Optimizing the Implementation of Discharge Planning in X General Hospital Jakarta

Discharge planning is a complex process aiming to prepare patients during a transition period in a hospital until they are home. One of general hospitals (X) in Jakarta has implemented discharge planning, but it is not optimally conducted. This research aims to analyze the implementation of optimizing discharge planning in X General Hospital in Jakarta. This research employed pilot study initiated by conducting assessment through questionnaire, observation, and interview. The next stages were root cause analysis by employing fishbone analysis, Plan of Action (POA) arrangement, Plan Do Check Action (PDCA) implementation, and evaluation by employing questionnaire. One of the problems of implementing discharge planning is was implementation method in which the guidance of discharge planning was not available. Therefore, standard operating procedures (SOP) and format of discharge planning were necessarily revised. After arranging the guidance draft, SOP, and format of discharge planning, the researcher socialized and tested the SOP and format of discharge planning in two inpatient rooms. The results reveal that 80% of respondents state that the arranged format of discharge planning is easily understandable, easily applicable, less complicated, not rambling, and practical. Therefore, the management of X hospital Jakarta necessarily conducts the follow-up to develop and legalize the guidance draft, SOP, and format of discharge planning. Furthermore, the management necessarily socializes them to duty nurses before the hospital applies them.


Introduction
Discharge planning is a complex process aiming to prepare patients during a transition period in a hospital until they are home (1). An effective discharge planning supports the continuity of healthcare. It is described as "a critical relationship between the nursing process received by patients in a hospital and post-discharge care provided by society" (2).
Discharge planning from a hospital to patients' house is not an easy process, and it probably indicates several problems, such as patients' less independence on performing daily activities, the deficit in self-care, a medicinal management problem, social problem, the need of information, and the emotional problem (3). Furthermore, it brings hospitalization effects which increase patients' dependency risk as a result of autonomy loss when they are hospitalized, and it mainly occurs in older adults and women (4).
Nurses are pivotal to identify the previous problem, plan patients' safer discharge planning from hospital to home, or provide other healthcare services. Discharge planning must become a vital consideration to decrease the problem of discharging patients. Discharge planning is nurses' intervention to prevent any complications in transferring patients from a hospital to home or other hospitals (4). Furthermore, well-performed discharge planning can increase the recovery process and assist patients in achieving optimal life quality before they leave the hospital (5) One of the strategies to support the optimal implementation of discharge planning is by preparing regulation in the form or infrastructures (i.e., format, leaflet), regulation (i.e., guidance and standard operating procedures), and policy (i.e., director's decree). It is in line with the research of Gholizadeh et al. which asserts that identifying and providing infrastructures as well as creating policy and regulation about patients' discharge planning are crucial requirements for effective discharge planning (6). Discharge planning has not been optimally implemented in X General Hospital in Jakarta. The implementation only focuses on the process when patients are discharging. Furthermore, the format of discharge planning contains more assessment. The guidance of discharge planning is not specific, and it merges with the direction of discharging patients.
The required leaflet to educate patients is available, but the leaflet required by patients when they are home is not available. Based on this background, the writers are interested in performing some changes to optimize the implementation of discharge planning in X General Hospital in Jakarta.

Objective
The study aimed to identify the application of discharge planning in X General Hospital in Jakarta.

Method
This research employed a pilot study conducted on October 29, 2018, to December 13, 2018. This method consisted of the assessment, creating planning of action, implementing the program, evaluating the program, and analyzing gap by employing a literature review. These processes received a written license from the hospital with a number:985/-1-776.4. The samples of this research were selected by using a random sampling technique to choose the room and by purposive sampling to determine the total of respondents. The instruments of data collection were an interview, observation, and questionnaire. Interview and questionnaire were conducted to the chief of the nursing officer, head of nursing services unit, head nurse, and team leader. The observation was done on the existing guidance, SOP, and documentation format of discharge planning. Initial data retrieval was performed by distributing questionnaires to 287 respondents in 16 rooms consisting of inpatient rooms and intensive care unit rooms on November 10-12, 2018.
Problem analysis was conducted in the form of fishbone diagram by analyzing the causes of the problem including man, method, machine, material, and money. The alternative priority to problem-solving was selected by considering five aspects: 1) strong tendency and frequency of the problem (Magnitude), 2) the amount of loss caused (Severity), 3) the probability to be solved (Manageability), 4) consideration and nurses' concern (Nursing Concern), and 5) availability of sources (Affordability). The range of values employed were 1-5, in which value 5=very important, value 4=important, value 3= important enough, value 2= less critical, and value 1= not important.
The implementation of problem-solving was solved by employing Plan Do Check Action process and was started by determining the plan, implementing, evaluating, and planning a follow-up. Planning was established to optimize structured and integrated discharge planning. The implementation begins with creating guidance, revising SOP, and revising the format of discharge planning. The existing guidance of discharge planning was an adapted result from discharging a patient in a hospital. Meanwhile, the SOP was a revised version from the current SOP. The format of discharge planning was created by inserting several elements to complete it.
The following step was socializing the program to head of rooms and nurses who were assigned as pilot projects in two inpatient rooms. The stage was continued by testing the format of discharge planning to investigate success or the obstructions of the implementation process. The result of the evaluation was conducted by distributing a questionnaire to examine if the room nurses could implement the tested format well.

Assessment
Initial data retrieval was performed by distributing surveys to 287 respondents in 16 rooms consisting of inpatient rooms and intensive care unit rooms on November 10-12, 2018. The result of the questionnaire on the assessment phase reveals demographic data of respondents as presented in table 1. From the result in table 1, it is concluded that most of the respondents are on productive age and still young, and they are expected to support transformation performed by X General Hospital in Jakarta. Most of the respondents' education is a diploma of nursing for 64.04%, and thus, it becomes the hospital's concern to develop the nurses' education.
The questionnaire is distributed to identify the content and implementation of discharge planning in X General Hospital, Jakarta, and it reveals nine main results. 1) 66.78% of the respondents agree that discharge planning is nurses' responsibility. 2) 45.30% of the respondents disagree with the statement that nurses, in general, less comprehend discharge planning. 3) 81.18% of the respondents agree that nurses are fully involved in the implementation of discharge planning. 4) 87.46% of the respondents agree with the family's involvement in discharge planning. 5) 41.81% of the respondents agree that discharge planning means excessive documents. 6) 91.64% of the respondents agree that discharge planning is beneficial for patients. 7) 75.61 of the respondents agree that discharge planning is implemented since a patient hospitalized. 8) However, in the following question, 53.66% of the respondents agree that discharge planning is started just before the patient leave the unit room. 9) 46.34% of the respondents agree that the estimation date of patients' discharge planning has been informed to them. Form these results; it is concluded that the respondents' cognition about discharge planning is good. Six of the nine questions result in incorrect answers (above 50%).
The interview conducted the forehead of the nursing service unit, and the head of the room reveals four results. 1) Discharge planning is more frequently performed just before patients discharge, and it is rarely conducted when they recently occupy in an inpatient room. Whereas, the format of discharge planning is urged to be completed within 2 X 24 hours since the patients hold an inpatient room. 2) The date of discharge planning is available on the format, but it is not filled down.
3) The discharge planning form was unclear because it contained more assessment tools. However, page two displays a blank page to record patient's health progress which influences discharge planning. 4) Respondents state that they never submit a financial proposal for any program to socialize discharge planning.
From the interview, the researchers achieve two results related to facility supporting the implementation of discharge planning. 1) There are many leaflets to assist the application of discharge, but the leaflets required by patients just before they discharge, such as tracheotomy treatment, colostomy treatment, and nasogastric treatment, are not available. Therefore, creating a leaflet containing those topics is essential. Furthermore, information about the use of technology in providing education is necessary. Thus, learning becomes more interesting, and it facilitates Professional Caregivers to teach. 2) When the patients have privacy about their illness, education is conducted in a room of head nurse and is usually performed by doctors because the nursing room has not been set to protect patients' privacy.
The observation of the implementation of discharge reveals four results. 1) Specific guidance of discharge planning which discusses a plan for discharge planning is not available. 2) A form of discharge planning in the inpatient room is possible, but it contains more about assessment while nursing diagnoses, nursing care plans, implementation, and evaluation are not available in the form. 3) Standard operating procedures of discharge planning is available in X general Hospital, Jakarta, but the methods contain more about the assessment of discharge planning. 4) A form of discharge instruction for patients when they leave the hospital is not available.

Root Cause Analysis
To assess the problem of discharge planning implementation, the researchers analyze that problem by using the Fishbone strategy as follows

Plan of Action
The result of fishbone analysis indicates that the implementation method of discharge planning has many roots of the problems. Therefore, Plan Of Action (POA) is designed to solve non-optimal discharge planning in X General Hospital by focusing on the implementation method. Three agendas intended to consist of 1) arranging guidance draft, revising SOP, and revising format, 2) socializing and testing the format, and 3) evaluating the implementation of the trial.
Arranging guidance draft, revising SOP of discharge planning, and revising format are conducted by observing available literature and discussing with academic supervisors, clinical supervisors, and heads of room. After the draft is composed, it is tested in two inpatient rooms decided as a pilot project. The test was conducted on December 10-18, 2018. Before the trial, the SOP and form of discharge are socialized to nurses in the rooms. It is done when pre and post-conference in the rooms. Each of the nurses then asked to conduct a trial for hospitalized patients.

Evaluation
The result of the trial is evaluated by interview and questionnaire to assess the form of discharge planning as presented in picture 2.
The assessment format of discharge planning is X General Hospital's format. It contains anticipation when discharging, investigation on necessary assistance (aids, who will assist, what daily activities will help, need support at home or not), the occurrence of pain, the need of education and specific skills, and the need of transportation when to discharge. The result of evaluation indicates that more than 90% of the respondents argue that the format is easily understood, readily applicable, less complicated, not rambling, and practical. The nursing diagnoses format of discharge planning refers to a book of the Indonesian Nursing Diagnosis Standards published by Indonesian National Nursing Associations, and nursing care plan refers to Indonesian Nursing Intervention Standards published by Indonesian National Nursing Associations. The evaluation result indicates that more than 80% of the respondents argue that the format is easily understood, readily applicable, less complicated, not rambling, and practical The implementation format is arranged in the form of a checklist to facilitate nurses in documenting any given cares. The result of the evaluation format trial indicates that more than 90% of the respondents argue that the format is easily understood, readily applicable, less complicated, not rambling, and practical. The respondents suggest that pharmaceutical unit has prepared a setup consisting of note about medicine and drug supply at home for the implementation. Therefore, the form should be separated from the documentation of nursing implementation, but it still includes in the format of discharge planning.

.Evaluation of implementation format of discharge planning
The evaluation of instruction discharge planning document consists of medicine given to patients in the hospital or at home, patients' diet, equipment/healthcare provided at home, health education taught to the patients, and regular health checkup. This form is designed to be brought home by the patients when discharging. The respondents suggest that the format for recording medicine should be more substantial. The result of evaluation indicates that more than 80% of the respondents argue that the format is easily understood, readily applicable, less complicated, not rambling, and practical.
The results of the questionnaire, it is concluded that 1) the tested form of discharge planning is possibly implemented well by duty nurses; and 2) more than 80% of the respondents argue that the format is easily understood, easily applicable, less complicated, not rambling, and practical.

Discussion
The role of nurses to the implementation of discharge planning is significant; the nurses who are standing by 24 hours taking care of the patients, should be the leaders in the implementation of discharge planning. Research in Philippine states that structured discharge planning patients led by the nurses are an effective intervention to increase patients' health statuses, self-dedication to the patients with heart disease, patients' satisfaction, and decrease patients' readmission in the hospital (7). Therefore, the intervention is suggested to be included in optimal caring patients in Philippine. Another research states about evaluation of the nurse's roles as a clinical leader in discharge planning and initiatives of patients' safety. Protocol of discharge planning which is done by nurses creates early of time discharge, significantly decrease reconciliation of medicine in the time of discharge and patients satisfaction (8). Therefore, factors of nurses personnel are critical in the implementation of discharge planning (9)The challenge had by nurses in the implementation of discharge planning is how to make patients feel the nurses role in preparing patients' discharge (10).
Discharge planning must be done for the first time the patients come to the caring rooms. Discharge planning is done for the first time and led by the nurses, started 48 hours after the patients come to the hospital and supported by the multidiscipline team, showing conclusively in decreasing the duration of inpatients, readmission, and death because of all the causes and fee of the hospital (11,12). Moreover, some researches state that discharge planning implementation must be done at the first time when the patients come to the hospital, including patients whom outpatients or emergency unit will increase patients selfefficacy to the illness and increase patients' satisfaction (7,13). Hospital Accreditation Standard (2017) in ARK 4 Standard states that the hospital determines regulation to imply the process of discharge from the hospital based on the patient's health condition and the caring continuity requirement or intervention. Discharge planning format must be arranged based on patients' requirement, structured, and integrated because it will support health care continuity (14). Based on the result of the research, the development of an integrated discharge planning model can be referenced by the nurses. Also, it will improve the nurses' capability to imply discharge planning, and there is a no more different perception of implementation in the room (15), so patients discharge will be better in the hospital.
Discharge planning format should consist of patients assessment, planning elaboration which agrees with patients requirement, supplying of services, including family education and reference services, and follow-up or continuity evaluation (16). According to Potter and Perry (17), discharge planning format consists of 1) analysis. At the first time, patients accept health services, take the analysis related to the requirement of patients discharge. Patients' health education and families, environmental factors, and patients' health problem are important to be analyzed. Having collaboration with other PPA is important. 2) Nursing diagnosis. It is important to take diagnosis accurately, improve the patients and families' requirement based on the analysis that has done before. 3) Planning. Do planning with a purpose to make patients autonomous after having treatment in the hospital. Involve their families in this planning. 4) Implementation. There are two kinds of implementation; they are implementation before discharge and at the time when they are discharging. In the implementation of before discharge, the nurses will give education about health services to the patients' and their families. In the implementation at the time when the patients are discharging, nurses give help to the patients and their families to prepare the discharge, let the patients and their families ask some questions about the treatments in the houses, examination of doctor instruction, therapy, and fulfillment of medical equipment, medicine, and transportation for patients and families -5) evaluation. Patients and families can demonstrate every medical treatment that will be continued in the house by noticing the environment or things that enable to endanger patients. Take documentation of patients discharge as continuity information about the problem status of the patients.
Nurses must concern with written instruction in discharging, schedule of a routine checkup, and leaflets of health education offered to patients. Kemp et al. (2017) assert that less involvement of patients in discharge planning and the absence of written instruction in discharging for patients will escalate patients' unplanned readmission for the following one year (18). Hospital Accreditation Committee (14) in ARK Standard 4.2 states that hospitals must create a summary about discharge planning offered before patients leave the hospital. The summary consists of several indications of inpatients, diagnosis, and another comorbidity; vital-physical examination and other examinations; diagnostic treatment and therapeutic procedure conducted; drugs taken by inpatients with any possibility of residual effects after discontinuous taking and all drugs are taken at home; and patients' condition (patients' status). A summary about discharge planning is explained to and signed by patients or their family because it consists of instructions.
The development of discharge planning by employing information technology is necessarily considered. Research by Hariyati posits that discharge planning by engaging CD as a learning media completely assists nurses, patients, and family in preparing the patients' discharge from the hospital. Furthermore, the use of CD as a learning media escalates nurses' knowledge and the implementation of discharge planning in hospitals (19). The role of nurses is still necessary for delivering the content of learning media as well as performing mentoring and counseling for patients and their family. To improve the implementation of discharge planning in hospitals, the use of CD as a learning media possibly becomes one of the solutions.
Based on the experiment conducted on December 10-18, 2018, the format of discharge planning developed by adding nursing diagnoses, nursing intervention, nursing implementation, and instructions handed by patients when leaving the hospital indicates satisfying results. More than 80% of the respondents argue that the format is understandable, applicable, easy, simple, and practical. Therefore, the follow-up and development of this format are necessarily conducted. Providing motivation and implementing supervision from the nursing section are necessarily undertaken during the implementation of discharge planning. Reinforcement theory explains that an attitude will become a habit with internal or external encouragement. This habit will become firm if the approach is immediately and frequently strengthened and assessed (20). The implementation of discharge planning requires continuous motivation and supervision from either direct supervisor's head nurse) or nursing unit. A manager is expected to provide motivation, new ideas, and arrangement to achieve the organization's goal (21).
Though the result of the questionnaire indicates that the nurses' knowledge is adequately good in implementing discharge planning, they still necessarily consider and escalate it. Training and socialization are necessarily conducted to improve the nurses' knowledge of implementing discharge planning. The result of a research conducted in Japan (22) asserts that training succeeds in escalating the knowledge of various systems of the implementation of discharge planning, improving the nurses' attitude toward discharge planning, and influencing the condition in all units. Therefore, the training or socialization about discharge planning Conducted by the nursing unit for the nurses is substantial. It is expected that training or socialization can improve the implementation of discharge planning.

Conclusion
The implementation of the pilot study in October 29-December 13 has through some steps, started from analysis to the evaluation. Based on the result of the analysis in X General Hospital Jakarta is identified that the implementation of discharge planning is not optimal yet in the hospital. The alternative solution is by arranging references, revising SPO, and revising the format of discharge planning. Then, socializing and trying out in the caring room which is chosen as a pilot project. The result of SPO evaluation and discharge planning format shows that the format that is tried out more than 80% of respondents state it can be understood easily, easily practiced, not too complicated, and practical.

Recommendation
The role of nursing field is significant in the implementation of discharge planning, so the nursing field can suggest reference draft, revised SPO draft, and form of a revised draft of discharge planning should be done development and legalized by the leaders of the hospital. Then, the references, SPO, and discharge planning which are approved by the leaders are socialized to all of the nurse assistants. Monitoring and evaluation need to be done to the implementation of discharge planning in the rooms.
The head nurse should supervise to the implementation of discharge planning which is conducted by nurse assistant, so they are expected enable to take analysis of patients discharge planning since the patients come to the hospital, doing implementation after patients overcome their critical phases, and noticing things that are needed by the patients when they discharge from the hospital.