Why Discharge Before Noon. . and other Hospital Metrics (Picetti, 9/9/2026)

A recording of this presentation is available HERE.

Thanks to Dr. Dominic Picetti, hospitalist and physician advisor at SSRRH, who gave an important presentation on Reimagining Care Progression.

He started with this article from the Choosing Wisely Campaign "Things We Do for No Reason", which debunks this oft-used metric as a means to decrease length of stay (LOS) and create more open beds for patients waiting in the ED.



While Dr. Picetti acknowledged that using this metric in isolation does not accomplish the goals stated above, he reminded us that prolonged ER boarding DEFINITELY leads to worse outcome (increased mortality, increased CAUTI, increased CLABSI, increased falls, increased delirium and a poor experience of the hospital).


However, arbitrary clock time metrics fail to solve hospital overcrowding because they target an order entry deadline rather than underlying operational throughput barriers.


How can we improve this quality? We can do so by implementing a multi-disciplinary care progression model, which considers "steps to home" from the beginning-- what is the estimated/target discharge date? what are barriers to this patient going home? There is evidence to support these models (see image below)





AHRQ states that daily multi-disciplinary rounds are the single most effective lever to decrease hospital days in complex patients.


We must consider the concept of throughput:
From ER (where we establish early trust or mistrust)--> Inpatient/on wards, where clarity vs. lack of clarity defines the patient experience (there are plenty of opportunities here for mistrust). One of the goals of multidisciplinary rounds is to establish the anticipated date of discharge and share that with the patient. It is okay if we are wrong, but better to give the information to the patient.


In other words, "discharge should start on day #1".


Dr. Picetti also lifted up the statement Why not home? Why not today? as a conversation to be had with and about each patient each day. Our goal should be for patients to spend LESS time in the hospital (because generally being at home is better for everyone) and ultimate disposition location should be home.


One of our jobs is to inform people when they are medically ready to leave the hospital.


***


Quality Metrics are measure of the quality of care we provider patients.


When patients spend extra days in an acute hospital bed (beyond medical readiness), patients are at increased risk of lots of things: CAUTI, CLABSI, pressure injuries, falls, delirium. All of these contribute to increased readmission AND increased morbidity and mortality.


The Sutter Playbook is a framework for understanding Inpatient progression. It includes:
1) Case management does an assessment <24 hours from admission. Goals are to identify post-acute placement needs, prior living arrangements, PCP, DME, social barriers
2) Daily MDRs why not home? why not today?
3) Real time delay tracking (case management does this in the "avoidable delay" tab on Epic)
4) Touch points (2pm meeting with leaders AND complex care rounds weekly, where all patients > 7 days and other challenging cases are discussed)