Published in the June 2006 issue of Today’s Hospitalist
When Eli Friedman, MD, set out to study the discharge process, he decided to focus on what patients knew about their medical condition when they left the hospital. When he discovered that more than half of the inpatients in the study were unable to identify their diagnoses at discharge, let alone the names of their medications, he was not the least bit shocked.
“I was surprised that so many patients knew anything at all,” says Dr. Friedman, chief of the nephrology division at the State University of New York (SUNY) Health Science Center at Brooklyn. “It is such a stress. The name of the medication, the dose of the medication, the frequency, the side effects, it’s very complicated.”
Dr. Friedman’s research, which was published in the August 2005 issue of Mayo Clinic Proceedings, found that that 72 percent of patients were unable to list the names of all their medications, while nearly 58 percent were unable to state their diagnoses.
“It is beyond the average reasonable person’s ability to grasp everything in a one- or two-minute discharge meeting with the doctor or social worker,” Dr. Friedman explains.
And as he quickly discovered, streamlining patient discharges is no easy task. At one point, Dr. Friedman tried to solve the problem on his own by attaching a sample pill to a file card. He then wrote the name of the medication next to the sample and explained the mnemonic device to the patient.
“I soon found I was stopping my work as a physician and serving as a scotch-tape-the-pill-to-the-card doctor,” he explains. “It was more than I was able to do.”
For hospitalists, the results of Dr. Friedman’s research ” and his experience trying to improve the discharge process ” will come as little surprise. Whether you look at the discharge process from the perspective of the patient’s wellbeing or the hospital’s need to streamline bed capacity, the discharge process is a sore spot in modern hospital care.
But because hospitalists, perhaps more than anyone, recognize the critical role that discharge summaries play, they are leading the charge to improve the discharge process.
Turbulence during discharge
Talk to Bradley Sharpe, MD, about the trouble with patient discharges, and he compares the discharge process to landing a plane.
“Air travel is often very exciting at the beginning and very exciting at the end,” says Dr. Sharpe, who is assistant chief of the medical service at University of California, San Francisco (UCSF). “Hospitalizations can be the same way.”
Turbulence during discharge, however, produces some obvious problems for quality of care. “It’s important to coordinate a quality discharge,” Dr. Sharpe explains, “one where all the providers are informed of the discharge ahead of time and patients are aware of their follow-up plans, their medications, have a discharge plan and have a ride home.”
Another concern, he adds, is the growing recognition that discharge can be a time when medical errors occur. “The literature shows the discharge period can be unsafe for patients, and we are consistently trying to improve communication and teamwork around discharge with that in mind,” Dr. Sharpe says.
To address those concerns, UCSF started an ambitious discharge-improvement project more than a year ago that focuses on patient quality. The university instituted daily “multidisciplinary rounds” in which the attending hospitalist meets with a large group that includes multiple members of the patient care team. That includes the case manager, who serves as the discharge planner, the charge nurse on the patient’s floor, a pharmacist, a nutritionist and, when appropriate, a geriatric specialist.
The primary topic of conversation at these meetings, says Dr. Sharpe, who is part of the 17-member hospitalist group at UCSF, is planning for the patient’s needs at the time of discharge. “Having all the different providers available to communicate about patients is not only good for discharge,” he explains, “but it’s good for the quality of care of the patient.”
Initially, at least, the meetings generated some resistance. After all, who needs another meeting to attend ” and a daily one at that?
“The attendings felt like they were being asked to do resident work, and they had to coordinate their mornings to show up for this 10-minute window,” Dr. Sharpe says. “The case managers felt like they had to sit in this room for an hour and couldn’t get anything done because they were waiting for the different attendings to show up.”
The meetings worked so well, however, that they quickly won over the detractors. Now when he asks for feedback at monthly meetings, Dr. Sharpe says he hears downright enthusiasm.
“Every month, universally, all the attendings say, ‘Definitely worth my time,’ ” he explains. “It has improved communication and the ability to discharge patients, both sooner and with a high-quality discharge.”
Building a better discharge summary
Improving discharge communication is also a top priority for the hospitalists at the University of Pennsylvania, but they have chosen to focus on improving the written discharge summary.
Jennifer S. Myers, MD, associate director of Penn Hospital Care Physicians, explains that the hospitalists at the academic medical center were dissatisfied with the quality of the summaries dictated by interns. Those documents were often either too brief or too long, failing to include important information or dwelling on insignificant details. And because the summaries were so poorly organized, they were hard to follow and easy to ignore.
Instead of just complaining about the quality of discharge summaries, however, the hospitalists decided to do something. They recognized that like internists everywhere, the interns had never been trained in how to do a better job. For that matter, neither have most of the hospitalists in practice today.
That’s a problem, Dr. Myers says, because the discharge summary is more important now than ever. As the number of hospitalists continues to explode across the country, the discharge summary is the main tool that links hospital-based and office-based physicians during the patient hand-off.
“Hospitalists have created a lot of the discontinuity that leads to errors from the inpatient to the outpatient setting,” Dr. Myers says, “so we should be the ones to focus in on and fix those discontinuities. One of the ways to do this is to improve the quality of the discharge summary.”
Upping the ante
Another development put even more pressure on the hospitalists at the University of Pennsylvania to improve the discharge process: Their discharge summaries were being entered into the hospital’s electronic medical records system.
“Our discharge summaries recently became available for review on our computer system,” Dr. Myers explains, “so they are often used to make future management decisions. If they are not done well, mistakes could be perpetuated during future hospital stays.”
In response, she created a research project that studied the effects of teaching interns how to dictate a quality discharge summary. The university created a curriculum that covers all the components of guidelines released by the Joint Commission on Accreditation of Healthcare Organizations on discharge summaries.
The curriculum also covers the basics and emphasizes the importance of clarity of writing, brevity, organization and readability. Dr. Myers says that all are important qualities of discharge summaries that the hospitalists in her group have learned to value through experience. The goal is to pass them onto the next generation of internists.
Early results of the study have shown that several aspects of discharge summary quality can be improved through a brief educational intervention.
Mapping the discharge process
In its effort to improve the discharge process, Boston Medical Center (BMC) took a slightly different approach: After an extensive study of its discharge process, the hospital decided that a new discharge protocol was the key.
“You think, ‘What’s so big about getting a patient in the hospital, getting him out, and having him follow up with his primary care doctor?’ But this is a complex thing,” says Christopher S. Manasseh, MD, director of family medicine inpatient services at BMC, which serves as the primary teaching hospital for Boston University School of Medicine.
As a reminder of just how complex the discharge process can be, Dr. Manasseh has a “process map” hanging on his office wall. It illustrates the myriad twists and turns that patients can be subject to as they leave the hospital.
The process map was created as part of research Dr. Manasseh led looking at ways to reduce the hospital’s readmission rate. With 22 percent of patients returning to the hospital within 90 days of discharge, BMC’s rate was in the normal range for an urban academic medical center, Dr. Manasseh says. But he and his colleagues thought the rate could be reduced “and patient safety could be improved “by overhauling the discharge process.
Whose responsibility is it?
The mapping project was a key part of the initiative, Dr. Manasseh explains, because it uncovered some significant problems. For example, interviews with various staff members revealed confusion over who was responsible for educating patients about their discharge medications.
“The residents would say, ‘It’s the nurse,’ and the nurse would say, ‘It’s the physician,’ ” Dr. Manasseh says.
He and his colleagues used the process map to develop a “discharge portfolio” that delineates seven specific steps that must be completed before the patient leaves.
“It’s like a checklist, just like a pilot has to check every box every time before the take-off and landing,” Dr. Manasseh explains. “We go down the checklist to say, ‘Yes, all the boxes are checked, so the patient is fine to go.’ ”
Among other things, the list encourages physicians to reinforce discharge instructions by engaging the patient in conversation that demonstrates comprehension; verifying that the patient’s schedule and transportation are in sync with the follow-up visit to the primary care doctor; and making sure the primary doctor receives the discharge summary.
Another team of researchers is currently testing the discharge portfolio to see how it works in real life and whether it is effective in reducing readmissions.
Standardized orders, protocols
Standardizing the discharge process was also the goal at Ochsner Clinic Foundation in New Orleans. Recognizing that outdated forms and unclear expectations resulted in great variation among the more than 21,000 discharges at Ochsner each year, physicians and hospital administrators wanted to improve patient satisfaction while decreasing the opportunity to make medical errors.
Steven B. Deitelzweig, MD, chairman of Ochsner’s hospital-based internal medicine department, says that a multidisciplinary committee spent three months flow-charting the discharge process. Smaller teams then split off to focus on specific aspects of discharge, such as identifying ways to make sure that follow-up appointments are scheduled.
The quality improvement initiative led to a standardized process that includes a preprinted discharge order set, a protocol for scheduling follow-ups, a patient instruction sheet, a computerized medication list and a “cheat sheet” that is inserted into every patient chart outlining the entire process.
Dr. Deitelzweig explains that one of the project’s overriding goals was to make streamlining the discharge process as easy as possible. “If it’s not easy,” he says, “no one’s going to do it.”
And while Ochsner plans to roll out its new discharge process throughout the hospital, Dr. Deitelzweig adds that such a massive change will have to occur incrementally. That’s why he advises hospitalists who are re-engineering their discharge process to start small and build on their successes.
“Don’t wait to try to make this universal for the organization,” he says. “This can be something that can be piloted with just a fraction of the organization. Show how well it is doing, then the others will feel some pressure to adopt it.”
Lola Butcher is a freelance writer specializing in the business of health care. She is based in Springfield, Mo.