Improving Timeliness and Quality: Discharge Summaries  Dictated by  Internal Medicine Residents Emily A. Mallin, MD Cheryl...
The Discharge Summary <ul><li>Historically served as communication tool between physicians </li></ul><ul><li>“The Age of t...
The Current Discharge Summary <ul><li>JC mandates discharge summary completed within 30 days of hospitalization </li></ul>...
Other Discharge Summary Guidelines <ul><li>JC National Patient Safety Goals </li></ul><ul><ul><li>Handoff communications <...
Challenges of the Discharge Summary <ul><li>Unavailable </li></ul><ul><li>Incomplete </li></ul><ul><li>Inaccurate </li></u...
Timeliness <ul><li>DS available for only 12.2% patients prior to outpatient visit </li></ul><ul><li>Trend toward decreased...
Timeliness and Quality <ul><li>Delayed availability and poor quality can contribute to adverse events after discharge </li...
Quality <ul><li>Educational intervention with and without individualized feedback improved quality of interns’ discharge s...
 
<ul><li>Could we improve timeliness? </li></ul><ul><li>Could we improve quality? </li></ul>
<ul><li>650-bed urban, university-affiliated, quaternary care teaching hospital </li></ul><ul><li>100 Internal Medicine, M...
STAT Discharge Process <ul><li>Instituted November 2008 </li></ul><ul><li>Hiring of transcriptionists </li></ul><ul><li>Ma...
Educational Intervention for Internal Medicine Residents <ul><li>Noon conference </li></ul><ul><ul><li>Reviewed the litera...
Timeliness Results Mallin E, O’Malley C, Gerkin R. Improving timeliness without compromising quality: Discharge summaries ...
Quality Results <ul><li>Completeness score improved, though not statistically significant </li></ul><ul><li>Readability of...
Quality Improvement <ul><li>Extension of study examines the effect of a standardized formal educational intervention on qu...
Educational Intervention for Internal Medicine Residents <ul><li>Monthly one-hour conferences, capturing all residents rot...
Evaluation of Discharge Summaries <ul><li>Pre-intervention </li></ul><ul><ul><li>12 summaries – 4 each by 3 raters </li></...
Preliminary Results <ul><li>Interrater reliability </li></ul><ul><ul><li>Intraclass correlation coefficient (ICC) </li></u...
Limitations and Future Directions <ul><li>Preliminary data </li></ul><ul><li>Patient charts were not reviewed for accuracy...
 
Additional References <ul><li>www.hospitalmedicine.org/BOOST </li></ul><ul><li>Moore, C., McGinn, T., and Halm, E. (2007, ...
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Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents

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  • We wanted to address some of these problems with discharge summaries and used a system process as a starting point.
  • Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents

    1. 1. Improving Timeliness and Quality: Discharge Summaries Dictated by Internal Medicine Residents Emily A. Mallin, MD Cheryl W. O’Malley, MD, FACP
    2. 2. The Discharge Summary <ul><li>Historically served as communication tool between physicians </li></ul><ul><li>“The Age of the Hospitalist” </li></ul><ul><ul><li>Vital communication tool </li></ul></ul><ul><ul><li>Legal document </li></ul></ul><ul><ul><li>Source for medications </li></ul></ul><ul><ul><li>Guide for outpatient follow up </li></ul></ul>
    3. 3. The Current Discharge Summary <ul><li>JC mandates discharge summary completed within 30 days of hospitalization </li></ul><ul><ul><li>Reason for hospitalization </li></ul></ul><ul><ul><li>Significant findings </li></ul></ul><ul><ul><li>Procedures performed and care, treatment, and services provided </li></ul></ul><ul><ul><li>Condition at discharge </li></ul></ul><ul><ul><li>Information provided to patient and family </li></ul></ul>http://www.jointcommission.org/NR/rdonlyres/B48B39E3-107D-495A-9032-24C3EBD96176/0/PDF32009HAPSupportingStds.pdf. Standard RC 02.04.01, EP 3, page 37. Accessed 10/6/10.
    4. 4. Other Discharge Summary Guidelines <ul><li>JC National Patient Safety Goals </li></ul><ul><ul><li>Handoff communications </li></ul></ul><ul><ul><li>Medication reconciliation at care transitions </li></ul></ul><ul><li>National Quality Forum </li></ul><ul><li>Agency for Healthcare Research and Quality </li></ul><ul><li>Society of Hospital Medicine </li></ul>
    5. 5. Challenges of the Discharge Summary <ul><li>Unavailable </li></ul><ul><li>Incomplete </li></ul><ul><li>Inaccurate </li></ul><ul><li>Inexperienced authors </li></ul><ul><li>Electronic health record </li></ul>
    6. 6. Timeliness <ul><li>DS available for only 12.2% patients prior to outpatient visit </li></ul><ul><li>Trend toward decreased readmission rates in patients whose physicians received DS prior to visit (RR 0.74, 95% CI, 0.5-1.11) </li></ul>van Walraven C et al. Effect of discharge summary availability during post-discharge visits on hospital readmission. JGIM 2002;17:186-192.
    7. 7. Timeliness and Quality <ul><li>Delayed availability and poor quality can contribute to adverse events after discharge </li></ul><ul><li>Literature Review of 73 studies </li></ul><ul><ul><li>14.5% reached PCP within 1 week of discharge </li></ul></ul><ul><ul><li>25% never reached PCP </li></ul></ul><ul><ul><li>66-88% patients contacted or were seen by PCP before arrival of DS </li></ul></ul><ul><ul><li>Missing information </li></ul></ul><ul><ul><ul><li>Hospital physician (median 25%) </li></ul></ul></ul><ul><ul><ul><li>Main diagnosis (17.5%) </li></ul></ul></ul><ul><ul><ul><li>Pending tests (65%) </li></ul></ul></ul><ul><ul><li>Physicians lacked awareness of pending tests in 40% of DS, </li></ul></ul><ul><ul><li>10% actionable </li></ul></ul>Kriplani S et al. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA 2007;297:831-841.
    8. 8. Quality <ul><li>Educational intervention with and without individualized feedback improved quality of interns’ discharge summaries </li></ul>Myers, JS. Are Discharge Summaries Teachable? The Effects of a Discharge Summary Curriculum on the Quality of Discharge Summaries in an Internal Medicine Residency Program. Academic Medicine 2006;81:10. pp S5-S8.
    9. 10. <ul><li>Could we improve timeliness? </li></ul><ul><li>Could we improve quality? </li></ul>
    10. 11. <ul><li>650-bed urban, university-affiliated, quaternary care teaching hospital </li></ul><ul><li>100 Internal Medicine, Med-Peds, Preliminary residents </li></ul><ul><li>5 ward teams </li></ul><ul><ul><li>Attending </li></ul></ul><ul><ul><li>2 residents </li></ul></ul><ul><ul><li>2 interns </li></ul></ul><ul><ul><li>Medical students </li></ul></ul><ul><li>Discharge summaries </li></ul><ul><ul><li>Dictated by upper-level residents </li></ul></ul><ul><li>Study Period </li></ul><ul><ul><li>December 2007 – February 2008 (pre-intervention) </li></ul></ul><ul><ul><li>December 2008 – February 2009 (post-intervention) </li></ul></ul>Methods
    11. 12. STAT Discharge Process <ul><li>Instituted November 2008 </li></ul><ul><li>Hiring of transcriptionists </li></ul><ul><li>Mandate that all hospitalists dictate summary on day of discharge </li></ul>
    12. 13. Educational Intervention for Internal Medicine Residents <ul><li>Noon conference </li></ul><ul><ul><li>Reviewed the literature on discharge summary quality </li></ul></ul><ul><ul><li>Reviewed the essential elements of discharge summaries </li></ul></ul><ul><ul><li>Offered strategies for dictating clear, succinct, and comprehensive summaries </li></ul></ul><ul><li>Pocket cards with instructions for dictating quality discharge summary </li></ul>
    13. 14. Timeliness Results Mallin E, O’Malley C, Gerkin R. Improving timeliness without compromising quality: Discharge summaries dictated by Internal Medicine residents. J Hosp Med. 2010;5(3)(suppl 2):S49.
    14. 15. Quality Results <ul><li>Completeness score improved, though not statistically significant </li></ul><ul><li>Readability of each section and overall readability were not affected </li></ul><ul><li>Limitation </li></ul><ul><ul><li>Did not ensure residents received education or used pocket cards </li></ul></ul>
    15. 16. Quality Improvement <ul><li>Extension of study examines the effect of a standardized formal educational intervention on quality of dictated discharge summaries. </li></ul><ul><li>Study period </li></ul><ul><ul><li>January – June 2009 (pre-intervention) </li></ul></ul><ul><ul><li>January – June 2010 (post-intervention) </li></ul></ul>
    16. 17. Educational Intervention for Internal Medicine Residents <ul><li>Monthly one-hour conferences, capturing all residents rotating on ward service that month </li></ul><ul><ul><li>Reviewed the literature on discharge summary quality </li></ul></ul><ul><ul><li>Reviewed the essential elements of discharge summaries </li></ul></ul><ul><ul><li>Offered strategies for dictating clear, succinct, and comprehensive summaries </li></ul></ul><ul><ul><li>Provided examples of poor and high quality summaries </li></ul></ul><ul><ul><li>Individualized feedback session with attending using resident’s recent discharge summary </li></ul></ul><ul><li>Pocket cards with instructions for dictating quality discharge summary </li></ul>
    17. 18. Evaluation of Discharge Summaries <ul><li>Pre-intervention </li></ul><ul><ul><li>12 summaries – 4 each by 3 raters </li></ul></ul><ul><li>Post-intervention </li></ul><ul><ul><li>5 summaries – each rated by 4 raters </li></ul></ul>
    18. 19. Preliminary Results <ul><li>Interrater reliability </li></ul><ul><ul><li>Intraclass correlation coefficient (ICC) </li></ul></ul><ul><ul><ul><li>Completeness ICC = 0.533 (p=0.138) fair </li></ul></ul></ul><ul><ul><ul><li>Total readability ICC = 0.926 (p<0.001) excellent </li></ul></ul></ul>Pre-intervention Mean Post-intervention Mean P value Completeness score 0.70 0.78 0.342 Total readability score 30.3 34.6 0.172
    19. 20. Limitations and Future Directions <ul><li>Preliminary data </li></ul><ul><li>Patient charts were not reviewed for accuracy </li></ul><ul><li>Analyze long-term effect of intervention </li></ul><ul><li>Evaluate impact of the intervention on patient outcomes and primary provider satisfaction </li></ul>
    20. 22. Additional References <ul><li>www.hospitalmedicine.org/BOOST </li></ul><ul><li>Moore, C., McGinn, T., and Halm, E. (2007, June). &quot;Tying up loose ends: Discharging patients with unresolved medical issues.&quot; Archives of Internal Medicine 167, pp. 1305-1311. </li></ul><ul><li>Greenwald, J.L., Denham, C.R., and Jack, B.W. (2007, June). &quot;The hospital discharge: A review of a high risk care transition with highlights of a reengineered discharge process.&quot; Journal of Patient Safety 3(2), pp. 97-106. </li></ul>

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