Evaluating an Emergency Department Discharge Center: A Learning Organization Approach for Efficiency and Future Directions.

Introduction Our pilot Emergency Department Discharge Center (EDDC) facilitates post-discharge appointments, and screens for social determinants of health (SDoH) with a long, paper-based tool. No criteria guide which patients to refer to EDDC for appointment-making. Patients screening positive for SDoH are texted or emailed a list of community-based organizations (CBOs) to contact; the screening tool doesn't assess patients' interest or ability to contact CBOs. Additionally, our ED's clinical and operational administrators run a follow-up call program for discharged patients to inquire about their recovery. This program is associated with improved patient satisfaction, a strategic initiative tied to reimbursement. Owing to high volume, only 8.6% (4,877 of 56,591) of discharged patients are called. We describe an application of Learning Organization principles and practices to evaluate EDDC efficiency and identify opportunities to create time for EDDC staff to participate in and expand the follow-up call program. Methods A "Learning Organization" follows five principles (systems thinking, personal mastery, mental models, shared vision, and team learning) to facilitate its members' learning and continuously transform itself. To evaluate EDDC processes ("systems thinking"), the overriding Learning Organization principle we adopted was "integrate learning into the business process." We established "team learning" by engaging EDDC staff and ED leadership ("leadership commitment"), thereby "promoting ownership at every level." We shadowed EDDC staff and analyzed data for 3,616 patients receiving appointment assistance, 342 offered SDoH screening, and 4,877 called by phone. We identified the validated SHOUT tool (which predicts discharge failure) and its highly weighted criteria (no home, insurance, or primary care physician). We randomly surveyed 50 patients to determine: 1) what percent met those highly-weighted criteria, with the idea being to guide providers about which patients particularly benefit from EDDC assistance, and 2) what percent had not only SDoH social service needs but also interest and ability to contact CBOs, as this would be their responsibility. Adopting these two changes (SHOUT tool and assessing interest/ability to contact CBOs) might yield more judicious utilization of EDDC personnel, freeing up time to staff the follow-up call program. Results EDDC staff spend ~35 minutes/patient. They don't make appointments but instead liaise with physicians' offices, which yields fewer ED returns and admissions. Only 6% (3 of 50) of surveyed patients met SHOUT criteria for EDDC assistance. Of 342 patients screened for SDoH, 31% (106) completed the survey, 20% (68) identified a need, and only 4.5% (15) completed it, identified a need, and followed up on their own after receiving CBO names and contact information. Only 50% of call-back patients were contactable: 77% had improved, 21% were unchanged; ~50% had made appointments without EDDC assistance; and 12.5% had clinical questions. Conclusion Learning Organization exercises identified the SHOUT tool and revealed the potential for SHOUT criteria and QR-code-accessible two-step SDoH surveys to create significant time for EDDC to staff follow-up program expansion. Thousands more patients would be screened for SDoH, saving 95% of the effort while retaining 100% of the benefit. EDDC staff would serve as a safety net for follow-up calls for patients unable to secure an appointment.