Initiative Improved Discharge Documentation
CHICAGO — A multimodal, multidisciplinary quality improvement process substantially improved the overall quality of discharge documents across five acute care hospitals, according to a new study by Partners HealthCare of Boston.
After the quality improvement initiative, 96% of discharge packets contained all 12 data elements required for discharge, compared with 65% at baseline.
The largest improvement was seen in documentation of preadmission medication, which rose 19% from 81% to 100%, Dr. Esteban Gandara said at the annual meeting of the Society of Hospital Medicine. Documentation also significantly increased from 91% to 97% for follow-up information and from 92% to 96% for warfarin information. The increases were particularly large for these three items because they had the most room for improvement, he said.
The retrospective analysis included 3,101 discharge documentation packets for patients discharged to subacute facilities from January 2006 through September 2008. Discharge documents included discharge summaries, discharge orders, and nursing instructions and were reviewed for 50 randomly selected patients per hospital per quarter.
Improvements were achieved at all five hospitals in the Partners HealthCare system without financial incentives to the hospitals or physicians, said Dr. Gandara, of the division of internal medicine and primary care at Brigham and Women's Hospital in Boston. The biggest motivator was that the data were reported to the chief medical officer every quarter.
The quality improvement initiative was prompted by two recent studies at his hospital that found only 70% of discharge summaries had all of the information required by the Joint Commission. Important deficits were found regarding medication reconciliation, pending test results, and anticoagulation. There was also no formal quality assurance process in place to review discharge documentation, he said.
Interventions used during the 3-year initiative included technological improvements to hospitals' discharge ordering systems to actively solicit and/or automatically import required information into discharge documents, creation of discharge templates, feedback to clinicians and their service chiefs, staff education, and documentation reviews by nurse care coordinators prior to discharge.
Some of the hospitals did not utilize all of the interventions. They were also allowed to customize their discharge template, as long as it included all necessary data, Dr. Gandara said. The 12 required elements were treatment rendered, treatment response, allergies, preadmission medications, follow-up information, physician contact information, procedures performed, discharge medications, target international normalized ratio, and warfarin indication, duration, and dose.
The smallest quality improvement was observed at a community hospital that did not use technological improvements, while the largest improvements were seen at two academic medical centers with the greatest use of information technology, he said. Community hospitals discharged 53% of the sample, and 74% of patients were from medical units.
“Multiple interventions can improve discharge documentation,” Dr. Gandara said. “Different hospitals might choose different approaches.
“Education, feedback, and publicity are necessary, but you also need some high-reliability components such as IT or case manager sweeps,” he added.
Dr. Gandara acknowledged that some, but not all, of the observed improvement was likely due to changes in measurement methodology and that the study design is subject to confounding. Also, the study failed to analyze the effect of the intervention on patient outcomes.
The investigators disclosed no relevant conflicts of interest.
