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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. You’ve Got Mail. Re: Hipaa

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Team Members: Mark Shen, M.D. Don Williams, M.D.

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  1. 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;297:831-841.

  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;297:831-841.

  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;17:186-192.

  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 AIMKEY DRIVERSINTERVENTIONS 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 are assigned to a team (attending included) member before the patient is discharged Dictations must be done by day of discharge or at most, by the next day 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

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