Factors with the most significant impact on prolonging patients' discharge time included prolongation of issuing the discharge order, illegibility of orders, the lengthening of the time required to write and control a patient file summary, and in some wards, the delay in file exit from the ward. Due to the educational nature of the hospital and the practice of morning rounds, the discharge order is typically issued following morning rounds, and the process of checking files and writing a summary following morning rounds appears to prolong the discharge process. In some cases, the lack of a workforce and the lack of necessary skills and training for staff to work with hospital information systems has led to a prolongation of this process.
A study by Patel et al. identified many barriers for discharging in a hospital, including delays in diagnostic tests and counseling, poor communication between members of the team of caregivers, and between patients and service providers (9). Statile et al. suggested a failure in communication and inadequate training as obstacles in discharging patients on time (10). Zoucha et al. stated that issues related to discharge time, shortage of medical staff, lack of a monitoring and evaluation system and effective training, as well as staffs' waiting for the attending physician of the ward, asking for ancillary services such as counseling, were the most important reasons for prolongation of the discharge process (11).
The study conducted by Ragavan et al. suggested patient unpreparedness, prolonged time to receive a consultation and its delivery, location of hospital facilities, communication between staff and patient, timely notification of discharge and lack of standardization of discharge process, and delays in the testing and counseling process, especially on weekends were the main reasons for late discharge (12). The results of these studies are consistent with the results of the present study.
Some of the solutions obtained in this study to improve the discharge period are writing the file summary by the residents before the start of the medical students' training classes, releasing a resident from the morning program in a rotating manner to write the patient file summary, reducing the time that the file stays in the writing file summary stage, improving attention to detail of the nurse in charge of file control to minimize the amount of returned issues, a timely file sending out of the ward, creating an electronic health file and recording patient information from the time of admission in the hospital to secretaries' excessive commuting between the wards, which in addition to reducing the delay in discharge, patients' satisfaction is also obtained.
By rotating a secretary between wards to collect and control patient files using a written checklist if the electronic file is not set up or if performing periodic and accurate timing to evaluate the ward's performance is too time-consuming, specialized nurse training on the Information Technology (IT) unit, as well as educational supervisor training, continuous monitoring by the head nurse to correct returned drugs, particularly in patients who have been circulated between wards, accurate notification of discharge time and information about patients' companions, and writing the file summary, which is a time-consuming process. Finn et al. suggested that the assignment of supporting staff to complete tasks, such as completing discharge documents, setting up follow-up appointments and prescriptions, communicating with other nurses and physicians for discharge, and answering discharged patients' questions, has improved many aspects of the discharge process (13).
Patel et al. believed that effective collaboration between multidisciplinary teams and patients positively affects discharge (9). Zoucha et al. recommended some strategies, such as preparing discharge sheets and medications the night before discharge, using checklists, having enough people on the medical team, providing instant feedback to staff and personnel, and using multidisciplinary medical staff to improve the discharge process (11). Rohatgi et al. suggested that solutions such as allocating sufficient resources and staff over the weekend to ensure safe and timely discharge of patients can help maintain the operational capacity of medical centers (14).
Harlan et al. also considered strategies such as quality improvement, including training and electronic discharge guidelines to effectively improve the discharge process in pediatric hospitals (15). Finally, Wu et al. believed that solutions, such as creating proactive programs for discharge, including educating families and patients about the disease and the discharge schedule, establishing and updating scheduled discharge times, and ensuring that financial problems do not prevent discharge could improve the discharge process (16), where the results of their study are in line with the findings of the present study.
Despite the limitations of this study, we attempted to cover all aspects of the discharge process. During the FGD and interviews, specialist physicians and medical students were not present, and thus their perspectives were lost; during the quantitative phase, technical difficulties with the recorder occasionally resulted in missing data.