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 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 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

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)

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

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

Quality Tool: Control Chart Unstable processes

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

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

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