The discharge of patients from hospitals is a process that is well known to be associated with a variety of problems. Research has shown:
- One in five patients is readmitted within 30 days.
- One in five patients experiences an adverse event after discharge, with one-third of them being preventable.
- According to one study, at discharge only 42 percent of patients could accurately state their diagnosis, 28 percent could list the names of their medications, 37 percent could state the purpose of their medications, and 14 percent could list common side effects of their medications.
Annual Integrating Quality Symposium on March 12
The Integrating Quality Symposium: Linking Clinical and Educational Excellence, is set for March 12. It is an opportunity for the health system community to share best practices and innovations in quality initiatives that include trainees and students, or that are integrated into undergraduate, graduate or lifelong learning programs.
To improve the discharge process, three departments at UC Davis Medical Center are collaborating on projects that incorporate central roles for residents. The projects support UC Davis Health System's "Integrating Quality and Safety Charter," under which medical center residents are engaged in incorporating quality-related practices in education.
The projects, led by Ulfat Shaikh, associate professor of pediatrics, will be among those presented at the annual Integrating Quality Symposium: Linking Clinical and Education Excellence on March 12 in the Education Building.
In addition to pediatrics, the departments of internal medicine and family and community medicine are working on projects to improve the discharge process. The champions for the departmental projects are:
- Craig Keenan, associate professor of internal medicine
- Laura Poggel, associate clinical professor of pediatrics
- Huey Lin, associate clinical professor of family and community medicine
Christina Slee, an analyst in Clinical Affairs, is the data analyst for all of the projects. Each of the projects will be featured at the Integrating Quality Symposium.
Shaikh is the principal investigator for one of the inaugural grants awarded in 2011 by the UC Center for Health Quality and Innovation. The center's grants are intended to support innovations at UC medical center campuses to improve quality, access and value in the delivery of health care. Shaikh's grant is being used to develop infrastructure for a quality-improvement network involving trainees at UC's five medical centers. The first focus area of the collaboration is the improvement of patient-care transitions during hospital discharge.
Shaikh and colleagues in family practice and internal medicine have chosen five projects to improve the discharge process. The projects center on best practices for safe discharge as identified in Project Boost, a national collaborative sponsored by the Society of Hospital Medicine that aims to:
- Reduce 30-day readmission rates for general-medicine patients, with a focus on older adults
- Improve patient-satisfaction scores and Hospital Consumer Assessment of Healthcare Providers and Systems (H-CAHPS) scores related to discharge
- Improve flow of information between hospital and outpatient physicians and providers
- Identify high-risk patients and target specific interventions to mitigate their risks for adverse events
- Improve patient and family preparation for discharge
Training residents to be quality-improvement experts
In working toward these objectives, pediatrics, internal medicine and family and community medicine are following goals to guide implementation of best practices at UC Davis Medical Center and provide training for residents to become quality-improvement experts in safe transitions of care. The medical center's Performance Improvement Unit will help provide training.
The departments' goals are as follows:
Increase the number of patients who are discharged with a follow-up appointment with their primary-care provider within seven days
- Internal medicine residents and attending faculty physicians will review lists of patients discharged the previous day during morning huddles to identify patients with immediate follow-up needs that can be addressed with a follow-up phone call or outpatient clinic appointment.
- Project leader: Craig Keenan, associate professor of internal medicine
Increase the number of patients who have discharge summaries completed within 72 hours of discharge
- Pediatric residents will receive monthly lists of discharged patients and assess barriers to timely completion of the discharge summary and transmission to the outpatient medical provider.
- Project leaders: Laura Poggel, associate clinical professor of pediatrics; Kate Sutter, assistant clinical professor of pediatrics; and Christina Slee, analyst, Clinical Affairs
Increase the percentage of discharge summaries rated as "excellent"
- Pediatric residents will evaluate discharge summaries to identify where critical information for safe discharge is missing, and target improvements to the content that would make the discharge summary "excellent."
- Project leaders: Ulfat Shaikh; Cherie Ginwalla, assistant clinical professor of pediatrics; and Su-Ting Li, associate professor of pediatrics
Increase the proportion of patients who rated their care related to hospital discharge as "excellent"
- Family practice will track patient satisfaction with the discharge process based on patients' responses to "The 3-Item Care Transitions Measure," or CTM-3, starting in January 2013. The CTM-3 covers the three major areas that patients have identified as critically important to their experience with the discharge process: understanding their self-care role after discharge, medication management and having their preferences incorporated into their care plans.
- Project leader: Huey Lin, associate clinical professor of family and community medicine
- Increasing medication reconciliation at discharge
- Residents in general medicine will review the medication list in the discharge summary and compare it to medications listed in the after-hospital summary, which is provided to patients upon discharge for documentation of their immediate follow-up care needs, such as changes in medication regimen, next doctor's appointment, instructions for self-care and emergency follow-up.
- Project leader: Craig Keenan, associate professor of internal medicine
National focus on improving hospital discharges
The safety of hospital discharges and the prevention of avoidable readmissions is a national concern among hospitals. Medicare currently pays for all readmissions for the same conditions, but there are proposals that will reduce payments for readmissions within 30 days on the basis of this schedule:
- 1 percent in 2013
- 2 percent in the 2014 program year, starting in October
- 3 percent in 2015
Fixing readmission problems and creating safe transitions of care largely depend on improved communication, said Shaikh. Communication about inpatient admissions and subsequent discharges does not always occur with the referring provider. In addition, patients and their caregivers often feel overwhelmed at discharge by the complex information they receive about after-hospital care.
To create a safer discharge process at UC Davis Medical Center, Shaikh and Slee have participated in two national collaboratives: Best Practices for Better Care, sponsored by the University Health System Consortium (UHC) and Association of American Medical Colleges, and Partnership for Patients, sponsored by the Centers for Medicare and Medicaid Services and UHC.