “STUDY OF DISCHARGE AND ANALYSE THE GAPS AND SCOPE
OF OPERATIONAL IMPROVEMENTS IN DISCHARGE PROCESS” at Yashoda
Hospital, Ghaziabad in partial fulfilments of the requirements for the award of the PGDM
(Hospital & Health Management). This dissertation has the requisite standard and to the best
of our knowledge no part of it has been reproduced from any other dissertation, monograph,
report or book.

Institute Mentor: Dr. Pankaj Talreja

Designation: Associate Professor, Controller of Examinations.

Organization: IIHMR, Delhi

Org. Mentor: Mrs. Nagma Khan

Designation: Senior Manager, Operations

Organization: Yashoda Superspeciality Hospital and Cancer Institute, Ghaziabad.

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 INTERNATIONAL INSTITUTE OF HEALTH MANAGEMENT
RESEARCH

NEW DELHI

CERTIFICATE BY SCHOLAR

This is to certify that the dissertation titled “STUDY OF DISCHARGE AND ANALYSE
THE GAPS AND SCOPE OF OPERATIONAL IMPROVEMENTS IN DISCHARGE
PROCESS” at Yashoda Superspeciality Hospital and Cancer Institute submitted by Dr.
Kashish Mohan (PT) Enrollment No. PG/21/140 under the supervision of Mrs. Nagma
Khan, Dr. Pankaj Talreja for award of PGDM (Hospital and Health Management) of the
Institute carried out during the period from 16th January 2023 to 31st May 2023 embodies my
original work and has not formed the basis for the award of any degree, diploma associate
ship, fellowship, titles in this or any other Institute or other similar institution of higher
learning.

Dr. Kashish Mohan (PT)

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7|Page
 Acknowledgement

The satisfaction and exhilaration that come with the successful completion of the project
would be incomplete without mentioning the people who made it possible, so first and
foremost I would want to thank The Almighty GOD whose favour makes all things
possible.

I would like to take this opportunity to thank and express my sincere gratitude to my
faculty supervisor, Dr. Pankaj Talreja (Associate Professor, Controller of Examination,
IIHMR, New Delhi), my hospital guide, Mrs. Nagma Khan, Senior Manager, Operations,
Yashoda Superspeciality Hospital & Cancer Institute, Ghaziabad, and to all those without
the help of whom I could not have written this unique piece of writing. They gave me
invaluable advice and time during the study, made helpful ideas, had a positive attitude
and was constantly encouraging, for which I am incredibly grateful.

I owe the entire hospital personnel my sincere gratitude and appreciation.

Last but not least, I want to express my sincere gratitude to my parents for their love,
support, education, belief in me, and for helping me get ready for the future.

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 CONTENTS
Abbreviations…………………………………………………………………11
Summary……………………………………………………………................12
Chapter 1: About Yashoda Hospital………………………………………13-15
Chapter 2: Discharge Process………………………………………............16-19
 Discharge Planning…………………………………………………..18
 Cash, Panel…………………………………………………………..18
 Insurance & TPA…………………………………………………….18-19
Chapter 3: Process Mapping………………………………………………..20
Chapter 4: Objectives………………………………………………………21
 General Objectives…………………………………………………..21
 Specific Objectives…………………………………………………..21
 Purpose of Study……………………………………………………..21
 Scope of Study……………………………………………………….21
Chapter 5: Methodology…………………………………………………22-24
 Study Area……………………………………………………………22
 Sampling……………………………………………………………...22
 Resources Used……………………………………………………….23
 Procedures Adopted…………………………………………………..23
 Data Collection……………………………………………………….24
 Primary…………………………………………………………24
 Secondary………………………………………………………24
 Expected Outcome…………………………………………………….24
 Time Frame……………………………………………………………24
Chapter 6: Literature Review……………………………………………25-28
Chapter 7: Discharge Process at Yashoda Hospital………………………29-34
 Standard Discharge Process in Hospital Policy……………………….29
 Discharge process at Hospital…………………………………………30
 Preparation of Discharge Summary……………………………………30
 Final Billing of Patient…………………………………………………31
 Patient Counselling…………………………………………………….31
 Billing Section Formalities…………………………………………….31
 LAMA (Leave Against Medical Advice)………………………………32
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  Discharge on Patient Request…………………………………………32
 Medico Legal Cases…………………………………………………...33
 Pharmacy Clearance…………………………………………………...33
 Patient Expiry………………………………………………………….33
 Records Generated……………………………………………………..34
Chapter 8: Data Analysis…………………………………………………35-39
 Discharge time for Cash Patients………………………………………37
 Discharge time for Panel Patients……………………………………...38
 Discharge time for TPA Patients……………………………………….39
Chapter 9: Results……………………………………………………………..40
 Cause and Effect Diagram……………………………………………...40
 Other Reasons for Delay in Discharge…………………………………40
Chapter 10: Conclusion……………………………………………………….42
Chapter 11: Recommendations………………………………………………..43
Chapter 12: Limitations of Study……………………………………………44
Chapter 13: References………………………………………………………..44
Annexure:
 Medicine Return Process……………………………………………….45
 LAMA Form……………………………………………………………46
 MLC Form……………………………………………………………...47
 DOPR Form………………………………………………………48-49

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 Abbreviations

NABH : National Accreditation Board for Hospital

TAT : Turn Around Time

TPA : Third Party Administrator

CGHS : Central Government Health Scheme

ECHS : Ex-Serviceman Contributory Health Scheme

ESI : Employee State Insurance

LAMA : Left against Medical Advice

MLC : Medico Legal Cases

HIS : Hospital Information System

OPD : Out Patient Department

IPD : In Patient Department

DGHS : Directorate General of Health Services

MCD : Municipal Corporation Department

ONGC : Oil and Natural Gas Corporation Limited

NDRF : National Disaster Response Force

NCR : Northern Central Railway

SPSS : Statistical Package for Social Sciences

GDP : Gross Domestic Product

AAC : Access, Assessment and Continuity of Care

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 Executive Summary

Every hospital's patient release procedure is a multi-step process that involves numerous
personnel and departments. These processes influence and have an impact on the patient
discharge procedure. Discharges must be timed to coincide with other activities and
prepared in consultation with all the departments and disciplines involved.

Prior to leaving the hospital, the patient develops a unique discharge plan with the help
of discharge planning, which ensures that they are released on time and with the
appropriate post-discharge care.

A universal discharge time can be established as a means of standardising events. The

process is made simple for personnel to follow along with. Following NABH principles,
consistency in structures and procedures, tactical and prompt service planning (year
reviews, monthly feedbacks), and other factors are significant components of such a
strategy. Conventions and paths that are linked (e.g., shared in primary and secondary
care) are based on international best practises, making it possible to quickly access
objective measurements of performance.

In terms of content, an attempt is made to evaluate the time access and content gaps in
the Yashoda Hospital discharge procedure. This research was done as a requirement for
the PGDHM programme given by IIHMR, Delhi.

The purpose of this study was to examine the discharge process for patients who were
admitted to the hospital in one of three patient categories: Private, Panel, or TPA.
Particular attention was paid to the length of time it took for files to be received at the
billing section, the creation of discharge summaries, their verification, and the creation of
final bills. This project also seeks to identify the underlying factors that contribute to
process delays, identify SOPs, and attempt to identify potential remedies and operational
enhancements. The Yashoda Hospital's IPD is where this study was carried out.

A total of 300 patients were discharged from the hospital over the duration of the study. Data
were acquired through descriptive and quantitative research, and process mapping was
carried out by direct observation. Out of 300 patients, 61 were TPA members, 22 were cash-
paying (Private), and 217 were panel members.

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 Chapter 1: About Yashoda Hospital

The Yashoda Super Speciality Hospitals' Cancer Institute was founded by Dr. Dinesh
Arora in 2019 with the unwavering goal of becoming a one-stop shop for offering
medical and counselling-based treatments to all of our cancer patients. We take great
satisfaction in being one of the top medical facilities for accurately detecting and
successfully treating a wide range of cancer-based problems, so if you're looking for
Medical Oncology therapies in Delhi NCR, your search ends at our welcome mat.

Our skilled oncologists have access to a wide range of medical oncology treatment
trajectories to combat their cancers and feel better. These treatments include standard and
experimental restorative techniques with chemotherapy and other biological therapies.
The Hospital is considered to be one of the most reputed hospitals of Western U.P.

Yashoda Hospital is located in the heart of the city, easily accessible from all the corners
of Ghaziabad.

With five floors, 110 beds, and superspecialties, including orthopaedics, plastic surgery,
medical oncology, surgical oncology, radiation oncology, haematology, robotic surgery,
general surgery, nephrology, urology, internal medicine and many others, the hospital is
surrounded by lush flora.

IPD Beds of a number of categories General, Semi-private, Private and Chemo Wards are
catering to varied requirements of our valued patients.

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Mission

Serving all people through exceptional health care, persistent quality, sympathy, respect
and

community outreach.

Values

Guide for Institutional and Organizational behaviour at Yashoda Superspeciality and

Cancer

Institute is CARE which stands for

- C for compassionate care for our patients and their loved ones

- A for accountability, transparency and honesty in our services

- R for respect towards our patients, their loved ones and towards each other

- E for excellence in everything we do

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As a part of social corporate responsibility, Yashoda Hospital conducts no cost Health
screening

camps, free OPDs and have dedicated facilities for the unprivileged patients.

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 CHAPTER 2 : Discharge Process
IPD and OPD services are two subcategories of hospital services. An organisation that
provides care for ambulatory patients who come for diagnosis, treatment, or follow-up
care is known as an outpatient department. The term "unit" describes medical services
that are offered the same day. Up until the point when hospitalisation may be required,
the patient is assessed and treated in the outpatient department (OPD). The hospital's in-
patient services, or ward section, make up 35–50% of the entire hospital complex,
making it the most significant and substantial component. The main goal of the in-patient
area is to accommodate patients at the stage of their sickness when their dependence on
others is the greatest. Thus, the nursing station, the beds it serves, and the work, storage,
and public rooms required to provide the patients' nursing care would be included in the
inpatient care area, ward, or nursing unit. The high operational costs have a direct impact
on hospital budgets. All hospital administrators must fully understand how expensive in-
patient care is and concentrate on excellent planning and efficient use of these services.

It is crucial for hospitals that patients who are admitted are released from their care in a
safe and efficient manner that is advantageous to both the patients and the organisation.
Studies observing rising disease trends and an increase in the population of seniors
clearly demonstrate the need for frequent use of healthcare services. Growing
competitiveness results from increased healthcare demand. A company's success depends
on maintaining the trust of its clients. Systems and processes are created to continuously
please customers. In addition to receiving satisfactory care, our customers' patients and
attendants expect timely service, accessibility and affordability of services, courteous
behaviour, privacy and dignity, and informed treatment and cure throughout their journey
from admission to leaving the hospital, or patient discharge.
Research has revealed that a number of events occur throughout the patient release
process that influence everyone involved, despite the hospital's efforts to ensure a prompt
and efficient departure. After the required interventions, several procedures that require
the involvement of numerous staff members and departments must be carried out after
the patient's release, making the process complex but efficient.

As per B.M. Sakharkar (The Author of ‘Principles of Hospital Administration and

Planning’), “Discharge is the release of an admitted patient from the hospital”.

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As per NABH, “Discharge is a process by which a patient is shifted out from the hospital
with all concerned medical summaries ensuring stability”.

When the consultant determines that the patient is well enough to continue receiving home
care services or needs to be transferred to a different category of facility (rehabilitation,
mental), the discharge process begins. In many hospitals, the admission and discharge
procedures can become bottlenecks, which negatively impacts the hospital's productivity.

People typically avoid being admitted to hospitals because of the unexpected expenditures
associated with doing so. Instead, they prefer to wait until they have been discharged and
then rush to get better and resume their regular lives. Any unjustified delay in the discharge
process hurts both the organisation and the patients. Lack of information and communication
causes the patient to be ignorant of the procedure and time commitment, which frequently
causes annoyance, discouragement, and discontent. Additionally, it raises the risk of hospital
acquired infections being contracted by a patient. Even when a patient had a positive
experience, a delay might cost the organisation money and damage the hospital's reputation.

TYPES OF DISCHARGE

LAMA

DEATH DOPR

CURED &
ABSCONDED
DISCHARGE

TRANSFER
TO OTHER
HOSPITAL

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 Discharge Planning

Future management functions can be developed from a fundamental planning

framework. Planning for discharge begins with choosing a good date for the end of
hospital care and notifying the patient's and their loved ones to get ready to take the
patient home. The procedure also includes planning for post-discharge services like
visiting care, physical therapy (physiotherapy or occupational therapy), and home sample
collection. It is a goal-oriented, ongoing activity with the dual objectives of cost
containment and patient outcomes improvement. In the end, it reduces unwelcome
extended hospital stays, unanticipated readmissions, and improves the promptness of
services and departmental coordination.

Planning for a patient's discharge starts early in their hospital stay. To maintain accurate
treatment data, hospitals should discharge patients. In order to accurately represent our
active client list and to compile statistics reports, it is crucial to keep track of discharge
patients.

Cash, Panel & Insurance/TPA

A group of patients, including Cash, Credit, and Insured/TPA patients, are released from the
hospital.

• A cash patient is someone who pays the entire bill in cash, credit/debit cards,
UPI payments, or local currency at the time of discharge.
• Empanelled patients pay a reduced fee for services, or the appropriate panel
makes the payment, or the patient makes the payment and receives a
reimbursement. In the study, a few of the panels that were studied included
CGHS, ECHS, ESI, UP POLICE, DGHS, OFM, MCD, ONGC, NDRF, and
NCR.

• Insurance is a contract (policy) that provides financial protection or

reimbursement against losses from an insurance firm to a person or an
organisation. In order to make payments to the insured more manageable, the
company combines the risks of its clients, for which the insured pays a premium.

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 The insurance provider, in turn, pays the insured for medical expenses under the
following conditions:

- Insured should be admitted to hospital/ nursing home

- Treatment of diseases should not fall under any exclusion under the policy

- Upper cap of compensation limited to sum insured under the policy

• TPA: Third Party Administrators are the link in the chain of the integrated delivery
system that unifies all the elements of the delivery of health care, such as doctors, hospitals,
patients, insured and insurers. Eg: ICICI Lombard, GIPSA, MAX BUPA, etc.

Hospital discharge is a process rather than a single occurrence. A plan for facilitating the
transfer of a patient from the hospital to the appropriate setting should always be developed
and put into action. Depending on the departmental locations, activities, and manpower
planning of an organisation, the discharge process may be unique to that organisation.
Process mapping can help to understand this.

The study's objectives include observing Yashoda Superspeciality and Cancer Institute's
patient discharge procedure, determining the timeliness of the procedure, identifying
bottlenecks and addressing them in the course of my employment.

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 Chapter 3: Process Mapping

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 Chapter 4: Objectives

General Objective:

• To study the process of discharge and analyse the gaps and scope of
operational improvement in the discharge process at Yashoda Hospital.

Specific Objectives:

• To access the Discharge time for Cash, Credit and TPA patients.
• To find the actual cause of delay & SOPs for the discharge process.

Purpose of the study:

The goal of the study is to comprehend the entire procedure and identify any issues with the
discharge process in order to make improvements based on the recommendations during my
additional training and education in the hospital.

Scope of Study:

The scope of this study is to assess the procedures, tasks, resources, and departments
involved in the process at Yashoda Hospital and to enhance both its general operation and
daily operations.

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 Chapter 5: Methodology

• Study design: A cross sectional study based on Observation and on process

mapping and Quantitative research enumerating the percentage of discharges
within time and enumerate analyses i.e., the time span of each of the steps for
discharge as well as various elements leading to discharge on or off time.

• Study Area: In Patient Department of Yashoda Superspeciality Hospital & Cancer

Institute:

 Ward 1: 18 Beds
 Ward 2: 20 Beds
 General Ward: 23 Beds
 Chemo ward : 15 Beds
 Icu : 24 Beds

• Sampling Method: Purposive Sampling

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- Sampling Strategy:
• All patients discharged from the Ward 1, 2, Chemo, ICU and General ward (Male &
Female). All patients are studied at each phase of discharge tracked (Patient file
received at MT Room, Preparation of Final Discharge Summary, Medicine indent and
receiving time, Time taken for TPA approvals, Time patient receives Gate Pass and
Signs Discharge Summary). These patients are from variety of segments including:

 Private (Cash patients)

 Government Panel (CGHS, CAPF, ESI, UP Police, Railways, UPPCL Etc.)

 TPA (GIPSA, NIVA BUPA, ICICI LOMBARD, STAR HEALTH, HDFC Ergo Etc.)

 Resources used:

 HIS (Pharmacy clearance, Final Billing, Admission, Discharge)

 Hospital Staff (GDA’s, Pharmacists, Nursing in charge, nursing staff at station,

Billing executive, TPA executive, Medical Transcriptionist, TPA & Billing Head,
DNS, Consultants, Medical officers)
 Admission & Discharge register at Nursing station

 Medical Records (Patient case file)

 Procedure Adopted:

 The hospital's manual, records, policies, MOUs, licences, concerned authorities,

and other sources were used to gather information about the Institute, the idea
behind its foundation, location, the surrounding region, history, planning,
manpower, organisational structure, and other facts.

 Observations were made of the hospital's various departments' clinical,

supporting, ancillary, and administrative services.
 Studying the recognised departments that were engaged also me in my effort to
gather facts and information. Personal observation, as well as coordinating and
directing the departments and personnel involved in that operation's management.

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 Data Collection:

Data was collected by primary and secondary sources:

o Primary:
• Participatory observation

• Discussions with Medical Officer, Pharmacists, Nurse, DNS, Ward

Coordinators

• Interaction with Medical Transcriptionist, Consultants, Billing Executive,

GDA Staff

o Secondary:
• Work manual of the departments

• Registered records of particular departments & patients

• Broachers, Website, Policy, Articles & Columns

• HIS

• Information was collected for location/ layout, equipment’s used, policies

and procedures .

 Expected Outcome:

The goal of a time motion study is to analyse a situation, look at the scenario's goals, and
come up with a better, more effective approach or system. To identify the crucial tasks and
search for indicators from which new approaches might arise, accurate observations and
recording of the current working procedures were made. To ascertain how long it takes the
competent staff to execute a given task to the current needed level of performance, several
work patterns were observed and timed.

 Time Frame:
12th April- 31st May 2023

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 Chapter 6: Literature Review

According to a joint research by an industry association and Ernst & Young, India will
require up to 17.5 crore more beds by the end of 2025. In 2017, 0.53 beds per 1000
inhabitants were identified in India, according to data from the World Bank. India is a
popular destination for medical tourists, which adds to the burden of disease and the
strain on the healthcare system in the nation.

The healthcare industry in the nation is expanding quickly and offers several
opportunities. By 2022, the government wants to raise healthcare spending to 3% of the
GDP. The government provided a sizable amount for COVID in the Union Budget of
2021 and is actively promoting healthcare and hospitals. India had an estimated 714
thousand hospital beds spread across 69 thousand hospitals in 2019, according to data
released by the Statista committee. Outnumbering governmental hospitals, the private
sector provided about 1.1 million of these beds. The healthcare industry faces intense
competition, and as a service industry, it is motivated by fulfilling and surpassing the
expectations of its clients. One of the most crucial phases of the patient journey is patient
discharge.

The procedure involves many different departments, such as Nursing, Billing, TPA,
Pharmacy, Dietetics, and Physiotherapy, as well as many different people, such as
Consultants, Duty Doctors, Medical Transcriptionists, Nursing staff, Billing executives,
General Duty Assistant Staff, etc. Understanding the overall procedure and its operations
is crucial for hospital managers in order to successfully and efficiently manage the
operations.

For my Literature Review, I have used the following keywords:

1. Discharge process

2. Patient Discharge

3. Patient Discharge and Hospital

4. TAT for Discharge and Study

5. Average time and delay in discharge

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The following published papers are reviewed:

Silva Ajami et al.'s study from 2007 examined the window for discharge. The team used
checklists, questionnaires, and their own observations to collect data, which was then
analysed using the SPSS programme. The researchers employed the queuing model. The
author's findings include an average time of 4.93 hours, a lack of staff supervision, a
delay in finishing the discharge statement, and a lack of HIS.

In a tertiary care healthcare organisation in 2012, Janita Vinaya Kumari et al. did a study
on the final stage of a patient's hospitalisation, or patient discharge. According to the
author, the discharge and billing processes are the ones that patients and attendants are
more likely to recall. The study's objective was to determine the typical wait time before
patient release. The research team created and personalised study registers, which were
kept in the wards and the billing department. A sample of 2205 patients was examined in
total. The results showed an average waiting time of 2 hours and 22 minutes.

In order to examine the delays in the discharge of all patient categories, including insured
patients, patients who paid with cash, patients who paid with DAMA, etc., Swapnil
Kumar et al. conducted a time motion study in a hospital in 2013. To compare the typical
time required for a patient to leave an institution, the NABH's standard time was
employed. It was discovered that the duration for insured patients, self-payments, and
DAMA was 5 hours and 13 minutes, 6 hours and 2 minutes, and 5 hours and 29 minutes,
respectively. In his study, the author also performed a satisfaction poll of patients,
finding that a total of 69.80% of them said the process was protracted and the remaining
30.20% said it took the expected amount of time for them to leave the hospital. A total of
61.53% patients voted that the discharge process should be speeded up.

In order to improve the appropriate findings, Dr. Silva et al. undertook a study in 2014 to
identify the primary cause of delays in the patient discharge process from two teaching
hospitals. Internal medicine ward patients' admission and discharge records were examined.
To establish the sample size, the author carried out a pilot study. They discovered that

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hospital A's release was delayed by 60% and hospital B's discharge was delayed by 50.7%
between the two teaching hospitals. The primary causes of the delay in the discharge process
were determined to be the lack of timely availability of investigation reports, the decision-
making process regarding the patient's clinical health and discharge, and the provision of
specialised consultation.

At Apollo Hospitals in Bhilai, a three-month study was carried out in 2014 with the aim
of determining discharge process delays compared to industry standards. The goal was to
analyse the entire process, analyse it, and identify any difficulties that might have arisen
at different stages of the process. The study's goal was to draw out a strategy for time
savings and process optimisation. The six units where the patient's records were
followed were included in the time motion study the author did. A sample of 300 patients
was chosen at random for this cross-sectional investigation over a three-month period.
During the study, respondents were interviewed, including nurses, employees of the
discharge pool, on-call physicians, and administrators. At least 50% of all patients
released during the trial period were to be followed up on by the researchers when they
arrived. The discharge took place two hours earlier than usual, at two hours instead of
four. All patients were tracked, including cash, credit, TPA, planned and unforeseen
discharges. Time for Cash, Credit, Unplanned, and Planned Discharge was found to be
3.6 hours. 4.2 hrs. respectively 4.1 and 3.4 hours.

The Asian Heart Institute conducted a study to determine the TAT of the discharge
process and to examine any gaps and standard operating procedures. It was a 45-day
cross-sectional research that included both quantitative and qualitative analysis.
Purposive non-probability sampling was the method utilised in the sampling process. In
order to gather the data, primary sources like observations and interactions with
employees and departments as well as secondary sources like the patient file and HIS
were used to determine the causes of the delay. The causes were divided into various
groups, including patient-caused delays, hospital-caused delays, delays brought on by
TPA approvals, delays brought on by the patient's worsening clinical condition, etc.. The
main reason found behind the delay in the discharge process was gap in the information
flow and inter-departmental communication.

Mr. Khanna et al. (2016) studied the timeliness of the discharge process and its impact on
crowding and flow performance at a tertiary care hospital. The study's goals included

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determining the best time for patients to be discharged, reducing overcrowding and workload,
and improving inpatient flow. The patient journey, from admission to discharge from the
hospital, was studied and improved using the patient records during a fifteen-month period.
Discrete event stimulation was used to comprehend the flow performance. Eighty percent of
the discharges were completed before afternoon, which left nine additional beds available for
incoming inpatients. The average time it takes for a bed to become available to be occupied,
duration of stay, and bed occupancy were targeted and lowered. The study revealed that
discharges completed before noon, or until 11 AM, improve patient flow and performance.

Dr. Soundara Raja (2017) conducted research in a tertiary care hospital with the intention of
identifying the factors influencing patient admission delays. The goal of the study was to
identify the underlying reason and make recommendations for resolving the issue utilising
useful information. The patients were dissatisfied for a number of reasons, including the
length of time it took to prepare the discharge report, clearance from the pharmacy, delays
caused by support services, and nursing staff.

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 Chapter 7: Discharge Process at Yashoda Hospital

Hospital Recorded Time for Discharge of Private, Government Panel and TPA Patients

S.NO CATEGORY TIME MEASUREMENT CRITERIA

1. CASH 2 HOURS
Patient medical records
GOVERNMENT Pharmacy clearance
2. PANEL 2 :30 HOURS
Ward admission
discharge register
3. TPA 4 HOURS HIS

Quality Objectives:

Performance Indicators Measurement Criteria

Sl. Quality Objectives
Criteria Frequency
Staff availability
(Doctors, Nurses & Duty Roster
Monthly
Support Staff) Attendance Record

Patient medical records

Discharge time
Pharmacy clearance
PVT Patients – 2 hrs.
Ward admission/ Quarterly
Govt. Panel – 2: 30 hrs.
Discharge
1 Service Level TPA–4 hrs.
register

Pharmacy clearance,
Billing completion time (25 Billing,
Monthly
minutes) Discharge record

Comprehensive Patient discharge

Discharge instructions summary Monthly

Coordination between all Patient feedback

Staff Form Monthly
2 Customer satisfaction
Patient feedback form
Courtesy level

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-Discharge process at Yashoda Hospital & Research Centre:
o The primary treating consultant is primarily in charge of making decisions
about patient discharge; they do so during their visit prior to the day of
discharge and communicate those decisions to the attendant, relative,
nursing staff, and medical officer.
o The doctor makes the final decision on the patient's discharge during the
visit on the day of discharge based on the patient's clinical condition.
o Patients are examined to determine whether they can be released on the
planned day or not.
o The ward nurse and RMO on duty are informed as soon as the patient is
deemed to be in good condition.
o The nursing staff returns any additional medications of the patient,
prepares draft of the discharge summary, and provides patient counselling
regarding post-discharge care.

-Preparation of Discharge Summary:

Once the final decision is made, Consultant or duty doctor on advice of the
consultant prepares the summary consisting of information of the following:
a. Reasons for Admission

b. Investigations performed and summarized information about the

results c. Diagnosis
d. Records of procedures performed

e. Patient condition on Discharge

f. Medical commands

g. Follow up Advice when and how to obtain urgent care

h. Emergency number of the hospital

i. Dietary advice

j. Revisit date

• Medical Transcriptionist types the Discharge Summary from the patient file received at
Billing and the discharge summary is sent for correction and signature by consultant.
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 3 copies of final discharge summary kept in patient file by ward nurse.

• Three copies are given: one to the accounting department, one to the
patient/attendant, one to the case file.
• The nursing staff provides the patient/attendant with medication collection and
instructions as provided by the treating consultant.
• The patient or attendant signs the report about receiving the discharge summary that
is kept at the billing counter.

-Final Billing of Patient:

• On the day of discharge, confirmation of patient discharge is made by the
consultant or the ward nurse.
• Patient’s file is sent to the billing section for the final billing settlement by floor in
charge or ward sister

-Patient Counselling:
• As stated in the DS summary, the dietician consults with the patient regarding
nutrition, the nurse instructs regarding medicines, and other matters before to final
discharge.
• The patient is told that they will be returning to the hospital.
• The nursing station's discharge register contains notes about the discharge.
• The patient and their family leave the hospital.
• The ward attendants wheel elderly patients, new mothers, and other patients to the
hospital exit area so they can be seen off.

-Billing Section Formalities:

Patient relative is called from the billing department after the patient file is transferred to the
billing department. The bill is cleared (if the patient is paying) and a cash receipt is taken by
signing all three copies of the bill; a clearance slip is then issued by the accounts officer /
patient attendant.

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• Clearance slip and a copy of the receipt were delivered to the in-charge sister in the ward by
patient attendant. Patient relative is called from the billing department after the patient file is
transferred to the billing department. The bill is cleared (if the patient is paying) and a cash
receipt is taken by signing all three copies of the bill; a clearance slip is then issued by the
accounts officer and given to patient attendant.

-LAMA (Left Against Medical Advice):

• No patient may be confined in a hospital against their will in accordance with their
rights.
• The nursing staff and the concerned doctor should attempt to convince the patient to
stay while also attempting to ascertain the reason for their desire to leave. If possible,
the issue should be remedied.
• In spite of this, if the patient still wants to discharge himself or herself from the
hospital, all reasonable measures should be taken to ensure the patient/authorized
attendant signs a form to this effect before leaving the hospital. It is the doctor's
responsibility to explain to the patient that if the patient leaves the hospital against
medical advice, the hospital ceases to be responsible for his or her care. In case
patient/relatives want to get discharged against medical advice; the same is indicated
in the patient case record by the primary treating consultant/medical officer.
• A written consent is taken from the patient/relatives in the LAMA form.

• If the patient declines to sign the form, it is expressly noted in the medical records.

• Records are kept of the conversations and risks related.

• The attendant or relative is urged to pay off all debts.

• A summary of the discharge is created and provided.

• One copy is included for record-keeping purposes in the patient file.

- Discharge on Request:

• Yashoda Hospital offers DOPR (discharge on patient request) in the event of the
patient's impending death. Discharge summary is prepared and is given.
• One copy is included for record-keeping purposes in the IPD file.

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 - Medico Legal Cases:

• All medical-legal cases and those accepted by court order are handled in the same
way as planned discharges, where information is forwarded to the relevant authorities
prior to discharge.
• In the case of MLC, the RMO or nurse fills out the medical legal papers and notifies
the police.
• All investigation reports and supporting documentation are kept safe; the on-call staff
nurse is in charge of ensuring this.
• MLC is documented and the police are notified upon admission, discharge to home,
transfer to another hospital, or death.
• A summary of the discharge is drafted and provided. A copy of DS summary is
enclosed in file for record purpose.

- Pharmacy Clearance:

Before clearing the bill and transmitting the file to the billing department, the
pharmacy staff makes any final deductions from the bill and receives "pharmacy
clearance" from the Ward nurse or Sister in charge.

- Patient Expiry:

• The principal treating consultant, medical officials, and nursing staff notify the patient's
family in the event of death. Family members of the patient are given access to the body.

• The ward nurse prepares the body for cleaning as necessary. The body is cleansed and
wrapped in a clean linen by designated professionals.

• Three copies of the death certificate and death summary are created by RMO.

• A stamp is placed on the death certificate and death summary.

• Within an hour after death, the body is given to family members or kept in the mortuary.

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• The body is given to the family members together with one copy of the death certificate and
death summary, while the second copy is attached to the patient's case files.

• The neighbourhood police station is notified in medical-legal matters, and they determine
whether a postmortem is necessary.

- Records Generated

• Patients Case File

• Discharge Summary

• Death Certificate

• Death Summary

• LAMA form

• Admission Discharge Register

• Final Bill (for Special Patients)

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 Chapter 8: DATA ANALYSIS
CATEGORY WISE TOTAL NUMBER OF PATIENTS

S.NO CATEGORY TOTAL NUMBER OF PATIENTS

1. CASH 22

2. TPA 61

3. PANEL 217

TOTAL 300

PATIENT CATEGORY

61, 20%

22, 8%

217, 72%

PANEL Pvt TPA

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 TYPE OF DISCHARGE

S.NO CATEGORY TOTAL NUMBER OF PATIENTS

1. UNPLANNED 237

2. PLANNED 63

TOTAL 300

TYPE OF DISCHARGE

21, 21%

79, 79%

PLANNED UNPLANNED

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 - Discharge Time for Cash Patients:

DISCHARGE TIME FOR CASH

PATIENTS

2:28

2:00

1:33

0:44

MAXIMUM DISCHARGE TIME IN HOSPITAL POLICY AVERAGE MINIMUM

- The average time for Discharge for 22 Cash Patients is 1 Hour 33 minutes.

- The discharge time as per hospital policy for cash patients is 2 Hours.

- The maximum recorded time is 2 Hour 28 Minutes.

- The Benchmark for the patient discharge of Cash category is 44 minutes.

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 - Discharge Time for Panel Patients:

DISCHARGE TIME FOR PANEL

PATIENTS

4:52

2:52
2:30

0:56

MAXIMUM AVERAGE DISCHARGE TIME IN HOSPITAL POLICY MINIMUM

- The average time for Discharge of 217 Panel Patients is 02 Hours 52 minutes.

- The discharge time for Panel patients as per hospital policy is 02 Hours 30
Minutes.

- The maximum recorded time is 4 Hour 52 Minutes.

- The Benchmark for the patient discharge of Panel category is 56 Minutes.

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 - Discharge Time for TPA Patients:

DISCHARGE TIME FOR TPA

PATIENTS

6:17

4:26
4:00

1:06

MAXIMUM AVERAGE DISCHARGE TIME IN HOSPITAL POLICY MINIMUM

- The average time for Discharge of 61 TPA Patients is 04 Hours 26 minutes.

- The discharge time for TPA patients as per discharge policy is 04 Hours.

- The maximum recorded time is 06 Hours 17 minutes.

- The Benchmark for the patient discharge of TPA category is 01 Hour 06 Minutes.

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 Chapter 9: Results

CAUSE AND EFFECT DIAGRAM

-Other Reasons for the Delay in Discharge Process:

• Lack of staff training and knowledge about discharge process.

• Untrained MTs: Typing errors and mistakes by Medical Transcriptionist in Discharge
Summary repeatedly.

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 • Shortage/ Unavailability of GDA: The GDA staff takes the unused medicines from
the IPD patient to the pharmacy and billing department for clearance. The GDA are
also assigned many other duties which include attending patient, doctors, nurses and
administrative staff and helping out them in their activities. Morning hour has
maximum number of discharges which demands a great number of GDA going for
discharges activities. Lack of GDA or absenteeism of them contributes to delay in the
discharge process.
• Lack of coordination between departments because sometimes the status of patient is
not known (whether Cash/ Panel/ TPA)
• Sometimes patient card doesn’t work.

• Excessive medicines ordered by Nurse: More return time.

• All reports are not available on HMS which is required to send TPA for Cashless.

• Photocopies & Printing of the reports/ discharge summary takes time.

 Another important matter of concern is late DS summary preparation as it involves

many steps:
a) Doctors who are not involved in the treatment are asked to write summary in patient
file. They have to go through entire notes which causes delay
b) Sometimes DS is prepared late due to workload on Medical Transcriptionist.

c) Sometimes everything is ready, but couldn’t still be served to patient because

nursing staff is very busy and they send the file late to Billing Section.
d) Sometimes staff tends to try accumulating 2 or 3 discharges simultaneously so delay
occurs in completing notes, pharmacy clearance, sending down file.
Miscellaneous: There are various other reasons which delay the discharge process.
Some patient prefers to leave after lunch. Some patients have conveyance and other
issues which extend their stay. Few have sudden queries for which they request to
consult doctor before going home which takes time.

• Patients are sometimes not in a condition to pay huge amount of bills genuinely so
discounts are given to such category of people based on humanitarian basis but this
requires consultation and approval of higher authority.

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 Chapter 10: Conclusion

It is challenging to discharge patients properly. Interdepartmental cooperation and effective

communication amongst all parties engaged in the discharge process can result in an efficient
and on-time release.

In this study, the time taken for Discharge of Cash, TPA and Panel patients at Yashoda
Superspeciality Hospital and Cancer Institute has been analysed. It has been found that the
Time taken for DS of Cash patients , 1 hour 33 minutes, is within the hospital policy which is
of 2 hours. For TPA patients, delay of 26 minutes has been found. And for Panel patients
delay of delay of 22 minutes has been found. The various reasons associated with the delay in
the process have been identified and will be worked upon.

The primary cause of the disarray in the discharge process is unplanned discharges. The
Discharge should be prepared in advance in conjunction with the patient/family, according to
NABH Chapter 1 AAC 13.

42 | P a g e
 Chapter 11: Recommendations

• Planned discharge: medicines return, cross consultations, report collection &

Summary preparation.
• Round timings of the doctor can be tried to be fixed preferably in the Morning. Nurse
should know the expected discharge date so that she could complete her notes, reports
collection, & return unused medicines to the Pharmacy.
• Patient shouldn’t be discharged immediately on request. He could be planned for
evening discharge so that it should also turns out as an appropriate discharge
otherwise, not only case in itself will be delayed but also shackles the strength of
other planned discharges.
• Discharge coordinator/ nurse should coordinate for parallel workflow which is seen
absent in many cases, such as to, inform to dietician or physiotherapy, or should
inform the housekeeping department for wheel-chair, transportation team for
ambulance services (if required) as initiated by treating physician during the time she
is preparing DS for smooth process.
• In cashless patients, documents should be collected with the time so that the nurse
doesn’t have to rush to collect reports or clearances.
• Patient to be well informed about time of whole process and steps involved in it.
• Giving priority to TPA patients file for making discharge summary, and Bill
preparation as they take the most time for receiving the approval of the claim.
• Colour coding of file folders.
• Interdepartmental coordination and communication (Training, sensitization, meetings,
communication channel)
• Timely report collection & departmental clearance.
• Training of Nurse to prepare Discharge Summary.
• Separate IPD & Billing counters.
• Training of Medical Transcriptionist on Regular basis especially in case of new
joinees and interns.

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 Chapter 12: Limitations of the Study

• Includes only In Patient Department patients admitted for more than 24 Hours.

• TAT for TPA patients is accessed through email.

Chapter 13: References

• Sakharkar BM. Principles of Hospital Administration and Planning. 2nd ed. New Delhi:
Jaypee Brother; 2009.
• https://www.yashodahealthcare.com
• https://www.nabh.co/images/Standards/NABH%205%20STD%20April
%202020.pdf
• https://www.jrfhha.com/doi/JRFHHA/pdf/10.5005/jp-journals-10035-
1113
• Goel S.L and Kumar R. Hospital Administration and Planning, 1st edition, Jaypeee
Brothers, Medical Publishers Pvt Ltd: New Delhi
• https://pubmed.ncbi.nlm.nih.gov/18195405/
• https://journals.indexcopernicus.com/search/article?articleId=2153764
• https://pubmed.ncbi.nlm.nih.gov/21740345/
• https://www.researchgate.net/publication/273340797_Role_of_discharge_planning_and_
othe r_determinants_in_total_discharge_time_at_a_large_tertiary_care_hospital
• https://pubmed.ncbi.nlm.nih.gov/26845068/

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 ANNEXURE: MEDICINE RETURN (IPD PHARMACY)

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 ANNEXURE: LAMA FORM

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 ANNEXURE: MLC FORM

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 ANNEXURE: DOPR FORM

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49 | P a g e
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