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  1. Kucharczuk, Colleen DNP, RN, AGACNP-BC
  2. Lightheart, Erin MBA, CSSBB
  3. Kodan, Allison MSN, RN, OCN, AGACNP-BC
  4. Haynes, Cassandra MPH, PA-C
  5. Rabatin, Susan MSN, RN, AGACNP-BC
  6. Burke, Joy MSN, RN, AGACNP-BC
  7. Senger, Jamie MSN, RN, AGACNP-BC
  8. Lee, Lindsay MSN, RN, AGACNP-BC
  9. Brinley, Sarah PharmD, BCOP
  10. Decena, Mary Angela MSN, RN, AOCNP, AGACNP-BC
  11. Cruz, Juanita M. MSN, RN
  12. Hirsh, Rebecca MD
  13. McCauley, Kathy PhD, RN


Background: In an inpatient setting, aspects of discharge planning are often left to the provider's memory, leading to errors, inefficiencies, and avoidable costs.


Methods: A multidisciplinary team of oncology practitioners used process improvement methodologies to redesign the discharge planning process.


Interventions: The primary intervention was an evidence-based discharge planning tool, called the discharge navigator, used from admission through discharge.


Results: Thirty-day unplanned readmission rates decreased by 29.0% from preimplementation (March 2017 through August 2017) to postimplementation (September 2017 through March 2020). The percentage of patients discharged before noon increased 76.2%. A comparable service not utilizing the intervention saw lesser or no improvement in these measures.


Conclusion: The tool provided a systematic approach to discharge planning. Key design elements included a centralized location within the electronic health record and an electronic shortcut to populate the tool. Although developed for a specialized population, most elements are applicable to any hospitalized patient.