To study the process of patient discharge in corporate hospital

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Acknowledgements
I take this opportunity as privilege to express my deep sense of gratitude to Dr. Rajendra
Takale, Director, Ashoka Institute of Healthcare, Nashik for their continuous
encouragement, invaluable guidance and help for completing the present research work.
He have been a source of inspiration to me and I am indebted to him for initiating me in
the field of research. I am deeply indebted to Prof. Dr. Shilpa Bhalgat, my research guide,
Ashoka Institute of Healthcare, Nashik, without her help completion of the project was
highly impossible.
I take this opportunity as privilege to articulate my deep sense of gratefulness to Dr.
Saraswat, COO, Apollo Hospitals; Dr. Jadhav, Marketing Head, Apollo Hospitals; Mr.
Robin Philip, Sr. HR Manager, Apollo Hospitals and Dr. Chitra Mukaddam, Head,
Quality, Apollo Hospitals. I would also like to Thank the Operations Executives Dr. Ram
Kedar, Mr. Nikhil Bayas and Mr. Kishor Salunkhe for their Support, and the staff of
Apollo Hospitals, Nashik for their timely help and positive encouragement.
I wish to express a special thanks to all teaching and non-teaching staff members, Ashoka
Institute of Healthcare, Nashik for their forever support. Their encouragement and
valuable guidance are gratefully acknowledged. I would like to acknowledge all my
family members, relatives and friends for their help and encouragement.
Place: Nashik Shah Rameez Iqbal
Date:

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“To Study the Process of Patient Discharge in Multispeciality
Corporate Hospital”
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 organisation 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 suffer add 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 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, locating 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,

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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 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
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
Hold family meetings of high-risk patients within 24-48 hours of admission
Provide patient and family with information concerning community resources and
encourage contact

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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
patient 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 result 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 are increased at the hospital.
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.
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

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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 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. Patients and 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.

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Discharge Process Flow Chart:
Confirmation of Discharge from
Consultant
Preparation of Cumulative Hospital Charges
for the patient and return Medications
Final cumulative charge sheet of the patient
sent to Cashier
Preparation and Processing of Final Bill
Cash Company TPA Insurance
Verification by respective payer
Inform respective ward by the cashier
once the bill ready
Patient Settles the bill and receives Payment paid slip
Patient goes to the respective ward and collect discharge
sheet (D.S) & Prescription
Patient buys the medication
Patient comes to the Nursing unit and R.M.O./ S.N.
explains D.S. and medications & follow up date
Discharge

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Patients and carers (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. Carers 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.
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 carer/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.
Patient and carer involvement includes good communication, involving patients and
carers at all stages of discharge planning, giving good information and ensuring patients
and carers are helped to make planning decisions and choices. Staff record all
assessments, discussions, referrals and actions relating to discharge on the
communication sheets alongside to aid coordination of discharge plans. 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 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.
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.

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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.
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 delayed 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.
Patients who need rehabilitation or intermediate care - If it appears the patient may not be
able to return to their own home, the potential for improving independence and self-care
ability is considered before seeking residential care. Patients are referred to intermediate
care to support timely hospital discharge, reduce falls risk, support medication
management and identify preventable causes of recurrent hospital admissions. This
integrated, multi-agency service is offered for up to 6 weeks in any suitable non-hospital
setting. Patients must have identified rehabilitation goals and cognitive ability to work
towards these.

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Patients with dementia may be transferred to temporary residential care for a longer
period of intermediate care than 6 weeks but are only transferred from acute care to long
term residential care in exceptional circumstances, such as following specialist stroke
rehabilitation, after unsuccessful attempts at supporting the patient at home, or if
temporary residential care followed by a move is expected to be distressing.
If the patient does not meet the criteria for intermediate care but has rehabilitation goals,
inpatient rehabilitation at a community hospital may be considered. There are some
similarities between rehabilitation and intermediate care. Both aim to promote recovery
and maximize the patient’s independence after an acute episode. Rehabilitation may be
provided in hospital or the patient’s own home, and includes physiotherapy, occupational
therapy and speech therapy. Intermediate care does not start until the patient leaves
hospital, is only offered on a short-term basis and may involve help from social services.
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, 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
chronological order.

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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.
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 possible to arrange a safe and effective
discharge by ensuring all discharge requirements are complete, and that the patient, carers
or independent advocates are involved with all decisions.
Escalate complex issues to the ward lead and delegates to other ward staff.
The ward lead (sister/ charge nurse/ midwife) will:
Ensure their teams are aware of this procedure and that discharge planning practice
complies with it.
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.
Organise and coordinate multi-disciplinary meetings, escalate discharge concerns to the
specialty matron for support to ensure patient safety.

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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 lead 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.
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, carers and partner organisations and promote collaborative
working with these organisations, including social services, housing, independent mental
capacity advocacy (IMCA), other hospitals, community health services, specialist nurses,
care homes and voluntary organisations.
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.

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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 carer(s) should be

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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 alternative, 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.
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.

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Educate the patient and family in plain language about the patient’s condition, the
discharge process, and next steps at every opportunity throughout the hospital stay.
Getting all the information on the day of discharge can be overwhelming. Discharge
planning should be an ongoing process throughout the stay, not a one-time event. You
can:
• Elicit patient and family goals at admission and note progress toward those goals each
day
• Involve the patient and family in bedside shift report or bedside rounds
• Share a written list of medicines every morning
• Go over medicines at each administration: What it is for, how much to take, how to take
it, and side effects
• Encourage the patient and family to take part in care practices to support their
competence and confidence in caregiving at home
Assess how well doctors and nurses explain the diagnosis, condition, and next steps in the
patient’s care to the patient and family and use teach back.
• Provide information to the patient and family in small chunks and repeat key pieces of
information throughout the hospital stay
• Ask the patient and family to repeat what you said back to you in their own words to be
sure that you explained things well
Listen to and honor the patient and family’s goals, preferences, observations, and
concerns.
• Invite the patient and family to use the white board in their room to write questions or
concerns
• Ask open-ended questions to elicit questions and concerns.
• Use Be Prepared to Go Home Checklist and Booklet to make sure the patient and
family feel prepared to go home
• Schedule at least one meeting specific to discharge planning with the patient and family
caregivers.

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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
delight and to find the factors extending time in discharge process and try to rule out
these factors.
Objectives of the Project
The objectives behind carrying out the project are as follows:
 To study the process of Discharge of patient from hospital
 To study the factors involved in the process of discharge
 To find out the factors leading to delay of discharge
 To study the human resource involved in discharge process
 To study the roles and responsibilities of hospital personnel in discharge process
 To find the loopholes in discharge process and find solutions towards it.

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Chapter II
REVIEW OF LITERATURE

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This chapter will review literature that studies the process of discharge and the need for
identifying delays in discharge processes occurring in hospitals that impede patient flow.
Hospitals are experiencing ongoing pressure to provide satisfactory care and the
resources involved are having trouble realizing expectations. Researchers did not only go
after the reasons for this increase in pressure, as they know that parts of it go back to the
root changes in the nation’s population’s heath status. However, a special effort was
spent in studying all sorts of delays that are occurring in hospitals based on observation
[1]. The delays were categorized into 9 major and 166 minor categories. This organized
classification was suggested to act as what was called “the delay tool”. The tool was
designed to be general enough to accommodate all hospitals, yet detailed enough to
extract the reasons for inefficiencies. It was meant to be affordable and simple to learn
and use. By utilizing it, the study suggests that time-wise feasible real-time assessments
can be done that will bring to light the delays and inefficiencies occurring in a particular
process at a hospital. When the delay tool was put in operation on general internal
medicine and gastrointestinal services for 6 months, it found that “30% of 960 patients
experienced delays” each averaging to 2.9 days. The study also showed that most delays
occurred in the following frequency [1]:
• Scheduling of tests (31%).
• Unavailability of post-discharge facilities (21%).
• Physician decision-making (13%).
• Discharge planning (12%).
• Scheduling of surgery (12%).
However, when defined in terms of delay days, and due to the length of the delays,
awaiting post-discharge facilities was found to cause 41% of them, hence being the most
important problem [1]. Even though this study proposes an indicative tool that can
highlight and quantify delays, it admits that the delay tool’s abilities stop there, and
further efforts, tools and analyses should be carried out to decide on optimal courses of
action.

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Another attempt to improve the efficiency of patient flow was conducted in Lucile
Packard Children’s hospital in California [2]. The hospital faced many problems when it
had to delay and turn away patients due to the lack of capacity. The flow was defined
from admission through discharge and all the steps were laid down for the purpose of
reengineering the process. The objective was to “achieve lasting performance
improvement”. The effort was directed to measure the effectiveness and improve the
following areas (2):
• Reducing patient placement delays.
• Decreasing diversion volumes and understanding causes.
• Improving accuracy of bed availability and admission predictions.
• Reducing the number of medically unnecessary patient days and payment denials.
• Decreasing the frequency of discharge delays.
• Improving bed turnaround time.
• Enhancing the consistency of care performance.
• Reducing variances from established standards of care.
To bring about those improvements, distinct measures were set that became standards of
performance. Continuously, the goal was to increase care and service coordination, create
and sustain cultural change and redefine staff job functions. To be able to track what has
been done throughout each week, reports were created about patient admission, bed
assignments, delayed discharge and bed turnaround among others. Meetings specially
conducted for evaluation of patient flow performance where carried out, and most of
what is discussed there is fed by that week’s report. In redefining staffing and job
functions, the study suggested modifying the nursing supervisor position such that they
are capable of making appropriate decisions in bed assignment and staffing based on their
solid clinical knowledge. They suggest that the nurse supervisor should be able to
manage and organize situations such as at peak demand levels, and to encourage case
managers to be more involved and active in facilitating the discharge planning process.
The results of creating those measures and redefining job responsibilities showed a 40%
increase in the ability to anticipate patient discharge (3). Medical residents collaborated
in improving predictability by effectively completing patient rounds and patient discharge
orders [2]. This paper brought general promising ideas that might be applicable in many

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other hospitals, though it did not mention the tools that were used to implement those
challenging changes. Instead of redefining roles under the different job descriptions, a
new job position altogether was a later modification in efforts to smoothen patient flow.
The need to investigate more solutions allowed the emergence of the bed management
concept [3]. For that, the Bed Manager title was given to a nurse that practices the
identification of empty beds and allocation of waiting patients to them. In many cases, the
admission clerk implements that role, though not in a comprehensive manner. Admission
clerks are informed about empty beds, and they assign new patients to them, rather than
active personnel in identifying those empty beds.
The research effort did not explicitly imply the effects of having bed managers on board,
but rather was more concerned about the training that they should receive in order to be
accountable and pro-active bed managers. A fundamental portion of the bed management
process is communication.
The following needs to be done to make sure that the communication of information is
done in a way that would allow bed management to be productive:
• Keeping the lines of communication with the inpatient to make sure that any new or
upcoming issues are known and addressed right away.
• The night shift supervisor should have a report ready in the morning for the bed
manager, the medical directors, and the unit manager to insure continuity of information
and reduce double processing. The bed manager here uses this report to discuss patient
throughput issues (4).
• Discharge data should be collected as well as a scheduled admission list.
• Nurses should meet every morning allowing unit charge nurses to be familiar with the
potential discharges from other units
• Based on known discharges, possible discharges and staffing, a plan is set by charge
nurses and the bed manager for scheduled admissions with keeping a proper margin for
emergency admissions.
In contrary to most literature that describes the bed manager role or the discharge
facilitator role as a solution to patient flow problems, one of the studies reported the
resistance of nurses when a bed manager position was newly introduced in their hospital

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for a 6-months trial period [4]. The unit staff felt that discharge should be the
irresponsibility. This trial was based on the notion of making a pull process out of the
patient journey. Instead of pushing from front end, it is better to make sure that the end of
the process is clear.
The delay tool mentioned above was designed to unravel delays, and for the same
objective, modeling techniques were used to identify bottlenecks that are causing those
delays [1]. System dynamics modeling is one technique that “combines both qualitative
and quantitative aspects and aims to enhance understanding of complex systems, to gain
insights into system behaviour.” At a hospital setting, the outcome of these models can be
patient pathways, information flow and resource use - wherever dynamic activities are
taking place [5].
Focusing on Discharge through the Healthcare Perspective
Very often when examining efforts to improve Discharge piece, rather special attention is
given to the Patient flow, in some cases, by clearly mentioning it among other issueswhen
discussing bed management, communication of information or even most importantly,
delays. This section summarizes the attempts strictly focused on discharge process related
issues. By focussing on lengthy patient episodes it was found that “...four types of system
obstacles prevented timely discharge; patient care issues, financial and legal issues,
administrative issues and deficiencies in coordination between hospital and community
personnel. Such nonmedical reasons for delayed discharges suggest that better planning
may be beneficial.” [6]
Discharge planning is suffering from a lack of information, poor communication and
synchronization between acute and long-term care. Consequently, it results in disrupted
flow, blocked beds, frustrated patients and distressed unit staff. Even though the process
is never the less always completed, it can be described as “unsuccessful” in some
literature. Unsuccessful discharges can either be unplanned readmissions within an
unexpected short period of time, or delays in length of stay causing it to be greater than
what is set by standards for particular patient groups [7].

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Solutions to the persistent problems came generally under [8]:
• Improving liaison
• Planning as far ahead as possible
• Improving communication
• Creating and maintain clear and concise documentation.
• Improving patient assessment.
Research literature is available that expresses and investigates those matters collectively
or separately. This section of the chapter will try to cover most of them that fall under
efforts conducted by professionals internal to the healthcare discipline.
“Planning cannot begin too early; planning can certainly begin too late. Planning that is
not flexible or modifiable as new information comes to light is as bad as no planning
atall” [18]. In the general concept of planning, this is very convincing, and for discharge
e-planning in particular this is the recommendation as found in many papers [9][10][11].
Evaluating the risk that the patient might need increased planning efforts for discharge is
a key element in preparing for what to do. Doing it early is even better. A study that
targeted 36 patients split them into an “early intervention group” and another
“control”group. The difference between the groups is that the planning process started at
day 3from admission for the early intervention group and after 9 days for the control
group. It concluded that early planning reduced readmissions and facilitated discharge
[9].
This risk evaluation can be brought about using tools created by healthcare professionals
at the hospital, and a scoring scheme can be identified and used as a base for decision
making. Also, it can be done by separately involving all necessary allied healthcare
professionals such as social workers, physiotherapists and occupational therapist, but
again; the earlier the better. Physicians’ predictions have been found to be valuable
enough by themselves. Some of the factors are backed up by rigorous studies and som
eare not. The following factors were considered helpful in deciding whether to involve
social workers:
• Age and gender.
• Decreased mental function

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• Inability to ambulate
• Presence of incontinence.
• Presence of chronic conditions.
• Complexity of social situations.
• Complexity of illness.
By estimating and accounting for the factors above, the need for social work involvement
is identified. Getting the requirements fulfilled early enough results in decreased length
of stay [11].
Older people come to the hospital with generally more complex health situations that not
only require more complex treatment, but certainly bigger discharge planning effort.
Many times they stay for lengthy periods beyond acute medical care [11]. One scoring
technique that was created for this matter is the Discharge Planning Questionnaire DPQ
[12]. The questions can come under the following: activities of daily living (ADL),
instrumental activities of daily living (IADL), and social support and environment issues.
Scoring for both categories would come out as: 0 = functional independence,
1=assistance needed, 1.1 = do not know, 2 = functional dependence. According to the
score, the nurse would communicate with social workers and the physician
[13].Interacting with social services is not an easy task by itself; delays and discrepancies
might occur. It is important not only to know what the nurses and the physicians need
from the social workers, but for them to give the social workers what they need so that
both sides have things organized in the best interest of the patient. Through another
attempt a computer software was developed to manage discharge - and more importantly
to ease the sharing of information [14].
It enabled:
• Capturing data relevant for discharge liaison including referral, assessment and
discharge details that are in the hospital patient system.
• Nurses to send electronic referrals direct from the ward or from the discharge liaison
office to the social services offices at any time of the day or night.
• The extraction of the most recent status for each patient from the hospital patient system
to keep social services up to date. Instant access to information such as patients’ next of
kin, mobility mental state and any changes in discharge date is possible.

25
• Social services to maintain their own memo data in relation to a particular case,
e.g. social services registration number, or details of which social worker is dealing with
the case.
Some of the attempts to address the discharge problem in the United Kingdom were
through creating workbooks and setting acts [1]. The Hospital Discharge Planning
Workbook [15], published in 1994 was written to highlight the full nature of the process
and to ensure that patients are discharged at the right time and with the right
arrangements. The National Service Framework (NSF)’s for Older People 2001 [16] and
Discharge from Hospital: Pathway, Process and Practice Workbook 2003 [17] were also
prepared for the same reason. The Community Care (Delayed Discharges) Act in
2003[18] stated the responsibilities for making discharge arrangements so that there
would be less disagreement about who is responsible for what. Such workbooks and acts
have not been published for the Canadian healthcare system.
Hospitals are trying to meet discharge goals and patients and families do feel this
pressure creating anxiety in the decision making process of discharge destinations [19].
Bridging Between Industrial Engineering and Healthcare in Examining Discharge
“Industrial processes provide a benchmark for the healthcare sector in the improvement
of production efficiency, assuming it can be achieved without sacrificing clinical quality
[20]”. In design and operations management of healthcare systems the patient-oriented
approach is widely adopted. This means, that each patient is treated as a project and is
managed just like project-oriented companies are managed. Work in Process (WIP) from
industry is translated to Patient in Process (PIP) in the healthcare world. The start to
finish of a PIP is called a patient episode [20]. When patient episodes vary greatly,
effective case management should be combined with process based approaches [21].
Effectiveness was tied to time by the Japanese in the 1980’s. And by doing things with
less time a competitive advantage is achieved. This gave birth to the principle of Time
Based Management (TBM). By applying TBM to patient processes, the patient episode
can be divided into a series of time categories [20]:

26
• Diagnostic and care time, including:
Diagnostic time of collecting and analysing diagnostic information.
Active care time of clinical interventions.
Passive care time when resources are not used actively, but the patient isunder
observation in inpatient units.
Superfluous time which is defined as medical diagnostic and care that is not based on
official care process recommendation.
• Administrative time that includes all the non-medical tasks related to a patient episode
• Waiting time including (15):
Positive waiting time where the patient’s condition is likely to improves spontaneously.
Passive waiting time where the patient condition is stable and delay does not influence
either the patient’s medical condition or the prognosis of the success of medical
operation.
Negative waiting time that indicates that the patient’s condition is likely to deteriorate
and they may require more complex procedures. It could also be that the prognosis of
patient’s (medical) condition after care episode is less favourable.
From a study that utilized this methodology, discrepancies in the current discharge
planning processes where found to be [22]:
• Patient issues: a tendency for them to change their minds regarding needs for discharge
at the last minute, and their being unaware of progress with discharge plans, resulting in
their unhappiness with what is being proposed.
• Communication difficulties: including telecommunication problem, delaying referral to
occupational therapists or physiotherapists.
• Documentation problem: lack or poor documentation from other healthcare
professionals following review of a patient for discharge.
• Time pressures: including nurses being too busy in dealing with patients’ physical
problems which in turn delays timely progressing of the discharge planning process, over
loaded nurses forgetting to communicate with community staff and junior doctors having
to wait for their seniors to authorise discharge.

27
• Policy issues: uncertainly regarding changes in practice resulting from constantly
changing government policies and local authority procedures. Also, nurses at the center
of the discharge process were not aware of social care policies and criteria that affect
their clinical area.
• Others: policy issues, lack of support from the patient’s family, patient needs regarding
discharge difficult to determine, and equipment needed in the patient Ideas for
improvement included the need for greater cooperation between all that is involved
including the patient, and also the adoption of effective communication technologies
[22]. The act of communicating with the patient, the family and the long term care
facilities does not seem to be sufficient. The quality in communicating with them
determines how successful this act would be.
The paper mentioned the adoption of what was called “The Model for Improvement”,
created by the Institute of Heath Care Improvement [13]. It requires a response to the
questions: What are we trying to accomplish? How will we know that a change is an
improvement? And what changes can we make that will result in an improvement? The
questions should come in conjunction with the Plan-Do-Study-Act [23]. While proposed
the methodology the use of those techniques and tools was not evident.
The two-part analysis strategy is translated by a flowchart part and a spreadsheet part
[24]. The flow chart depicted the stages the patient goes though from admission to
discharge, and was prepared through a team brainstorming session confirmed by
conceptual framework that was guiding the process. The chart clearly identified a very
important milestone in the process which was called “functionally and medically stable
for discharge”. Though a very critical point in the patient episode in general and for
discharge planning in particular, this point in time was not commonly documented and
written in the patient chart at the moment it was identified. In the flow chart an ideal path
was set by the team. It was sketched with sub-paths branching out from it illustrating
possible delays. The delays were categorized under:
• New or recurrent health issues requiring further assessment or treatment.
• Conflict or resistance to the possibility of discharge from patient or family.
• Late identification of discharge issues.
• Waiting for placement.

28
The “teach-back” process is a comprehensive, interdisciplinary, evidence-based strategy
which can empower nursing staff to verify understanding, correct inaccurate information,
and reinforce medication teaching and new home care skills with patients and families.
The Evidence-Based Practice Fellows at Children's Hospital of Wisconsin designed and
implemented an educational intervention for nurses on “teach-back” which encouraged
nurses to check for patients' and caregivers' understanding of discharge instructions prior
to discharge. Pre and post survey data collected from nurses specifically demonstrated the
positive effect “teach-back” could have on preventing medication errors while also
simultaneously identifying areas for further study. (25)
Strategies for improving the patient discharge process have a beneficial effect on many
hospital activities. The main objective of this research was to analyse the discharge
process at Kashani Hospital in Esfahan, Iran in the fall of 2004. This study took the form
of a case study in which data were collected by questionnaire, observation and checklist.
SPSS and Operations Research (O.R.) methods were used to analyse data. The results
showed that the average time for patients to complete the discharge process was 4.93
hours. The hospital personnel involved identified the main factors affecting average
waiting time as patients’ financial problems and distance between different wards. The
longest hospital stay was 5.7 days in the Neurology ward. Findings showed there was a
queue in completing medical records at the nursing and medical equipment stations. (26)
Discharging older patients from hospital to care at home presents considerable challenges
for those concerned about the current mandate of quality management. A great many
professionals with different priorities and organizational commitments are involved. The
policies and procedures of at least two agencies, a hospital and a home care agency, play
a role hi shaping the whole process. The purpose of this study was to explore and
describe factors other than medical condition and treatment which shaped the quality of
the discharge experiences of older patients. Qualitative research methodology was used to
document the discharge process from the perspective of 12 rural and nine urban patients,
and a purposeful sample of 22 family caregivers and 117 professionals involved in then
care. As well, 24 agency administrators with an overview of related policies and
procedures provided data. Findings provide an in depth description of the different
implementation approaches and related quality issues in rural and urban settings. Quality

29
management was undermined by role confusion, compromised and overly zealous pursuit
of efficiency, fragmented work, variable physician practice style, and communication and
coordination problems. Several readily implemented solutions to these problems are
recommended. The Implications of the more difficult leadership challenges related to
achieving reasonable efficiency and maintaining a humane orientation hi the complex
care system are addressed. (27)
One ethnographic study was undertaken in an Australian metropolitan tertiary hospital
that had a 14-bed level 3 intensive care unit. Intensive care and acute care unit medical
and nursing staff, and other hospital staff who were involved in the intensive care patient
discharge process participated in this study. A total of 28 discharges were observed, and
56 one on one interviews were conducted. Findings were three patient activity systems
were identified: intensive care patient discharge activity, acute care unit accepting patient
activity, and hospital bed management activity. Analysis of the interactions among these
activity systems revealed conflicting objects (goals), communication breakdowns, and
teamwork issues. Conclusion of the study was Discharge delay was found to be a
significant problem, which was associated with limited acute care unit bed availability.
Strategies to improve acute care unit bed availability are needed. Routine after-hours ICU
discharge could raise patient safety concerns which need to be considered. All team
members’ input in discharge decision making should be encouraged. Problems identified
in clinical handover call for actions to change the handover practice. Activity theory
successfully guided the study by providing a practical and descriptive framework for the
study, facilitating the understanding of the interrelationships among the activity systems.
(28)
The study reported here is part of a larger thesis exploring critical care nurses’
perceptions and understanding of the discharge planning process in the health care system
in the state of Victoria, Australia. As part of the survey participants were asked to define
discharge planning as it related to the critical care environment in which they worked.
Method was utilising an exploratory descriptive approach, 502 Victorian critical care
nurses were approached to take part in the study. The resultant net total of 218
participants completed the survey, which represented a net response rate of 43.4%. The
data were analysed using quantitative and qualitative methodologies. Findings were three

30
common themes emerged. A significant number of participants did not believe that
discharge planning occurred in critical care, and therefore, thought that they could not
provide a definition. There was uncertainty as to what the discharge planning process
actually referred to in terms of discharge from critical care to the general ward or
discharge from the hospital. There was an emphasis on movement of the patient to the
general ward, which was considered in three main ways by first, getting the patient ready
for transfer; Second, ensuring a smooth transition to the ward and third, transfer of the
patient to the ward often occurred because the critical care bed was needed for another
patient. The research concluded that at a nursing level, the discharge planning process is
not well understood and some degree of mutual exclusivity still remains. There is a need
for further education of critical care nurses with regard to the underlying principles of the
discharge planning process. (29)
This paper studied the barriers to successful discharge practices in a general hospital
medical service. Design was Focus groups with health professionals and in depth
interviews with patients were used to identify and explore themes arising from the
concept of a good discharge. Thematic analysis was undertaken to identify and link the
concepts highlighted. Results: Five major themes emerged from the focus group data
including; 1) Communication, 2) Teamwork and Roles, 3) The process of discharge and
co-ordination 4) Resources, and 5) Time. Patients discussed their experiences, concerns
and lack of knowledge, of the discharge process. Researchers concluded in this pape that
the barriers to influencing the discharge process were shown to be complex and
interrelated. The way, in which teams work together is an important factor, which appears
not to have been addressed in research into discharge interventions. No single strategy or
intervention is likely to be successful in changing discharge practice. Future research to
improve discharge should focus on combinations of strategies that target local barriers at
the level of the individual, team and organization. (30)
The 1990 NHS Community Care Act established a requirement for hospital discharge
policies and procedures in the United Kingdom (UK) to be developed in collaboration
with local government authorities in order to ensure supported discharge for those in
need. One research aimed to the study reported in this paper was to track decisions about

31
hospital discharge in relation to outcomes for a sample of medical patients and their
carers, identified as at risk of experiencing unsuccessful discharge processes. Methods
themed unstructured interviews were conducted in three different hospitals with 30
patients identified as at risk of unsuccessful discharge and their carers pre- and post
discharge. Hospital, community and social care staff involved in the care of the patient
were also interviewed.
Findings - Patients and carers were constantly negotiating their social roles, seeking to
juggle appropriate identities and limited resources to maintain their own and each others’
dignity and quality of life. When the negotiation process was destabilized (for example,
by exacerbation of chronic disease, withdrawal of some resource, or the experience of
additional stressors – not necessarily health-related), then either or both parties sought a
way out. In all the cases examined the result was admission to hospital – usually, but not
always, mediated by community professionals. It concluded that the effective discharge
of patients from hospital needs to move from a functional focus on symptom
management to a negotiation of quality of life that seeks to promote health for all parties
involved. (31)
One study in literature so far aimed to understand the perspective of hospital based health
professionals with regard to preparing patients for discharge from an acute hospital in
England. Background. The hospital experience in England over recent years is
characterised by increasing admission rates and decreasing length of stay. Legislation and
policy initiatives have also focussed upon the need to reduce delayed discharges.
Discharge preparation is known to be a complex intervention with multiple obstacles
within and outside of the hospital setting. Design was Qualitative. Methods included
posters displayed within a hospital asking health professionals to take part in a focus
group. Maximum variation, in terms of job titles, was sought for within the sample. Focus
groups were held in December 2006. Six senior members of staff divided into pairs to run
them. All groups were taped and transcribed verbatim and analysed using a framework
approach. Results were three focus groups were conducted, which involved 11 nurses, 15
allied health professionals, five social workers and one doctor. Analysis identified the
following themes and sub themes:

32
1 pressures on staff:
• Keeping patients in hospital vs. getting them out;
• Striving for flexibility within a system;
• A paucity of intermediary provision.
2 Casualties arising from conflicting pressures:
• Professionals losing their sense of professionalism;
• Patients being ‘systematised’.
The research concluded: Pressures described during focus groups stemmed from five
main sources: external targets placed upon the system, internal hospital inflexibility and
poor communication, the dominance of the medical model of care, a desire to address the
complex needs of individuals and a lack of community services. Staff felt themselves to
be victims of these competing pressures and that many of the solutions were beyond their
influence. Staff described the dehumanising effect of sometimes having to ignore patient
concerns, wishes and choices. Relevance to clinical practice. Understanding of the
pressures surrounding discharge could inform relevant service improvements. (32)

33
Chapter III
PROFILE OF ORGANISATION

34
Apollo Hospitals is Asia's largest and most trusted healthcare group and its presence
includes 9,215 beds across 64 Hospitals, 2,200 Pharmacies, over 90 Primary Care and
Diagnostic Clinics, 110 plus Telemedicine Centers and 80 plus Apollo Munich Insurance
branches panning the length and breadth of the Country. As an integrated healthcare
service provider with Health Insurance services, Global Projects Consultancy capability,
12 plus medical education centers and a Research Foundation with a focus on global
Clinical Trials, epidemiological studies, stem cell & genetic research, Apollo Hospitals
has been at the forefront of new medical breakthroughs with the most recent investment
being that of commissioning the first Proton Therapy Center across Asia, Africa and
Australia in Chennai, India.
Focus on clinical excellence has led to 8 JCI Accreditations and 11 NABH
Accreditations.
Centers of Excellence
 Busiest solid organ transplant program in the world since 2012
 Best surgical team of the year awarded by BMU for robotic surgery in India
 First ever reported surgical separation of pygopagus twin boys
 Heart transplant in a 65 year-old patient
 Joint replacement surgeries on patients aged over 100 years
It was in 1983, that Dr. Prathap C. Reddy made a pioneering endeavour by launching
India's first corporate hospital - Apollo Hospitals in Chennai. Now, as Asia's foremost
and trusted integrated healthcare services provider, the group's presence includes
Hospitals, Pharmacies, Primary Care & Diagnostic Clinics and Telemedicine units across
10 countries, Health Insurance Services, Global Projects Consultancy, Colleges of
Nursing and Hospital Management and a Research Foundation with focus on Global
Clinical Trials, epidemiological studies, stem cell & genetic research. Today, Apollo
Hospitals are consistently ranked amongst the best hospitals globally for advanced
medical services and it has touched the lives of over 45 million patients, from 121
countries.

35
Over the past three decades, Apollo Hospitals' transformative journey has forged a legacy
of excellence in Indian healthcare. One of Apollo's significant contributions has been the
adoption of clinical excellence as an industry standard. Alongside, its ethos rests on the
pillars of technological superiority, a warm patient - centric approach, affordable costs
and an edge in forward-looking research and academics.
Apollo Hospitals was the first to invest in the pre-requisites that led to international
Quality accreditation like the Joint Commission International and Indraprastha Apollo
Hospitals was the first hospital in India to be accredited with this gold standard in 2006.
An early adopter of technology, Apollo Hospitals was one among the first few in the
world to leverage technology to build integrated healthcare delivery models, which
facilitate seamless healthcare delivery through electronic medical records, hospital
information systems and telemedicine-based outreach initiatives. Another critical
manifestation of widespread technology has been the amazing advancement in medical
equipment and Apollo has repeatedly pioneered the introduction of such innovations in
India. Soon the country will have its very first Proton Beam Therapy centre at Apollo
Cancer Hospitals.
Tender Loving Care (TLC) was at the core of Apollo Hospitals' model of care and it
continues to be the magic that inspires hope, warmth and a sense of ease in the patients.
Processes are relentlessly improved upon to ensure maximum patient-centricity.
Apollo Hospitals has taken the spirit of leadership well beyond business metrics. It has
embraced the onus of keeping India, healthy. Taking cognizance of the undeniable fact
that India is reeling under the onslaught of Non Communicable Diseases (NCDs), Apollo
Hospitals has assumed the responsibility to educate and influence mind set of the people
of India. Increased focus on tactical initiatives like personalized preventive healthcare
bears testimony to this new thrust. On January 1, 2015, Apollo Hospitals declared war on
NCDs, and is leading the entire healthcare fraternity into this battle. The Billion Hearts
Beating Foundation was envisioned by Dr. Reddy to keep India heart healthy and over
half a million people have taken a pledge on www.billionheartsbeting.com
Apollo Hospitals has always strongly believed in social initiatives that help transcend
barriers. In keeping with this, the group has started several impactful programs.

36
SACHi (Save a Child's Heart Initiative) - a community service initiative was introduced
with the aim of providing quality paediatric cardiac care to children from underprivileged
sections of society suffering from heart diseases. Apollo also runs the SAHI (Society to
Aid the Hearing Impaired) and the CURE Foundation, focused on cancer screening, cure
and rehabilitation for those from a financially challenged background.
Apollo Hospitals, Nashik
Apollo Hospitals, Nashik, is a NABH Accreditated Hospital, 118 bedded unit situated on
a scenic campus. It has more than 20 speciality with some of the best Doctors in Nashik.
Apollo Hospitals, Nashik is spread across 1,25,000 Sq. Ft of land near Panchavati, a holy
place near Nashik. Apollo's mission of bringing healthcare of international standards
within the reach of every individual has inspired the group to start this facility at Nashik.

37
Highlights:
 A Multi-disciplinary Intensive Care Unit which has successfully treated more than 100
Neurology patients in the initial month of the launch.
 Emergency & Trauma Care: Round-the-clock facility to manage any medical emergency
with an ambulance designed as a mobile ICU, supported with an emergency call no 1066.
Contact
Apollo Hospitals, Swaminarayan Nagar, Near Lunge Mangal Karyalaya, New Adgaon
Naka, Panchavati, Nashik – 422003. Maharashtra
+91-253 2510 250 / 350 / 450 / 550 / 750
Emergency Contact: -1066+91-253 2510350
VISION
Apollo’s Vision for the next phase of development is to “touch a billion lives”
MISSION
“Our Mission is to bring healthcare of international standards within the reach of
every individual. We are committed to the achievement and maintenance of
excellence in education, research and healthcare for the benefit of humanity.”

38
Chapter IV
RESEARCH DESIGN
&
METHODOLOGY

39
Methodology
1. Nature of Data
In accordance with the above objective primary data were collected from the
Hospital during winter internship training.
 Primary data were collected by:
 Day to Day interaction with hospital staff on nursing station in ward.
 Day to day interaction with the ward floor executive
 Day to day interaction with nurse incharge
 Day to day interaction with pharmacist and typist
 Secondary data were collected from the hospital and others journals and
books related to the topic referred.
 Standard operating procedures (SOP’s)
 Organisation’s discharge manual
 In Patient’s guide
 Organisation’s Patient discharge policy.
2. Sample Size
There are 4 types of bill payment options :
_ Self Paid
_ TPA
_ Employers Paid
_ CGHS
Inclusion in the Study _ Self Paid Patients stayed more than 48 Hours in the
Hospital. A sample size of 40 patients in the process of discharge from hospital,
who are self paying/ out of the pocket paying hospital bill were arbitrarily
selected, observed and tracked during the tenure of training period.
Exclusion from the study _ Day Care Patients and other mode of payments.

40
3. Method for Data collection
Observation and interaction with Hospital Personnels.
Stratified Random
4. Research Design:
 The study is a process mapping with Observation.
 It is a qualitative and quantitative research.
Qualitative Research is primarily exploratory research. It is used to gain an
understanding of underlying reasons, opinions, and motivations. It provides
insights into the problem or helps to develop ideas or hypotheses for potential
quantitative research. Qualitative Research is also used to uncover trends in
thought and opinions, and dive deeper into the problem. Qualitative data
collection methods vary using unstructured or semi-structured techniques. Some
common methods include focus groups (group discussions), individual interviews,
and participation/observations. The sample size is typically small, and
respondents are selected to fulfill a given quota.
Quantitative Research is used to quantify the problem by way of generating
numerical data or data that can be transformed into useable statistics. It is used to
quantify attitudes, opinions, behaviors, and other defined variables – and
generalize results from a larger sample population. Quantitative Research uses
measurable data to formulate facts and uncover patterns in research. Quantitative
data collection methods are much more structured than Qualitative data collection
methods. Quantitative data collection methods include various forms of surveys –
online surveys, paper surveys, mobile surveys and kiosk surveys, face-to-face
interviews, telephone interviews, longitudinal studies, website interceptors, online
polls, and systematic observations.

41
Limitations of study
Following are the Limitations of the Study
 The Study is focused on one particular hospital located in Nashik, Maharashtra.
 The Study is focused on In Patient Department only.
 The Study period is two months only.
 Only self paid patients were taken into consideration which is actually a smaller
portion of overall patient population in the Hospital.

42
Chapter V
DATA PRESENTATION
&
ANALYSIS

43
Discharge Process in Apollo Hospital – Flow Chart
1
• Consultant's Intimation of patient discharge
2
• Discharge Summary Prepared
3
• Draft Checked
4
• Discharge Summary Finalised
5
• Drugs Returned to Pharmacy
6
• Drugs Returned Acknowledged by Pharmacy
7
• Discharge Initiated
8
• Activity Card send to billing
9
• Bill Generated
10
• Patient Settlement of bill
11
• Patient discharged (Check out)
Phase
I
Phase
II

44
Guidelines for the discharge of in-patients from Apollo Hospital
 All patients leaving the organization are provided with Discharge summary
including patients leaving against medical advice. Discharge procedures shall be
followed to ensure patients are discharged effectively and efficiently, allowing
for optimal utilization of available resources. The discharge shall be planned at
the time of admission.
 An authorized hospital discharge shall only be made by an authorized, written
order wherein a consultant advises discharge on satisfaction with the patient’s
condition. Discharge information shall be given to the registrar/resident/staff
nurse/ward secretary. Discharge summary shall be prepared by the resident and
approved by the consultant. However, a patient shall also have the right to obtain
discharge against Medical advice
 The physician shall be required to document discharge instructions in the
patient’s medical record at the time of anticipated discharge. The final Discharge
Summary should be signed by the Consultant and the resident, before handing it
over to the patient. In any situation the discharge summary will not be dispatch
without the treating consultant signature.
 The In charge Doctor shall be the responsible person to ensure compliance with
this policy.
 In case of patients being in hurry, prescription written by the Consultant
/Registrar/ Resident shall be made available immediately and the discharge
summary signed by the Consultant shall be sent to the patient by post. A copy of
the discharge summary shall also be filed in the patients’ medical record.
 The Discharge summary shall include- the reasons for admission, significant
findings, diagnosis and patient’s condition at discharge.
 It shall also include the investigation results, important laboratory results, the
medications given and the procedure performed (if any).
 It shall include the follow up advice, medications and other instructions and how
to obtain urgent care in an understandable manner
 In case of death the same shall include the cause of death.

45
There are three types of Discharge:
 Discharge on advice
 Discharge on request
 Discharge against Medical Advice (DAMA)
Discharge on advice:
 The consultant shall advise discharge on satisfaction with the patient’s condition.
Discharge information shall be give to the resident / registrar / staff nurse/ ward
secretary. Discharge summary shall be prepared by the resident in writing and
approved by the consultant with signature. Consultants shall sign all discharge
summaries / discharge briefs / death summaries, stating the date.
 The discharge medications shall be checked by the prescription audit team.
 All discharge summaries / discharge briefs / death summaries, after being checked
and signed by the treating consultant and shall be handed over to the patient or
next of kin, where applicable.
 The nurse shall be responsible for completing the discharge checklist. The
Registrar/ Resident doctor shall explain the discharge summary and discharge
medication to the patient. Patient / family understanding shall be documented on
the discharge checklist by obtaining the patient/family signature.
 A copy of the discharge summary shall also be made available to the physician
responsible for the patient’s continuing care.
 The floor patient care provider shall be responsible for monitoring that all
discharge summaries / discharge briefs / death summaries are signed by the
consultants and complete in all respects.

46
Discharge on request:
 In case the patient / attendant / request for discharge while further treatment is
advised due to financial / any other reasons, the consultant shall prepare a clinical
case summary of the patient.
 Discharge formalities shall be completed.
 A copy of investigation reports and clinical case summary shall be handed over to
the attendants after billing procedure is completed.
Discharges/Leave Against Medical Advice (DAMA):
The process for patient leaving the hospital on DAMA shall be the same as discharge on
advice. However consent from patient is recorded on DAMA form.
The patient’s readiness for discharge shall be determined by his/her treating doctor and
when appropriate, includes the family in the discharge planning.
The content of discharge summary.
It is a responsibility of Medical Administration, Treating Doctor or his / her team
member or DMO and PRE to implement and comply with this procedure.
Procedure
 Discharge Summary is to be provided to the patients at the time of discharge.
 Patient’s medical record contains a copy of Discharge Summary or Death
Summary (when possible or retained in soft copy in server or CD).
Content of the Discharge Summary to include:
 Patient's name
 Unique identification number
 Date of admission and date of discharge
 Reason for admission or chief complaints.
 Significant positive and negative points of history and findings.
 Diagnosis.

47
 Patient condition at the time of discharge.
 Investigation results.
 Procedure(s) performed.
 Medications.
 Other treatment given.
 Follow up advice, medications and other instructions.
 When and how to obtain urgent care.
 Contact numbers of doctors (for urgent care).
 Cause of death (in case of death summary).
Preparation of Discharge Summary:
 Once the treating doctor declares that the patient “Fit to be Discharged” (after
discussing with patient / patient attendant), the Executive coordinates with RMO /
treating doctor (or) his / her team member for the preparation of Discharge
Summary.
 RMO / Treating doctor (or) his / her team member to prepare discharge summary
in specified format based on the information from patient and Inpatient Record.
 The draft is prepared and forwarded to treating doctor or his / her team member
for necessary corrections or authorization.
A sample size of 40 patients in the process of discharge from hospital, who are self
paying/out of the pocket paying hospital bill were arbitrarily selected, observed and
tracked
Following onwards the next page is the data regarding the subject:-

48
Turnaround time from Discharge Initiation to Bill Generation
Sl No
Pt.'s IP
Number Discharge Initiation Bill Generated
TAT Billing
(Minutes)
19 NSKIP7503 10-02-2017 00:38 10-02-2017 00:40 2.13333334
1 NSKIP7487 24-02-2017 16:51 24-02-2017 16:56 4.183333326
5 NSKIP7566 16-02-2017 19:57 16-02-2017 20:09 11.38333333
8 NSKIP7453 15-02-2017 12:12 15-02-2017 12:24 11.8
33 NSKIP7416 03-02-2017 13:43 03-02-2017 13:55 12.33333334
35 NSKIP7404 03-02-2017 12:57 03-02-2017 13:09 12.48333334
37 NSKIP7421 02-02-2017 17:08 02-02-2017 17:22 14
28 NSKIP7467 07-02-2017 16:39 07-02-2017 16:53 14.20000001
30 NSKIP7403 06-02-2017 12:22 06-02-2017 12:42 19.53333334
24 NSKIP7483 08-02-2017 20:08 08-02-2017 20:30 21.58333334
26 NSKIP7445 08-02-2017 12:30 08-02-2017 12:56 26.21666668
4 NSKIP7564 17-02-2017 11:14 17-02-2017 11:43 28.6
3 NSKIP7522 19-02-2017 11:01 19-02-2017 11:32 31.31666666
6 NSKIP7513 16-02-2017 13:55 16-02-2017 14:32 36.76666666
17 NSKIP7496 09-02-2017 16:46 09-02-2017 17:24 38.28333332
21 NSKIP7456 09-02-2017 09:23 09-02-2017 10:04 41.46666667
36 NSKIP7405 03-02-2017 08:52 03-02-2017 09:34 41.75000001
27 NSKIP7426 08-02-2017 12:23 08-02-2017 13:06 43.08333334
16 NSKIP7428 10-02-2017 10:05 10-02-2017 10:50 44.91666667
25 NSKIP7448 08-02-2017 11:01 08-02-2017 11:52 50.63333334
18 NSKIP7492 09-02-2017 17:15 09-02-2017 18:08 53.34999999
2 NSKIP7568 21-02-2017 10:58 21-02-2017 11:57 58.96666667
15 NSKIP7429 10-02-2017 12:00 10-02-2017 13:01 61.45
22 NSKIP7458 09-02-2017 09:10 09-02-2017 10:18 67.81666667
38 NSKIP7569 27-02-2017 12:50 27-02-2017 14:01 71
32 NSKIP7401 03-02-2017 08:06 03-02-2017 09:20 74.48333333
9 NSKIP7548 14-02-2017 16:45 14-02-2017 18:15 90.35
31 NSKIP7413 03-02-2017 03:55 03-02-2017 05:25 90.63333333
23 NSKIP7411 09-02-2017 10:11 09-02-2017 11:44 92.58333333
7 NSKIP7549 15-02-2017 11:08 15-02-2017 12:45 97.48333333
39 NSKIP7465 08-02-2017 10:20 08-02-2017 12:05 105
20 NSKIP7431 09-02-2017 10:00 09-02-2017 11:49 109.0333333
13 NSKIP7500 14-02-2017 09:26 14-02-2017 11:21 115.6166667
14 NSKIP7457 14-02-2017 09:32 14-02-2017 11:30 118.1833333
12 NSKIP7442 14-02-2017 09:23 14-02-2017 11:27 124.0833333
34 NSKIP7399 03-02-2017 10:03 03-02-2017 13:40 217.5333333
10 NSKIP7482 12-02-2017 08:54 12-02-2017 12:34 220.2
11 NSKIP7491 14-02-2017 12:18 14-02-2017 18:53 394.7833333
40 NSKIP7415 06-02-2017 09:51 06-02-2017 16:49 418
29 NSKIP7447 07-02-2017 09:51 07-02-2017 16:49 418.3333333
Within ½ an hr – Maximum i.e. 12 out of 40 took Turnaround time from Discharge
Initiation to Bill Generation

49
Turn around Time from Bill Generation to Bill Paid
Sl
No
Pt.'s IP
Number Bill Generated Patientbill paid
TAT patientbill
settlement(Minutes)
11 NSKIP7491 14-02-2017 18:53 14-02-2017 18:54 1
29 NSKIP7447 07-02-2017 16:49 07-02-2017 16:53 3
40 NSKIP7415 06-02-2017 16:49 06-02-2017 3
28 NSKIP7467 07-02-2017 16:53 07-02-2017 16:58 4
33 NSKIP7416 03-02-2017 13:55 03-02-2017 14:00 5
14 NSKIP7457 14-02-2017 11:30 14-02-2017 11:37 6
17 NSKIP7496 09-02-2017 17:24 09-02-2017 17:31 6
23 NSKIP7411 09-02-2017 11:44 09-02-2017 11:51 6
35 NSKIP7404 03-02-2017 13:09 03-02-2017 13:18 9
3 NSKIP7522 19-02-2017 11:32 19-02-2017 11:46 14
24 NSKIP7483 08-02-2017 20:30 08-02-2017 20:44 14
5 NSKIP7566 16-02-2017 20:09 16-02-2017 20:24 15
1 NSKIP7487 24-02-2017 16:56 24-02-2017 17:15 19
7 NSKIP7549 15-02-2017 12:45 15-02-2017 13:09 23
39 NSKIP7465 08-02-2017 12:05 08-02-2017 12:28 23
27 NSKIP7426 08-02-2017 13:06 08-02-2017 13:31 25
9 NSKIP7548 14-02-2017 18:15 14-02-2017 18:42 27
30 NSKIP7403 06-02-2017 12:42 06-02-2017 13:13 31
18 NSKIP7492 09-02-2017 18:08 09-02-2017 18:41 33
34 NSKIP7399 03-02-2017 13:40 03-02-2017 14:14 33
4 NSKIP7564 17-02-2017 11:43 17-02-2017 12:17 34
37 NSKIP7421 02-02-2017 17:22 02-02-2017 18:06 44
19 NSKIP7503 10-02-2017 00:40 10-02-2017 01:29 48
16 NSKIP7428 10-02-2017 10:50 10-02-2017 12:18 68
36 NSKIP7405 03-02-2017 09:34 03-02-2017 10:44 70
6 NSKIP7513 16-02-2017 14:32 16-02-2017 15:56 84
2 NSKIP7568 21-02-2017 11:57 21-02-2017 13:23 86
38 NSKIP7569 27-02-2017 14:01 27-02-2017 15:29 88
22 NSKIP7458 09-02-2017 10:18 09-02-2017 12:15 117
13 NSKIP7500 14-02-2017 11:21 14-02-2017 13:24 123
32 NSKIP7401 03-02-2017 09:20 03-02-2017 11:37 137
26 NSKIP7445 08-02-2017 12:56 08-02-2017 15:40 164
8 NSKIP7453 15-02-2017 12:24 15-02-2017 15:01 167
25 NSKIP7448 08-02-2017 11:52 08-02-2017 14:40 168
20 NSKIP7431 09-02-2017 11:49 09-02-2017 15:13 182
21 NSKIP7456 09-02-2017 10:04 09-02-2017 13:10 186
15 NSKIP7429 10-02-2017 13:01 10-02-2017 16:17 196
12 NSKIP7442 14-02-2017 11:27 14-02-2017 15:01 214
10 NSKIP7482 12-02-2017 12:34 14-02-2017 19:12 398
31 NSKIP7413 03-02-2017 05:25 03-02-2017 18:21 776
Within ½ an hr – Maximum i.e. 17 out of 40 took Turnaround time from Discharge
Initiation to Bill Generation

50
Turnaround time of patient Bill Paid to Patient Physically left the Hospital
Sl No
Pt.'s IP
Number Patientbill paid Patientdischarged TAT
16 NSKIP7428 10-02-2017 12:18 10-02-2017 12:30 11.93
2 NSKIP7568 21-02-2017 13:23 21-02-2017 13:35 12.38
34 NSKIP7399 03-02-2017 14:14 03-02-2017 14:27 13.93
31 NSKIP7413 03-02-2017 18:21 03-02-2017 18:38 16.98
8 NSKIP7453 15-02-2017 15:01 15-02-2017 15:21 20.43
35 NSKIP7404 03-02-2017 13:18 03-02-2017 13:41 22.22
33 NSKIP7416 03-02-2017 14:00 03-02-2017 14:28 27.95
27 NSKIP7426 08-02-2017 13:31 08-02-2017 13:59 28.13
10 NSKIP7482 14-02-2017 19:12 14-02-2017 19:43 30.52
13 NSKIP7500 14-02-2017 13:24 14-02-2017 14:01 37.05
11 NSKIP7491 14-02-2017 18:54 14-02-2017 19:42 48.05
21 NSKIP7456 09-02-2017 13:10 09-02-2017 14:00 49.33
15 NSKIP7429 10-02-2017 16:17 10-02-2017 17:07 49.68
12 NSKIP7442 14-02-2017 15:01 14-02-2017 15:54 53.10
39 NSKIP7465 08-02-2017 12:28 08-02-2017 13:24 56.00
38 NSKIP7569 27-02-2017 15:29 27-02-2017 16:27 58.00
20 NSKIP7431 09-02-2017 15:13 09-02-2017 16:11 58.13
17 NSKIP7496 09-02-2017 17:31 09-02-2017 18:35 64.53
40 NSKIP7415 06-02-2017 06-02-2017 17:58 65.00
29 NSKIP7447 07-02-2017 16:53 07-02-2017 17:58 65.35
23 NSKIP7411 09-02-2017 11:51 09-02-2017 12:57 66.53
30 NSKIP7403 06-02-2017 13:13 06-02-2017 14:40 86.25
3 NSKIP7522 19-02-2017 11:46 19-02-2017 13:13 86.50
4 NSKIP7564 17-02-2017 12:17 17-02-2017 13:49 91.63
14 NSKIP7457 14-02-2017 11:37 14-02-2017 13:12 95.27
22 NSKIP7458 09-02-2017 12:15 09-02-2017 13:59 104.90
28 NSKIP7467 07-02-2017 16:58 07-02-2017 19:06 128.48
36 NSKIP7405 03-02-2017 10:44 03-02-2017 13:06 141.98
5 NSKIP7566 16-02-2017 20:24 16-02-2017 23:49 204.78
6 NSKIP7513 16-02-2017 15:56 16-02-2017 20:18 262.28
7 NSKIP7549 15-02-2017 13:09 15-02-2017 17:33 264.43
19 NSKIP7503 10-02-2017 01:29 10-02-2017 06:30 300.95
32 NSKIP7401 03-02-2017 11:37 03-02-2017 17:09 331.88
26 NSKIP7445 08-02-2017 15:40 08-02-2017 21:41 361.48
1 NSKIP7487 24-02-2017 17:15 24-02-2017 23:46 391.35
25 NSKIP7448 08-02-2017 14:40 08-02-2017 21:41 421.77
24 NSKIP7483 08-02-2017 20:44 09-02-2017 10:54 850.12
18 NSKIP7492 09-02-2017 18:41 10-02-2017 09:48 907.00
9 NSKIP7548 14-02-2017 18:42 15-02-2017 14:11 1168.28
37 NSKIP7421 02-02-2017 18:06 02-03-2017 19:01 40375.00
Within 1 hr – Maximum i.e. 17 out of 40 took Turnaround time from Patient Bill Paid
to Patient Physically left the Hospital

51
Turnaround Time of Discharge Initiation to Patient Physically left the hospital
Sl No
Pt.'s IP
Number Discharge Initiation Patientdischarged TAT Disharge
35 NSKIP7404 03-02-2017 12:57 03-02-2017 13:41 43.73
33 NSKIP7416 03-02-2017 13:43 03-02-2017 14:28 45.35
28 NSKIP7467 07-02-2017 16:39 07-02-2017 18:02 83.02
27 NSKIP7426 08-02-2017 12:23 08-02-2017 13:59 96.45
17 NSKIP7496 09-02-2017 16:46 09-02-2017 18:35 109.20
3 NSKIP7522 19-02-2017 11:01 19-02-2017 13:13 131.87
30 NSKIP7403 06-02-2017 12:22 06-02-2017 14:40 137.43
16 NSKIP7428 10-02-2017 10:05 10-02-2017 12:30 144.80
4 NSKIP7564 17-02-2017 11:14 17-02-2017 13:49 154.48
2 NSKIP7568 21-02-2017 10:58 21-02-2017 13:35 157.32
23 NSKIP7411 09-02-2017 10:11 09-02-2017 12:57 165.65
39 NSKIP7465 08-02-2017 10:20 08-02-2017 13:24 184.00
8 NSKIP7453 15-02-2017 12:12 15-02-2017 15:21 189.22
38 NSKIP7569 27-02-2017 12:50 27-02-2017 16:27 217.00
14 NSKIP7457 14-02-2017 09:32 14-02-2017 13:12 219.92
5 NSKIP7566 16-02-2017 19:57 16-02-2017 23:49 231.55
36 NSKIP7405 03-02-2017 08:52 03-02-2017 13:06 254.15
34 NSKIP7399 03-02-2017 10:03 03-02-2017 14:27 264.65
13 NSKIP7500 14-02-2017 09:26 14-02-2017 14:01 275.52
21 NSKIP7456 09-02-2017 09:23 09-02-2017 14:00 277.17
22 NSKIP7458 09-02-2017 09:10 09-02-2017 13:59 289.05
15 NSKIP7429 10-02-2017 12:00 10-02-2017 17:07 307.57
19 NSKIP7503 10-02-2017 00:38 10-02-2017 06:30 351.82
20 NSKIP7431 09-02-2017 10:00 09-02-2017 16:11 370.72
6 NSKIP7513 16-02-2017 13:55 16-02-2017 20:18 383.62
7 NSKIP7549 15-02-2017 11:08 15-02-2017 17:33 385.48
12 NSKIP7442 14-02-2017 09:23 14-02-2017 15:54 391.23
1 NSKIP7487 24-02-2017 16:51 24-02-2017 23:46 414.75
11 NSKIP7491 14-02-2017 12:18 14-02-2017 19:42 444.05
32 NSKIP7401 03-02-2017 08:06 03-02-2017 17:09 543.12
26 NSKIP7445 08-02-2017 12:30 08-02-2017 21:41 551.12
25 NSKIP7448 08-02-2017 11:01 08-02-2017 21:41 640.15
31 NSKIP7413 03-02-2017 03:55 03-02-2017 18:38 883.15
24 NSKIP7483 08-02-2017 20:08 09-02-2017 10:54 886.37
18 NSKIP7492 09-02-2017 17:15 10-02-2017 09:48 993.73
9 NSKIP7548 14-02-2017 16:45 15-02-2017 14:11 1285.90
40 NSKIP7415 05-02-2017 09:51 06-02-2017 17:58 1927.00
29 NSKIP7447 06-02-2017 09:51 07-02-2017 17:58 1927.58
10 NSKIP7482 10-02-2017 08:54 14-02-2017 19:43 6408.63
37 NSKIP7421 02-02-2017 17:08 02-03-2017 19:01 40433.00
Maximum number of patient i.e. 11 No’s; completes turnaround time of phase two of
discharge process in more than 2 hr but less than 4 hrs

52
Chapter VI
FINDINGS
&
SUGGESTIONS

53
Findings
1. Within ½ an hr – Maximum i.e. 12 out of 40 Patients took Turnaround time
from Discharge Initiation to Bill Generation
2. Within ½ an hr – Maximum i.e. 17 out of 40 Patients took Turnaround time
from Discharge Initiation to Bill Generation
3. Within 1 hr – Maximum i.e. 17 out of 40 Patients took Turnaround time from
Patient Bill Paid to Patient Physically left the Hospital
4. Maximum number of patient i.e. 11 No’s; completes turnaround time of “Phase
two” of discharge process in more than 2 hr but less than 4 hrs

54
Suggestions
It was found that, amongst 3 processes of phase 2 in discharging the patient whose
timings were considered in project i.e.,
1. The time from Discharge Initiation to Bill Generation
2. The time from Bill Generation to Patient settlement of Bill
3. Time from Discharge Initiation to Bill Settlement by patient
And the overall Phase two -
 Time from Discharge Initiation to Physically patients gets off the
hospital.
 Amongst all these steps, the 1ststep take few minutes above ideal standards. But it
is not that problematic. More stringent follow up of this step can lead to ideal
completion time.
 The 2ndstep too took few minutes above ideal standards. But it is not that
problematic. More stringent follow up of this step can lead to ideal completion
time.
 The 3rd step takes far too more time than it should ideally be happen. This is
because many factors like;
 Patients bargain at the billing counter at the time of bill settlement, this lead a lot
of time consumption and chaos at the billing counter.
 Patients seek time to arrange funds for the payment of the bill
 There are sometimes mistakes in the billing which result in overcost estimates.
This the patient resist and then corrections were made. Though this problem don’t
happen many times, but is do happens as it has been observed in the tenure of
internship.

55
 Patients are sometimes genuinely incapable to pay the total amount of bill, so on
humanitarian basis they are given discounts by consulting at various levels of the
hospital. These factors lead to extension in time.
 Patients seek detailed explanations of each and every items included in the bill
which the bill counter executive is unable to solve their query.
Solutions for the above issues can be:
 Timely interim of bills to patients, which does happen in the hospital, but
sometimes patient don’t understand. It should be conveyed to patients with more
detailed explanation on timely basis and on each progression of the patient in
hospital.
 It has been observed in a negligible amount so, while putting the bills, things
should be double verified to ensure that the bill is not overestimated than the
original factual one.
 Billing counter Staff should be thorough and should know the in and out of each
and every item billing purpose.
 Every patient is not given or shown the detailed tariff list of the hospital services
and items. So at the time of billing, each and every patient should be shown the
detailed tariff list of the hospital.
 It is a tentative time of patient leaving the hospital which has been
recorded in the data. There were patients who left the hospital as early as
possible after bill settlement so the findings cannot be generalised.
Factors Affecting Phase two Discharge Process positively as well as negatively.
 Explaining the prescription to the patient.
 The removal of I.V. Canulla.
 Availability of wheel chair sometimes while leaving Hospital.
 Availability of ward boys or housekeeping staff to see off the patient till outside
hospital.

56
 Management and execution of The “Fond Farewell” system as a policy of Apollo
Hospitals.
Solutions for the above issues can be:
 Before patient settlement of the billing, the discharge medications should be
explained to the patients.
 There should be ‘on priority’ basis removal of I.V. Canulla as soon as patients
relative display the discharge slip.
 The number of well conditioned wheelchairs should be available constantly on
each ward floor.
 For fond farewell each ward staff should proactively get involved.
 As soon as the activity card is sent to billing the patients relative should be
informed to visit the billing department for the payment of bills.
 For discharging the patient there should not be waiting of ward boys or
housekeeping staff to see of the patients. Whoever is bit free at the ward should
come ahead to see off the patient till the hospital gate.
 The analysis of Phase Two TAT Discharge process was found out to be way too
high than the ideal timings. It should be approx. and less than 60 minutes for out
of pocket paying patients. The reason it was found out to be very high is because
of the last processes of patient bill settlement and patients physically leaving the
hospital.
If solutions for the above two processes is found out and implemented and
involvement of each staff is and there education regarding this is done, then surely
the ideal timings can be achieved easily.

58
Two Months Training internship project were carried out in Apollo Hospitals, Nashik as
part of the Academics for partial fulfillment of the requirement for MBA Health Care
Administration to submit to the Maharashtra University of Health Sciences. During the
project internship period, after consultation with internal Institutional guide and external
Organisational guide and also with personal liking and feasibility of the study, the project
on discharge process were decided to be carried out entitled “To Study the Process of
Patient Discharge in Multispeciality Corporate Hospital”. The study on discharge process
were successfully completed during the tenure of the winter internship.
Apollo Hopitals Ltd. is one of the leading hospital chain across India and has branches
across the globe too; and still expanding. It is one of the best corporate hospitals in
Nashik. It is 118 Bedded Multispeciality and Superspeciality, NABH accreditated
Hospital.
From Literature reviewed on database so far, it was found that patient Discharge process
in Hospitals is evergreen topic and rigorous research is being carried out and much is
needed to make the discharge process ideal for patient satisfaction and to leave them
delighted while leaving the hospital. Also reducing the discharge process timings of
hospitals lead a lot of benefits to the hospital and proves to be very fruitful in terms of
cost benefit analysis, in terms of revenue and for patient satisfaction to sustain in this
competitive world.
In accordance with the objective of the study, primary data were collected from the
Hospital during winter internship training by daily observation and day to day interaction
with the hospital ward staff. Secondary data were collected from the hospital’s SOP’s and
policy’s on discharge and others journals and books related to the topic referred.
A sample size of 40 patients in the process of discharge from hospital, who were paying
hospital bill in cash were arbitrarily selected during the tenure of training period. The
study was a process mapping with observation. It was a qualitative and quantitative
research.

59
Following was the discharge process studied and mapped in Apollo hospitals, Nashik.
Discharge Process in Apollo Hospital – Flow Chart
Timings between each step were tracked. In Phase 1; from Consultant Doctor’s
intimation of discharging patient till the drugs return acknowledged are standard and
happen in time and no problem were noticed. That is why in data analysis, timings of
these 6 steps were not taken into consideration.
Discharge timings of Phase II i.e., Discharge initiated till the patient physically checks
out from hospital, were taken into consideration for data analysis, findings and suggestion
purpose. Ideally, according to Apollo hospitals Ltd. policy and standards, this process
should take not more than 1 hour in Self paying patients.
1 • Consultant's Intimation of patient discharge
2 • Discharge Summary Prepared
3 • Draft Checked
4 • Discharge Summary Finalised
5 • Drugs Returned to Pharmacy
6 • Drugs Returned Acknowledged by Pharmacy
7 • Discharge Initiated
8 • Activity Card send to billing
9 • Bill Generated
10 • Patient Settlement of bill
11 • Patient discharged (Check out)
Phase I
Phase II

60
It was found out that much time is needed for patient settlement of billing and patient
seeing off from hospital because of varied reasons and solution to which were suggested
in findings and suggestion chapter of this project report.
The timings reported in this project and final analysis is a genuine work on observation
which is subject to change from patient to patient as each and every patient in hospital
who comes for treatment each day is of different kind and no two days in a hospital are
same. The report is totally based on observation and on interaction basis.

62
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