Having more beds available is the biggest concern for most hospitals, and the Consorci Sanitari Alt Penedés-Garraf is no exception. In the medical field, we have long been trying to increase the number of patients discharged before noon.

We tried several things, but all the experiments we conducted were somewhat improvised and not particularly structured. They were mostly the result of individual initiatives, and in the end they had no effect. They achieved only short-term results: the situation improved for a week or a few months, but it could never be sustained. Our solutions were not solid enough.

Then came Lean Thinking and Hoshin Kanri. They helped us thoroughly analyze and fully understand the problem. We decided that we needed to look at (and address) the discharge problem from different perspectives - not just doctors and nurses, but also patient transport partners, administrative staff, etc. Now that we have a more holistic view of the process and are trying to revise our physicians' and nurses' routines, we are hopeful that we can achieve lasting results. We are finally changing the way we think and act.

In order to change habits in practice and increase the number of patients discharged before noon, we made three important changes:

• The medical staff is now expected to turn in the patient's medical records to administration by 11 a.m. so that we have enough margin to arrange discharge by noon. Before lean this was unthinkable, but now it is seen as a common goal that motivates our team and facilitates their adjustment to a new way of working.
• We are trying to introduce a new standard for physicians, encouraging them to prioritize patients who are about to be discharged during their morning rounds. This has been difficult because doctors have been told since their first day as residents that they should go to newly admitted patients first, in case some of them are unstable or need special attention.
• We notify nurses of discharges taking place the next day so they can do all the necessary preparatory work. Before lean , this was also done, but not consistently enough.

We realize that we are trying to change very old habits and routines, so we have to do it gradually. The good thing is that lean is widespread in our organization and everyone sees its value. We have all seen the great results the methodology has generated and feel comfortable embracing it and experimenting with it.

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THE AUTHORS

From the left: Dr Àlex Culla is an Internal Medicine Specialist at Hospital Residencia Sant Camil; Dr Helena Camell Llari is Director of Intermediate Care at Consorci Sanitari de l'Alt Penedès i Garraf; Dr Maria Lopez-Dieguez is Head of Internal Medicine at Hospital Comarcal de l'Alt Penedès

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