Improving the Timeliness of Hospitalist
Discharge Communication
Team Members:
Mark Shen, M.D.
Don Williams, M.D.
You’ve Got Mail
• Re: Hipaa
– I just called Hipaa's dad to see how she's
doing...He said that she was discharged
yesterday. Could someone send me a
summary of what has been going on please? I
haven't seen her in months...Thanks, Head of
Big Pediatric Group
The Problem of Discharge
Handoffs
• Systematic review of
literature
JAMA. 2007;297:831-841.
Poor Timeliness of Discharge
Communication
• PCPs and patients often made contact
before discharge information arrived (16%88%)
• Delayed or absent discharge
communication was estimated to
adversely affect management in 24% of
cases
JAMA. 2007;297:831-841.
• Trend towards decreased risk of readmission for
patients seen for follow-up by a physician that
had received a discharge summary
– Only 24.5% of summaries were available for at least 1
follow-up visit
J Gen Intern Med 2002;17:186-192.
Pediatric Consultation and Referral
Service (PCRS)
• Traditionally strong ties to the pediatric
community of Austin
• Vision: Leaders in communication in
complex systems
• PCP Feedback: inconsistent discharge
communication
Our Aim
90% of discharges will have a
discharge letter dictated within 2 days
of hospital discharge by July 2010
Sampling Method
• Numerator: presence of a discharge letter
in the EMR
– Within 12 hours of dictation:
• Transcription
• Auto-fax to PCP
• Population in EMR
• Denominator: hospitalist discharges from
the primary medical units on M, Th and Su
Quality Tool: Key Drivers Diagram
AIM
90% of
hospitalist
discharges will
have a discharge
letter dictated
within 2 calendar
days of discharge
KEY DRIVERS
INTERVENTIONS
All discharges should
be dictated as letters
with the “50” code.
Educate 2nd and 3rd year residents
Dictations must be
done by day of
discharge or at most,
by the next day
Dictations are assigned to a team
(attending included) member before
the patient is discharged
Dictations are
reconciled daily
Attending makes it clear that s/he is
part of the dictation team
Dictations are a daily topic on rounds
A “Dictation Done” column is added
to sharepoint; pts not removed until
done
Attendings look at sharepoint list
daily (or personal COMPASS list)
Complex/Long/ICU
Stays done prior to
discharge when
possible, with brief
addendum on actual
d/c
See if pre-service change (offservice, weekend, etc.) notes can be
dictated under a “40” or other code
Someone remembers to bring this up
prior to changes in service
Quality Tool: Process Maps
• Common feedback: “We don’t really have
a process; everyone does it differently…”
In reality, there IS a process
(it’s just hard to diagram when there is too
much VARIATION)
Resident &
Attending Have
Conversation re:
Discharge
Current Process
Current Process
Decision to
discharge
Maybe
Yes
Dictation
Assignment is
made
No
Dictation
assignment is
made
Yes
No dictation
assignment is
made
Dictation Occurs
Yes
Dictation
occurs
No
Three Scenarios
Resident dictates
discharge
Resident
discharges w/out
talking to
attending
Pt stays
overnight
Yes
Resident talks
with attending
Assignment is
made
Dictation
Occurs
Yes
No
Dictation
complete
Attending sees
no dictation on
list next day
No
Resident
remembers to
dictation next day
No
HIM contacts
PCRS for
dicataion
Resident/
attending does
not dictate @
discharge
Dictation did not
occur before
discharge
No
Too many options dependent on
too many “what ifs”
Resident &
Attending Have
Conversation re:
Discharge
Ideal Process
Ideal Process
Decision to
discharge
Yes
Maybe
Dictation
assignment is
made
Yes
Resident/
attending dictates
discharge
Dictation
occurs
A better process: reduce the
number of steps, and
No
Resident/
attending does
not dictate @
discharge
Attending sees
no dictation on
list next day
No
Resident
remembers to
dictation next day
No
HIM contacts
PCRS for
dicataion
STANDARDIZE
/1
5
11 /20
/2 09
2
11 /20
/2 09
9/
2
12 00
/6 9
12 /20
/1 09
3
12 /20
/2 09
0
12 /20
/2 09
7/
20
1/ 09
3/
2
1/ 01
10 0
/2
1/ 01
17 0
/2
1/ 01
24 0
/2
1/ 01
31 0
/2
0
2/ 10
7/
2
2/ 01
14 0
/2
2/ 01
21 0
/2
2/ 01
28 0
/2
0
3/ 10
7/
2
3/ 01
14 0
/2
3/ 01
21 0
/2
3/ 01
28 0
/2
0
4/ 10
4/
20
10
11
Quality Tool: Control Chart
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Interventions
• Shift primary responsibility to interns for
dictating discharge letters
– Education at beginning of academic year
• Identify low performers and help them
– Dictation responsibility discussed daily
– Reconcile whether dictations were completed
the next day
Interventions
• Financial Incentive
– Clinical incentive worth about 3.5% of each
physician’s salary
• Base Target: 75% timeliness = half of incentive
• Outstanding: 90% timeliness = full incentive
Results
Return on Investment
• Survey of pediatric community by local
Pediatric Alliance:
– PCRS received the highest marks for
communication
– “Communication is so much better”
– “Discharge summaries have been received
promptly on a consistent basis”
Unexpected ROI: Decrease in
Delinquent Medical Records
Resident Suspension Occurrences 2008 - 2010
60
51
50
40
30
30
20
10
9
0
2008
2009
2010
Generalizability: National Collaborative
Percent of discharges with documented communication with PCP within
2 calendar days of discharge, by months of participation
100
90
80
70
60
Center
50
A
40
B
C
30
D
20
E
F
10
G
0
1
2
3
4
5
6
7
8
Lessons Learned
• The beginning of each academic year is
critical for imprinting quality behavior on
new residents
• Financial incentives can measurably
improve physician behavior over the short
term
• Improvement lessons may be shared
nationally
Next Steps
• Pediatric Hospital Medicine Discharge
Handoff Collaborative: Part II
– Disseminate lessons learned and successes
– Address content of discharge communication
– Grow new improvement leaders
– Secure funding/resources for the
Collaborative