Student name
Capella University
NURS- FPX4005
Professor’s Name
Submission Date
Introduction
Hello everyone. My name is __. I am a nurse at Riverbend Community Hospital. I will talk about the backlog of boarded patients that are boarding in our med/surg units and share an interdisciplinary approach to make it better. This strategy is based on a standardized communication model, an organized implementation guide, relevant tools and monitoring systems. Examples include Capella FlexPath and the FlexPath Capella University, which emphasise practical approaches to improving quality of health care that are in alignment with the methods we are employing in this pilot.
Presentation Objective
Th is paper combines a multidisciplinary evidencerelated care package to have a negative impact on delayed transfers of care at Riverbend Community Hospital. The program enhances communication between the nurse, doctor, case manager and therapist through structured rounds with the aid of a common communication tool. Through utilisation of this system the rights of patients and staff are realised, with transparency and openness. I am asking if I can get permission to pilot this in one of our units. It is consistent with principles from the Capella capstone project model and can be adapted for other healthcare improvement projects.
Organizational Issue
RCH have major problems with delayed discharges, particularly on the medical-surgical floor. These holes are a result of poor communication, inadequate understanding of discharge readiness and unsatisfactory documentation. Benefits of Sharing Information Systematically Not to systematically share information obstructs decision making and sacrifices patient safety, satisfaction with care, and efficient operations. SBAR, interprofessional rounds are evidence-based methods that help decrease these gaps and improve workflow and patient outcomes. These approaches align with best practices supported by Capella University RN-BSN degree programs and other FlexPath institutions.
What Happens if We Don’t Address the Problem
Without consideration of late discharges, patients may experience longer hospital stays that actually make them more susceptible to hospital-acquired complications and re-admission. Hospitals maximize their profits by moving people out as soon as possible; and while that is financially sound for the government, it may not be great for infectious disease control. It is bad for hospitals if there isn’t enough patient flow, because they can’t turn the beds over often enough and can’t control costs. If it is true then staff burnout and demotivation will be inevitable, thus leading to other negative effects on patient care. When you don’t close the gap in communication, what happens is your patients end up frustrated, you have a lack of production and teams aren’t performing at their best. There are two evidence-based countermeasures to these risks, structured communication and multidisciplinary involvement.
Adoption of an Interdisciplinary Team Approach
The optimal answer is coordinated multi-disciplinary care, where a team of nurses, doctors, case managers pharmacists and therapists meet regularly to discuss the patient’s treatment. Implementation of standardized communication tools will reduce errors, omissions and ‘Chinese whispers’ to facilitate safe & streamline discharge planning. Team rounding supports patient-centered care delivery by involving clinical, social, therapy and case-management expectations in team-based care as reflected in the teamwork competencies emphasized throughout Capella FlexPath learning escalr. module. static.
Summary of evidence based interdisciplinary plan
Purpose: We aim to enhance discharges through standard communication using the SBAR (SituationBackgroundAssessmentRecommendation) report and these structured IDRs. “Reconciliation will help staff to ‘lock in’ patient status and discharge information at least 24 hours before the planned transfer, so that there can be more timely transitions of care.
Design: The program implements SBAR and redesigned daily interdisciplinary huddles with intentional, direct communication. Sirs We would like to validate the importance of SBAR for discharge planning, on whom it may add precision avoid miscommunication and facilitate and expedite the process of decision making.1-ink. Transition will be both verbal and electronic through brief structured rounds and facilitated with a templated discharge sheet.
Cross-discipline team roles: Nurses do clinical assessments and teaching, physicians discharge orders/medical readiness, case managers follow-up planning/insurance, therapists mobility assessment/homestead safety. Shared decision making allows obstacles to be highlighted fairly promptly in the process so that safe and effective disposition planning can occur. This group approach is reflective of skills acquired within the Capella RN to BSN curricula.
Described how the composite strategy was carried out.
The model will first be introduced in the medical-surgical units of Riverbend Community Facility, which are more frequently affected by delay in discharge. Employees will receive SBAR, interdisciplinary rounds, and how to use standardized scripts for discharges training. Rounds will be held daily for inpatients expected to go home 24–48 h later; this protocol daily schedule allows nursing staff shift organization but also means that each round will be led by the same nurse manager. Evidence suggests that structured rounds improve communication, lead to a lower median time to discharge and favorably impact team function. Uptake and adherence will be monitored at 4–6 weeks, with staff feedback and impact on workflow.
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No new staffing is required, the existing nurses, physicians, physical therapists and case managers are involved. Even short huddles can add about 10 minutes per patient, or nearly five hours a week for a unit with 30 patients. Costs are very low – it’s mainly just printing costs for standardized worksheets ($25–40/month). Structured discharge planning approaches have been effective for reducing LOS, readmissions and bed day costs that would warrant a relatively cheaper intervention. This is indicative of the practical skills that are part of Capella Capstone Project for health care improvement projects.
Considerations When evaluating if the Project Has Been Successful
The measure of success will be quantitative and qualitative data gathered over a 6–12 month period. Key domains include mean number of days in the hospital, time from discharge order to actual discharge, 30-day readmission rate, % discharged before noon, SBAR and daily rounds implementation. Staff satisfaction and quality of interdisciplinary communication will also be measured, in addition to patient/family feedback regarding their readiness for discharge. This comprehensive assessment approach is similar to that used in place for FlexPath Capella University programs.
Conclusion
Risk factors Risk data not recorded for many patients Contributing factors Poor communication Lack of discharge planning Impact There is no major healthcare issue that Riverbend affects, but late discharges are a significant cost to the hospital. Interdisciplinary care combined with standardized SBAR improves timely, complete care while also reducing discharge hoarding and enhancing patient outcomes. Administration support and staff participation will be key to its success – and it is already busy with plans to boost efficiency, reduce readmissions and make care simpler. These tactics show the skills that Capella Flex Path (and programs like it) can help you develop, as well as advanced education in our RN to BSN at Capella University.
References
Aldamouk, A. (2024). The Impact of patient-centered, structured interdisciplinary bedside rounds on medical staff satisfaction, education, and experience. Cureus, 16(12). https://doi.org/10.7759/cureus.76412
Fatani, A., Alzebaidi, S., Alghaythee, H. K., Alharbi, S., Bogari, M. H., Salamatullah, H. K., Alghamdi, S., & Makkawi, S. (2025). The role of the discharge planning team on the length of hospital stay and readmission in patients with neurological conditions: A single-center retrospective study. Healthcare, 13(2), 143–143. https://doi.org/10.3390/healthcare13020143
Ghosh, S., Ramamoorthy, L., & Pottakat, B. (2021). Impact of structured clinical handover protocol on communication and patient satisfaction. Journal of Patient Experience, 8(1), 1–6. https://doi.org/10.1177/2374373521997733
Institute for Healthcare Improvement. (2025). SBAR Tool: Situation-Background-Assessment-Recommendation. Ihi.org. https://www.ihi.org/library/tools/sbar-tool-situation-background-assessment-recommendation
Kovacevic, M., Fisher, S., Faulkner, S., Kharasch, M., Fernandez, N., Luebeck, C., & Ahsan, A. (2024). Rounds redesign: our experience in splitting interdisciplinary rounds. Journal of Brown Hospital Medicine, 3(2). https://doi.org/10.56305/001c.115837
Schwartz, J. I., Colaso, R. G., Gan, G., Deng, Y., Kaplan, M. H., Vakos, P.-A., Kenyon, K., Ashman, A., Sofair, A. N., Huot, S. J., & Chaudhry, S. I. (2021). Structured interdisciplinary bedside rounds improve interprofessional communication and workplace efficiency among residents and nurses on an inpatient internal medicine unit. Journal of Interprofessional Care, 38(3), 1–8. https://doi.org/10.1080/13561820.2020.1863932
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FAQs
Q1: What is the role of SBAR multidisciplinary in relation to delayed discharges?
You are encourged to communicate with the nurse, / physician case managers and therapists which is a proffessional. This rescue team can keep errors — and patients who are ready to be discharged — from languishing longer than necessary.
Q2: But where do the mechanics of doing daily interdisciplinary rounds fit into that plan?
They allow the care team to group on overall patient needs, help identify discharge barriers early and coordinate care.
Q3: How are the pilot plan distributing resources?
This system of existing labour and cheap materials, relatively little extra time per patient (patients do not yet have strict discharge criterion) for dramatically improved discharge times.
Q4: How could we assess staff adherence and performance?
Through tracking certain measurements (LOS, Readmission rates, SBAR compliance), attendance in rounds – both prompted and discussion contributed), staff satisfaction surveys and patient feedback.
Q5: How well does this proposition align with Capella University?
It reflects evidence-based practices as taught in Cappella- FlexPath, Capella Capstone Project and Ca-pella University RN to BSN and focuses on interdisciplinary teamwork, communication and quality patient care within healthcare.