Background

Hospital overcrowding has become a widespread problem, with constrained bed capacity and admission bottlenecks having far-reaching negative impacts on quality and safety. Focus on timing of discharge may be the least disruptive and most effective way to address constrained bed capacity, yet there may be significant institution-specific barriers to implementation.

Methods

With the creation of a "Value Team," a 627-bed, tertiary care academic medical center embarked on a quality improvement (QI) project using Lean Six Sigma process improvement methodology. After defining the problems around timeliness of discharge, the team went through the steps in the Define, Measure, Analyze, Improve, Control (DMAIC) framework. Interventions, which were implemented on the basis of an in-depth analysis of barriers to the discharge process, included geographic cohorts of internal medicine physicians on specific hospital units and multidisciplinary huddles one day before anticipated discharge.

Results

After accounting for the concurrent trends in the control group, the percentage of discharge orders released by 10:00 a.m. increased by 21.3 points (p < 0.001; adjusted odds ratio [OR] = 2.62; 95% confidence interval [CI] = 1.91-3.59), and the percentage of patients discharged by noon increased by 7.5 points (p = 0.001; adjusted OR = 1.70; 95% CI 1.15-2.51). There were no significant changes in the 30-day readmission rate or length of stay.

Conclusion

A QI program shaped by Lean Six Sigma principles and reinforced by clinician huddles and geographic cohorting was associated with earlier posting of discharge orders and physical discharge by noon.

Introduction

We explored the impact of a temporary tobacco-free public policy for the 2008 Summer Olympics on the smoking prevalence and secondhand smoke exposure among the population of a co-hosting city, Qingdao, China.

Methods

The Qingdao Diabetes Survey was analyzed for 2006 (n = 4599) and 2009 (n = 4680), which are survey years before and after the tobacco-free Olympics public policy period (July 2007 to January 2009). We analyzed the differences in self-reported smoking prevalence and exposure to secondhand smoke at home and/or workplace, and compared odds of smoking by survey year and of exposure to secondhand smoke among nonsmokers.

Results

From 2006 to 2009, the male smoking prevalence declined from 51.4% (95% confidence interval [CI] = 49.0% to 53.9%) to 42.6% (95% CI = 40.2% to 45.1%), and the proportion of lighter smokers decreased more. Among nonsmokers, the secondhand smoke exposure rate declined from 62.2% (95% CI = 60.5% to 63.9%) to 56.8% (95% CI = 55.1% to 58.6%). Regression analyses show 34% lower odds of men smoking after Olympics (OR = 0.66, 95% CI = 0.57% to 0.77%). Rural residents and individuals who are not retired were more likely to smoke. Female nonsmokers report 17% less exposure to secondhand smoke after Olympics (OR = 0.83, 95% CI = 0.70% to 0.98%). Urban nonsmokers were more likely to be exposed than their rural counterparts.

Conclusions

Smoking prevalence among men and secondhand smoke exposure among women significantly decreased in Qingdao, China, after the tobacco-free Olympics public policy period. As only the proportion of lighter smokers decreased, this may help explain why urban nonsmokers reported increased exposure. Unintended increased secondhand smoke exposure and cessation support need to be addressed in large-scale policy campaigns.

Implications

Hosting the Olympic Games can help to initiate large-scale tobacco-free public policies for hosting cities. Although previous studies have demonstrated reduction in nonsmoker exposure to secondhand smoke, the impact on the hosting city's smoking prevalence or exposure rates is unclear. After the Olympic Games in Qingdao, China, smoking prevalence among men significantly decreased, mostly due to light smokers. Secondhand smoke exposure at home and/or workplace significantly decreased among female nonsmokers. Urban nonsmokers had an unintended consequence of increased secondhand smoke exposure after the tobacco-free Olympic policy period. Concurrent promotion of cessation support for heavier smokers may be needed.