Optimization of Nursing Management Rounds and Implementation of Discharge Planning in Fatmawati Hospital Jakarta

The results of the study identified the existence of obstacles in the implementation of discharge planning which had an impact on the lack of optimization of discharge planning implementation and the determination of the length of stay of the patient. The author uses the case study method. The innovation agreed upon with the nursing manager was in the form of implementing a nursing management round which was expected to have an impact on improving the implementation of discharge planning, as well as revisions to the standard operating procedures and the discharge planning documentation in accordance with Standard Nasional Akreditasi 2018. The result is an increase in knowledge of the head nurse and clinical care manager related to nursing management rounds (49.25%) and experience improvement (39.13%). Standard operational procedure of discharge planning draft and discharge planning form are agreed upon by the nursing manager. Resocializing discharge planning to doctors, nurses, nutritionists, pharmacists, and other health workers is needed to support patient safety and patient comfort before returning home.  


Introduction
Discharge planning is a preparation process before a patient leaves from one level of service to another level of service or exits from a service unit to the home, which is carried out during the treatment process, to decide what is the best action for the patient's health after leave the hospital (9). The discharge planning process is carried out comprehensively and involves multidisciplinary activities that cover all health care providers involved in providing health services to patients, as well as the involvement of patients and families (12). Discharge planning is done holistically including bio-psychosocial, cultural, and spiritual that needs to be achieved (2).
Fatmawati hospital as a national referral hospital for people throughout Indonesia sets a standard for health workers to plan a patient return, in accordance with national (KARS) and international (JCI) accreditation standards and supports the implementation of patient care standards related to Access to Care and Continuity to Care (ACC). Fatmawati hospital has clear guidelines regarding discharge planning, standard operational procedure, and flow that are already available well, along with the forms that are available to help implementation. Discharge planning is needed, related to the characteristics of patients in Fatmawati Hospital from across the province and there is an increase in the proportion of patients with severity level 3 (up to 30-40% of cases), meaning patients who come have a disease with a major complication rate (11).
Based on observations about 3 months, nurses experienced problems including the lack of integration between caregivers for the implementation of discharge planning. In addition, not all professional caregivers consistently plan a discharge planning, so estimates of the length of stay often cannot be determined, and the patient's length of stay becomes elongated. Nursing rounds are effective in improving the quality of a nurse's performance and increasing patient satisfaction with nursing services. Rounds with direct interaction with patients can help identify patient needs, conditions and environment that will support patient recovery and become problem-solving solutions. There needs to be socialization of the implementation of rounds and the involvement of managers in the process of optimizing discharge planning.

Objectives
The objective of this study is to identify optimization of nursing rounds and implementation of discharge planning in Fatmawati Hospital in Jakarta.

Method
The method used is in the form of case studies by reviewing documents, interviews, and questionnaires distributed to nursing staff that has worked for more than three years in unit Teratai of Fatmawati Hospital in Jakarta. This study is an innovation legalized by a permit number DM 01.01/ VII.2/ 1361/ 2019 to collect data and publish the research result conducted in Fatmawati Hospital in Jakarta.
Situation analysis is carried out with a SWOT analysis to identify strengths, weaknesses, threats, and opportunities related to discharge planning, then plans of action are made together with the head of the room, clinical care manager, installation coordinator, nursing committee and nursing field based on existing problems. The basis of analysis is based on the role and function of management. Innovations that will be carried out based on existing problems are in the form of nursing rounds and policy revisions related to discharge planning as the embodiment of ongoing health services (continuum of care).

Result
Based on the results of the documentation review, there is incomplete documentation of discharge planning. For example on the status of Mr. A, in the remarks column has not been explained in detail regarding family members who care for patients at home. Information about hazard at home and return transportation has not been filled. Estimated length of stay cannot be determined. The results of the documentation review on Mrs. C with the patient's status returning, the nurse is sufficiently complete to screen the patient's risk factors to go home. In the remarks column, the nurse writes that there is a patient's concern before discharge, but does not explain in detail the reason the patient is worried about returning home and family members who care for the patient at home. Also not explained about the number of children who are still the responsibility of the patient and the type of follow-up needed. Based on interviews with inpatients at Unit Teratai, nurses have carried out patient education in the form depend on needs and questions posed by the patient, but some patients say that nurses have not given education related to care needs.
Based on the results of the questionnaire, it was found that most (50.98%) nurses understood the discharge planning function appropriately, namely to prepare a follow-up plan from admission to return to home.
The results of the questionnaire showed that nurses did not feel clear about filling in form discharge planning. In addition, the nurse said that the means to support the implementation of the discharge planning were inadequate. The means referred to here are for example leaflets, brochures, CDs, and so on. The Health Promotion and Public Relations Installation (IPKH) stated that several leaflets had been made in accordance with the disease that often appeared but incomplete. In addition, most nurses (73.3%) knew that all caregivers gave discharge planning; include doctors, nurses, nutritionists, pharmacists, and rehabilitation. But in fact, nurses only fill discharge-planning form. Suggestions put forward by nurses regarding the implementation of discharge planning are the socialization carried out by management to all staffs' involved and increased commitment to the sustainable implementation of discharge planning.
Based on interviews with the Head of Monitoring and Evaluation Nursing, Fatmawati Hospital formed the Access and Continuity to Care Team to identify problems, monitor, and evaluate the discharge planning implementation so that it was carried out continuously in accordance with established standards. There isn't a nursing round, but there is a Case Reflection and Discussion (DRK) activity conducted at least once a month by each room at Teratai Unit to discuss specific cases specifically including the repatriation plan that will be given.
Because the Teratai Unit has held Case Reflection and Discussions (DRK), the nursing rounds are not carried out in this unit. In fact, nurse, the head nurse, and PN only carried out case reflection discussions, by inviting the nursing coordinator. Complicated problems that occur in the room cannot be directly conveyed to top management without nursing rounds.
The author makes a TOWS matrix to find solutions to problem solving using opportunities and strengths that exist both inside and outside the organization, as well as conducting target setting and activities with the balance scorecard. Innovations agreed upon by low, middle, and top managers based on the results of discussions are the implementation of nursing rounds and new drafts containing standard operational procedure and discharge planning forms based on National Accreditation Standards and JCI.
Identifying problems is illustrated in the situation analysis below: The formation of the ACC team that identifies the problem, supervises, evaluates the implementation of discharge planning 2.
Availability of guidelines and standard operational procedure related to the implementation and documentation of discharge planning 3.
The existence of discharge planning form issued by the Medical Services Field 4.
There are DRK activities carried out in each Teratai Unit to discuss specific diseases 5.
The Health Promotion and Public Relations Installation facilitates discharge planning 6.
Fatmawati Hospital has been accredited by KARS and JCI Weakness 1. Some nurses do not understand about the format and content of discharge planning 2.
There is no agreement between health care team to determine expected discharge date 3.
Revisions to standard operational procedure and discharge planning form have never been done 4.
Re-socialization regarding the implementation of discharge planning has not been carried out 5.
There is no commitment to implementing discharge planning together in an integrated manner 6.
The big round of nursing has not been carried out Opportunity 1. KARS and JCI provide the necessity for every hospital to carry out discharge planning to improve service quality 2.
The high public need for knowledge about what to do after returning home 3.
There is support from the government to the Hospital under KEMENKES Threat

1.
High competition with hospitals around South Jakarta 2.
Many reports in the media about the high demands of the public for health services 3.
Communities in the BPJS era demand optimal care from all professions Standard operational procedure and form are socialized to the head nurse and PN. The input given is in the form of a more representative and efficient form in writing related to Fatmawati Hospital, which will use a computerized system. Additional points in accordance with National Accreditation Standards are agreed. The discharge planning draft is stated to be more complex and complete and facilitates filling in according to the authority of each caregiver professional. The standard operational procedure and the form are received by the ACC team and will be submitted to the medical service field for the revisions. The follow-up plans that will be carried out include the revision and ratification of the standard operational procedure and form this month. The target that cannot be implemented is to socialize the implementation of discharge planning to all staff of professional caregivers because they plan to conduct socialization to all professional caregivers after completing revisions.
After socializing the nursing round to low, middle, and top management, there are differences in understanding and experience regarding the implementation of rounds before and after socialization. It can be seen that the knowledge of the head nurse and clinical care manager regarding the round has increased as much as 49.25% , and the experience of the head nurse and clinical care manager in the round has increased by 39.13%.

Discussion
Fatmawati Hospital uses the primary nurse (PN) method. Nursing care based on the PN method, also called relationship-based nursing, has the principle that the nurse has responsibility or authority from the beginning of the patient's admission to the hospital until repatriation preparation, and for 24 hours is responsible for providing nursing care. The nurse examines the patient's needs so that discharge planning can be done immediately (8).
Discharge planning is one of the points of assessment in a patient-centered care scenario and integrated patient care (16). It is important to do the nursing round. Matron rounds are carried out by going around to one room to another room with the aim of asking about the patient's condition and checking the standards of care for care, hygiene, tidiness, and checking the quality of nurses in implementing nursing care (4). Required roles and functions of the manager to carry out nursing rounds to ensure the implementation of patient-centered care. Nursing management always begins with the process of planning, organizing, staffing, direction, and supervision (18).
Planning is a result of all sequences of thoughts about what will be done in accordance with agreed objectives. Planning consists of what, how, where, when, and why it is done. With good planning, assignments that are more specific and detailed can be determined by the staff, so that managers can carry out appropriate monitoring or supervision in accordance with the indicators of achieving organizational goals. Points from planning compile organizational policies and formulate organizational performance standards. The policies compiled in the form of guidelines, standard operational procedure, guidelines regarding the nursing round and the standard operational procedure of discharge planning. In addition, there is a need to revise the discharge planning implementation policy. In the assessment, identified patients who need discharge planning with several criteria such as age, mobilization inability, the need for nursing assistants, and need assistance for an activity daily living (ADL). It also identified the needs of social assistance, nutrition, finance, psychology, transportation, and the need for preventive efforts at home. Caregivers professionals are also required to review patient and family expectations regarding hospital care until home return (16). Discharge planning implementation includes special education or training needed by patients and families for continuity of care outside the hospital.
Hospital refers patients to health practitioners where patients live if patients come from other communities or regions. Families are contributed in the return planning process (6). The form can be added by identifying activities that allowed to be done at home according to the daily living activity based on the value of patient dependence (17). In addition, signatures and identities of recipients of information can be added to prevent the provision of repeated information and to ensure the accuracy of the information.
The organizing function focuses on implementing a range of controls in the implementation of discharge planning care. Organizing focuses on the structure of the job description of each individual at each level (5). In the organizing function, clearly written about the organizational structure, meaning clearly stated the function of each staff, to whom he must be responsible, and how their flow to communicate. This also applies to the implementation of a nursing round.
In the major rounds of nursing, the top manager plays the main role in carrying out the round followed by the nursing committee, the installation coordinator, the head nurse and the clinical care manager. The person in charge of the patient is tasked with ensuring optimal discharge planning implementation as well as overseeing the completeness of the discharge planning documentation, conveying matters that are obstacles to the implementation of discharge planning to the nursing field during the nursing round. This is so that the top manager knows clearly about the problems that exist to determine the most appropriate problem solving that can be done. On the other hand, the quality committee is significantly responsible for carrying out documentation audits including complete documentation of discharge planning.
Actuating is how methods are carried out by managers to organizational members to carry out their roles in accordance with their authority (19). Effective communication and strong motivation help a direction to go well. In motivation, there needs to be a positive reinforcement that can be used by managers to increase strong incentives. Actuating in this innovation includes re-socializing rounds and brainstorming between leaders in planning and obstacles that may occur during the round. The purpose of the nursing round is understood together, namely increasing patient safety, identifying patient needs, communication inability between nurses and patients, and increasing patient satisfaction. Nursing rounds are proven to improve the skills and knowledge of a nurse so that the quality of nursing care will also increase (3).
Controlling is a way of evaluating staff performance to run according standards. The object of supervision is in the form of managerial abilities and nursing care. The findings from the basis for providing alternative improvements that must be done together, and preventing similar problems happened again. The function of supervision (controlling) is carried out to maintain or improve the quality of organizational performance. Knowledge evaluation can be done through the questionnaire method, study documentation, observation, or assessment of procedures carried out directly. Questionnaires distributed to participants who took part in the nursing round socialization showed that there was an increase in knowledge and experience from round participants.
Effective leadership can influence the behavior of others so that the goals of the organization can be achieved (5). Managers increase the role of discharge planning implementation by nursing staff. Speaking of the role of manager, managers need to evaluate the motivation of each staff because the levels of motivation vary by individual. Mintzberg said that giving motivation is one of the interpersonal roles of a leader (10). Motivation of each individual can be assessed depending on what needs are underlying (13).
According to Douglas Mc Gregor, it is said that managers have two perspectives on their staff, namely the theory X says that some staff have a dislike nature of work so managers need to direct and motivate staff in full, while Y theory states that some staff have a creative and responsible nature. Fredrick Herzberg said that there are two things that become motivations in a person, namely extrinsic factors such as supervision, wages, and work conditions, and intrinsic factors such as responsibility and achievement. Managers need to review this to find out the right follow-up for all members of the organization. Managers need to know the need for achievement, strength, and affiliation so that staff has self-efficacy to devote themselves to their work both physically, mind and emotion; deepen their role in work and are fully committed to their work (13).
The informational role of a manager is one of them related to effective communication. Communication consists of transfers and understanding. This means that the message must arrive at an understanding so that communication is said to be effective if the sender and recipient of the message have one common understanding. The direction of communication that can be done by a manager, namely on the staff in the form of instructions, work direction, policy information, or work procedures. Staff provides feedback for information that has been submitted. Managers play a decisive role when together with staff discuss issues and solve the right problem. This discussion can be done in a nursing management round. Shared commitment is needed so that the implementation of the round continues every month, with the involvement of the nursing field in making a monthly schedule for implementing nursing rounds according to guidelines, standard operational procedure, flow, and round assessment instruments that have been prepared. Ratification of the round guide by the nursing field and the president director is a follow-up plan, so that the implementation of the nursing round is not only carried out in one installation but also throughout the care unit in Fatmawati Hospital.

Conclusion
This study concluded that the socialization of nursing management rounds was effective in increasing patient knowledge and experience. Nursing rounds can help nurses in finding complex problem-solving solutions related to nursing care including discharge planning. The drafting of the discharge planning policy according to National Accreditation Standards is approved by low-middle-top nursing management and will be taken into consideration in the making of the revised standard operational procedure. Managers need to implement managerial roles and functions appropriately so that the discharge planning process can be carried out effectively and efficiently.

Recommendation
Continuous and well-structured discharge planning is one of the manifestations of patient-centered care. Therefore, the author's recommendations may be needed to improve quality in the implementation of discharge planning. Commitment to the implementation of the nursing round scheduled by top management of nursing can improve cooperation involving all staff to follow up on problems that occur while conducting discharge planning. Recapitulation of readmission numbers should be documented every month in order to evaluate the success of discharge planning. In addition, the implementation of discharge planning related education needs to be carried out. Managers provide motivation to staff on the basis of implementing discharge planning to patients before returning home with effective communication. Discharge planning re-socialization to all professional interdisciplinary Implementation of discharge planning resocialization 1.

PLAN OF ACTION
Discussing with the management of medic services related to re-socialization of discharge planning to all caregivers professionals 2.
Evaluate after the re-socialization process