New ways to address an old problem

Discharges before 12 at CSAPG


FEATURE – Freeing up beds is an age-old problem for hospitals. The medical area of this Catalan hospital group has found in lean a creative way to solve it. 





Words: Dr. Àlex Culla, Dr. Maria Lopez-Dieguez and Dr. Helena Camell Llari





Having more beds available is the number one concern for most hospitals, and the Consorci Sanitari Alt Penedés-Garraf is no exception. In the medical area, we have been trying to increase the number of patients who are discharged before 12pm for a long time.


We have tried several things, but all the experiments we ran were somewhat improvised and not particularly structured. They were typically the result of individual initiatives, and they ultimately didn’t have legs. They were only able to achieve short-lived results: the situation improved for a week or for a couple of months, but it could never be sustained. Our solutions were not solid enough.


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


Practically, to change habits and increase the number of patients discharged before 12pm, we introduced three main changes:

  • Medical staff is now expected to provide the patient’s medical chart to Administration by 11am, to give us enough of a margin to arrange the discharge before noon. This was unconceivable before lean, whereas now it’s seen as a common objective that motivates our team and facilitates their adaptation to a new way of working.
  • We are notifying nurses about discharges taking place the following day, so they can do all the necessary preparatory work. This was done before lean, too, but not consistently enough.
  • We are trying to introduce a new standard for doctors, encouraging them to prioritize soon-to-be-discharged patients during their morning rounds. This was tricky, because, since their first day as residents, doctors are told to go see newly admitted patients first, in case some of them might be unstable or require special attention.

We realize that we are trying to change very old habits and routines, and that’s why we need to do so gradually. The good thing is that, in our organization, lean is widespread, and everybody understands its value. We have all seen the great results the methodology has generated and are comfortable embracing and experiment with it.







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