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BACKGROUND Data suggest that delays in discharges from inpatient units affect hospital throughput and contribute to emergency department crowding. Lean/Six Sigma (LSS) has been shown to improve inefficiencies in other industries. There are no published data on what impact LSS can have on advancing and sustaining earlier patient discharges. OBJECTIVE Determine the impact LSS has on advancing times of placement of discharge order and patient discharge compared to control. Secondary outcomes were length of stay (LOS) and readmission rates. DESIGN Prospective quality study with concurrent controls. SETTING Academic medical center. PATIENTS Hospitalized pediatric patients compared to remainder of the children's hospital services. INTERVENTIONS Staff reallocation, creation of standard workflow, multidisciplinary predischarge planning, and creation of a discharge checklist. MEASUREMENTS Median time of discharge order entry and median time of actual patient discharge, proportion of patients discharged before noon and 2 pm, and LOS and readmission rates. RESULTS The median time of order entry was 10:45 compared to 14:05, and the median time of discharge was 14:15 compared to 15:48. The LOS and the readmission rates remained the same in both cohorts. The control group had faster baseline discharge order entry and patient discharge, but discharge performance did not improve, despite a significantly lower average daily census. CONCLUSIONS We determined that Lean approaches can have an immediate and sustained impact on advancing patient discharges, with no negative affect on LOS or readmission rates. Our intervention generated consistent results independent of personnel during the busiest months of the year at a tertiary care children's hospital. Journal of Hospital Medicine 2015;10:220–227. © 2014 Society of Hospital Medicine

BACKGROUND: Venous thromboembolic events (VTE) are a significant cause of mortality in hospitalized medical and surgical patients. Despite recommendations and guidelines, current evidence demonstrates that VTE prophylaxis remains underutilized in at-risk patients. The process of providing VTE prophylaxis begins with assessing each patient's VTE risk. Using an individualized, point-based protocol in the assessment process is a complex task, and might contribute to variability in VTE prescribing behavior. There are no published data on how reliably residents can perform risk assessment and prophylaxis using a point-based VTE risk assessment tool. OBJECTIVE: Our aim was to determine inter-rater reliability of a point-based risk assessment tool by residents early in the academic year. DESIGN: The design was a cross-sectional-cohort observational study. SETTING: The site was an academic medical center. PATIENTS: Case-based clinical vignettes were used. INTERVENTIONS: Verbal instructions were given to medical residents about how to apply our hospital's point-based VTE risk assessment tool. MEASUREMENTS: Interobserver agreement was measured of: 1) risk score, 2) risk-stratification, 3) identification of contraindications, 4) VTE prophylaxis plan, and 5) resident adherence to the protocol. RESULTS: The intra-class correlation (ICC) for the total risk score was 0.66 and the kappa coefficient for risk stratification was 0.51. The kappa scores for absolute and relative contraindications were 0.29 and 0.23, respectively. The kappa score for the VTE plan was 0.28. CONCLUSIONS: We determined that, following brief instructions early in the academic year, a point-based VTE risk assessment tool has only fair to moderate inter-rater reliability, with suboptimal adherence to the protocol. Both might lead to underutilization of VTE prevention strategies. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.