Megan McGervey (Cleveland Clinic), carlos godoy (Cleveland Clinic), Jessica Donato (Cleveland Clin)
Decreasing hospital readmissions has been a major focus locally and nationally over recent years. Multiple components of the patient’s hospital discharge process have been shown to impact readmission rates. Frequently, residents in academic hospitals play a major role in the discharge process and in providing discharge instructions to patients.
Few efforts have focused on discharge planning in the Cleveland Clinic Main Campus general medicine teaching services, which host some of the most complex patients in the hospital. A discharge instruction template was created to hardwire multiple components that have been shown to prevent readmissions into the patient instructions used on the teaching services in hopes to improve discharge planning and reduce readmission rates.
A QI project to improve the quality of discharges from the internal medicine teaching services was undertaken starting September 2017. Current state was assessed by reviewing discharges from four teaching service teams over one week and collecting surveys from 48 Internal Medicine senior residents. Residents fail to comply with several components of a safe discharge including confirming the patient’s PCP, performing medication reconciliations, including information needed to be followed up on and providing patients with customized instructions in the after visit summary. A new discharge instruction template was created, which required residents to confirm the PCP, make follow-up appointments, create customized bulleted instructions, and provide patients with specific anticipatory guidance and instructions on who to contact after discharge. The template was launched on one of the teaching services December 2017.Process measures include PCP confirmation, creation of follow-up appointments, inclusion of customized bulleted instructions and specific anticipatory guidance. Readmission rates are being collected as an outcome measure.
Forty-one discharges on the Tucker service over one week were studied prior to the intervention. The discharge summary template has been rolled out to half of the teaching services with variable compliance. After introducing the new discharge instruction template, PCP confirmation increased from 71% to 100%, follow-up appointments from 20% to 83%, detailed discharge anticipatory guidance from <10% to 100% and bulleted discharge instructions from 58.8% to 100%.
Through the creation of a novel discharge instruction template, we have hardwired several components of a safe discharge into the template that were frequently overlooked by residents previously. We have adjusted the template based on resident input and continue to make changes based on feedback. Preliminary data is promising and the new template is being rolled out on many of the teaching services. Further data collection is underway with plans for template modification and adjustments to scale over the course of the QI project. Data regarding readmission rates is being collected.
Implications for the Patient
By using this template as the default patient instruction template throughout the teaching services, we have improved the discharge process and encouraged patient activation in their healthcare. We hope that these efforts will lead to a decrease in readmission rates.