1. Team Members: Mark Shen, M.D. Don Williams, M.D.
Improving the Timeliness of Hospitalist Discharge Communication
Team Members:
Mark Shen, M.D.
Don Williams, M.D.

2. 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

3. The Problem of Discharge Handoffs

4. Systematic review of literature
JAMA. 2007;297:

5. 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:

6. 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:

7. 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

8. Our Aim
90% of discharges will have a discharge letter dictated within 2 days of hospital discharge by July 2010

9. 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

10. Quality Tool: Key Drivers Diagram
AIM KEY DRIVERS INTERVENTIONS
All discharges should be dictated as letters with the “50” code.
Educate 2nd and 3rd year residents
Attending makes it clear that s/he is part of the dictation team
90% of hospitalist discharges will have a discharge letter dictated within 2 calendar days of discharge
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 a daily topic on rounds
Dictations are reconciled daily
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 (off-service, weekend, etc.) notes can be dictated under a “40” or other code
Someone remembers to bring this up prior to changes in service

11. 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)

12. Current Process
Too many options dependent on
too many “what ifs”

13. Ideal Process A better process: reduce the number of steps, and
STANDARDIZE

14. Quality Tool: Control Chart
Unstable processes

15. 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

16. 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

17. Results

18. 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”

19. Unexpected ROI: Decrease in Delinquent Medical Records

20. Generalizability: National Collaborative
Percent of discharges with documented communication with PCP within 2 calendar days of discharge, by months of participation
Center

21. 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

22. 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