Improving Timeliness of Patient Discharge Summaries within Orthopaedic Surgery: A Quality Improvement Initiative

1. INTRODUCTION

The transition from hospital admission to home is a critical point in a patient’s care. Discharge summaries provide patients and community-based care providers with written communication detailing their hospital stay, diagnosis, interventions performed, and follow-up plans. Discharge summaries are crucial to patient continuity of care post-hospital discharge, and the timely transfer of information at the time of discharge helps contribute to a safe and effective transition of care [1]. Delays in dissemination of discharge summaries have been shown to result in higher readmission rates [2-5]. Based on the recognized importance of timely and accurate completion of discharge summaries, Health Quality Ontario (our institution's governing quality body) has highlighted discharge summaries as a priority and has included this on its list of mandatory quality indicators to be reported by hospitals [4].

At London Health Sciences Centre, a multi-site tertiary care hospital, the institutional target for discharge summary completion is >80% completion within 48 hours. At project initiation in June 2022, the Division of Orthopaedic Surgery was identified as a negative outlier, with a completion rate of 48% within the 48-hour target timeline. The Department of Surgery was identified as the lowest-performing department within the hospital, and the Division of Orthopaedic Surgery was identified as the lowest-performing division within the Department of Surgery. Barriers to timely completion of discharge summaries were previously identified as including the high-volume nature of the clinical service, decreasing lengths of stay as a result of other ongoing improvement initiatives, lack of role clarity, and suboptimal use of our electronic medical records.

The discharge summary process at our institution consists of a member of the medical care team (typically a medical student, medical resident, or fellow) dictating a discharge summary, which is transcribed by a transcriptionist into the electronic medical record. This is then authorized by the most responsible physician, who must complete a discharge summary for all inpatients within 48 hours of discharge prior to being disseminated [6].

The purpose of this quality improvement initiative was to improve the timeliness of discharge summary completion, with a specific goal of achieving >80% completion within 48 hours by June 30^th, 2023.

2. METHODS

2.2. Settings and Participants

This study was conducted in Western University’s Division of Orthopaedic Surgery. The University of Western Ontario's Research Ethics Board has granted this study ethics exemption. This study was reported in accordance with SQUIRE guidelines.

2.5. Interventions

The first intervention consisted of educational efforts and stakeholder engagement to ensure that team members were aware of the importance of timely discharge summary completion and to identify any barriers to accurate and timely completion. Educational efforts were repeated with the onboarding of new residents in June of 2023.

The second intervention consisted of an auto-authentication feature for discharge summaries. Time to authentication was identified as a major barrier to timely discharge summary completion, with authentication times exceeding 72 hours in many cases. Departmental consensus was reached on the feasibility of allowing discharge summaries to be auto-authenticated without compromising patient safety, and educational initiatives for team members were conducted to ensure this feature would be used at the time of dictation.

The third intervention consisted of an audit and feedback system that was developed to inspire collegial competition in order to improve completion. The Division of Orthopaedic Surgery is divided into six CTUs, each of which has 3-7 faculty members. On a monthly basis, data was compiled and circulated across the division to comment on overall performance and to identify the strongest and weakest performing CTU each month.

The fourth intervention consisted of the engagement of nurse practitioners to assist in completing discharge summaries. This was specifically targeted at lower-performing CTUs and for Monday morning completion for patients who were discharged over the weekend, as Monday mornings were identified as a particularly busy time for medical residents.

3. RESULTS

This project led to a significant improvement in the rate of discharge summary completion within 48 hours, from 48% in the three months prior to project initiation to 87.1% at project completion. The statistical process control chart (Fig. 4) demonstrates progressive and sustained improvement in discharge summary completion rates. The chart is labelled with the timing of all four of the interventions.

In July, 2022, 257 discharge summaries were completed within 48 hours among all CTUs compared to 354 discharge summaries completed within 48 hours in June, 2023.

4. DISCUSSION

Timely and accurate completion of discharge summaries is a challenge faced by many healthcare systems [1-3, 5, 7-10]. Primary care providers (PCPs) and other healthcare providers struggle with treating patients if they do not have adequate information about their patients' health status readily available [3, 11-14]. This can cause delayed or inaccurate communication between hospital-based physicians and primary care physicians, resulting in an inaccurate representation of a patient's recent interventions, hospitalizations, drug plans, or other intended care plans [2, 13, 15]. Our quality improvement initiative successfully improved our performance in this important quality indicator, allowing us to surpass our institutional and provincial targets. This also elevated the Division of Orthopaedic Surgery to the second-highest-performing surgical division and increased the hospital-wide metric from a total of 72% to 76%.

There were several critical features of this project that we believe contributed to the overall success of this initiative. Firstly, broad stakeholder engagement and buy-in helped ensure our division was working collaboratively towards this common goal. Additionally, the engagement of residents and nurse practitioners helped with identifying the unique barriers to success for different CTUs and ensuring that we could address those with change ideas.

Secondly, access to timely and detailed data helped target interventions where they would be most effective. For example, it was identified that time to authentication was a key driver of delays to discharge summary completion, with authentication times of >72 hours in several months. This allowed us to develop and implement the auto-authentication feature, ensuring that we could bypass this lengthy authentication process.

Finally, the audit and feedback system was essential in achieving ongoing improvement in this area. This ensured that attending physicians, medical trainees, and nurse practitioners across the division were paying attention to this important metric. Additionally, it helped leverage the competitive nature of orthopaedic surgeons to help foster collegial competition and provided the incentive for lower-performing CTUs to improve their performance on a monthly basis. In four of the nine months, the lowest-performing CTU in one month became the highest performer in the subsequent month, likely as a result of this audit and feedback system.

When implementing the audit and feedback system, a decision was made to disseminate the results on a CTU level rather than identifying individual providers. This ensured that no individual attending surgeons or trainees felt ‘singled out’ for their performance. Individual self-performance data was made available to each provider upon request.

Subdividing the results on a CTU level rather than an individual provider level also allowed the improvement team to work with the identified CTUs physician extenders. When two specific CTUs were noted to consistently have lower completion rates, three nurse practitioners who support these CTUs were engaged in the project. Slight changes were made to the workflow based on their feedback, which allowed them to become more easily involved in the discharge summary completion process.

Another important feature that contributed to the success of this initiative was broad institutional support. Improving discharge summary completion was identified on institutional and departmental levels as a priority and was included as a key metric within the hospital’s quality improvement plan. As a result, there was good organizational consensus regarding the importance of this initiative.

This study builds on other studies in the literature demonstrating that simple quality improvement projects can be effective in improving discharge summary completion rates [1, 7]. Using similar strategies to our study, You et al. [8] completed a quality improvement project within the Department of Otolaryngology at our institution and demonstrated that the implementation of an auto-authentication and audit and feedback system increased the timeliness of when discharge summaries were being distributed. Our quality improvement initiative commenced using strategies similar to those applied by You et al. [8]. These were then tailored to some of the unique challenges within the Orthopaedic Surgery division. Specifically, the fact that at our institution, Orthopaedic Surgery is a high-volume service with many patients admitted for <24 hours led to the residents providing CTU coverage to take a more team-based approach to discharge summary completion.

Similarly, while this study outlines strategies to improve discharge summary completion that can be spread and scaled more broadly, it is important to tailor them to the local context in which they are being applied. This project’s success was dependent on consensus among providers to auto-authenticate the discharge summaries, accurate and timely data provided by our quality and performance team, and a collaborative and engaged group of residents and attending surgeons. Without each of these features, the aforementioned improvement strategies may have been less impactful. The strategies and collaboration described were specific to our centre, and thus limit the generalizability of the results of this project.

Several challenges were encountered during the implementation of this study. These included frequent changeover of medical trainees and the introduction of visiting medical trainees from other sites, necessitating multiple formal and informal educational sessions for trainees. The monthly audit and feedback emails also helped address this challenge by serving as a regular reminder of the necessity to complete discharge summaries.

Additionally, the extremely busy nature of the clinical service posed challenges. Most resident groups developed a standardized workflow, where the primary resident supervising a patient would complete the discharge summary the following morning. This posed a challenge on weekends. Resident coverage decreased from an average of 6 residents per site during weekdays to an average of 1.5 residents per site on weekends. Combining this with the busy nature of weekend call coverage meant that very few discharge summaries were being completed on weekends. Discharges on the weekends had their discharge summaries completed on Monday mornings, but our 48-hour completion target meant that Friday discharges were frequently not completed within the required time frame.

Additionally, due to personnel changes in our institution’s Surgical and Quality and Performance Departments, we were unable to continue data collection beyond June, 2023, as data was no longer reviewed regularly or systematically. While we achieved excellent improvement over the study period, we were unable to assess the sustainability of this improvement.

Overall, our study was successful in improving the discharge summary completion rate within 48 hours from 48% to 87.1% over the nine-month study period. The improvement strategies outlined in this study can be utilized to sustain improvement at our institution and can be applied to facilitate similar improvements at other institutions with adaptations to the local environment.

CONCLUSION

A dedicated quality improvement initiative can significantly improve the timeliness of discharge summary completion in a high-volume tertiary care orthopaedic surgery unit, with significant positive implications for patient care through transitions of care. Critical drivers of improvement included broad stakeholder engagement and buy-in, audit and feedback systems, streamlined processes, and access to timely and detailed data.

AUTHORS’ CONTRIBUTION

E.S., N.S., S.N., C.D., K.E., and R. K.: Proposed the project rationale; E.S., N.S., S.N., C.D., K.E, J.D, C.P., and R.K: Developed the project plan; S.N., C.D., K.E., and R.K: Led stakeholder engagement; E.S., N.S., S.N., C.D., K.E, J.D., C.P., and R.K.: Interpreted and analyzed data and carried out Plan-Do-Study-Act cycles; E.S., N.S., J.D., and C.P.: Prepared the manuscript.

References