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Improving the quality of discharge summaries: implementing updated Academy of Medical Royal Colleges standards at a district general hospital.

ABSTRACT: Quality of documentation is harder to quantify and incentivise, but it has a significant impact on patient care. Good discharge summaries facilitate continuity between secondary and primary care. The junior doctors' forum led this project to improve the quality of electronic discharge summaries (eDS). Baseline measurement revealed significant room for improvement. We measured the quality of 10 summaries per month (across all inpatient specialties), against 23 indicators from the revised Academy of Medical Royal Colleges (AoMRC) standards (2013) that were prioritised by GPs as a "minimum dataset". Junior doctors felt that the Trust's dual eDS systems were responsible for great variation in quality. This was confirmed by the results of a comparison audit of the systems in April 2014: one system greatly outperformed the other (57% mean compliance with iSoft clinical management (iCM) based system vs. 77% with InfoPath-based system). We recommended that the Trust move to a single eDS system, decommissioning the iCM-based system, and this proposal was approved by several Trust committees. We worked with information services, junior doctors, general practitioners and hospital physicians to develop and implement a generic template to further improve compliance with AoMRC standards. In August 2014, the iCM-based system was withdrawn, the new template went live, and training was delivered, coinciding with the changeover of junior doctors to minimise disruption. Median compliance increased from 66.7% to 77.8%. Quality of discharge summaries had improved across the specialties. There was a reduction in the number of complaints and positive qualitative feedback from general practitioners and junior doctors. Completion of discharge summaries within 24 hours was not affected by this change. There is still more to be done to improve quality; average compliance with the full AoMRC standards (39 indicators) is 59.5%. With the approval of the Trust executive committee further plan, do, study, act (PDSA) cycles are underway, working to improve the remaining specialty-specific templates.

SUBMITTER: May-Miller H

PROVIDER: S-EPMC4645815 | biostudies-other | 2015

REPOSITORIES: biostudies-other

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Improving the quality of discharge summaries: implementing updated Academy of Medical Royal Colleges standards at a district general hospital.

May-Miller Hannah H Hayter Joanne J Loewenthal Lola L Hall Louis L Hilbert Rebecca R Quinn Michael M Pearson Nicola N Patel Alisha A Law Rebekah R

BMJ quality improvement reports 20150515 1

Quality of documentation is harder to quantify and incentivise, but it has a significant impact on patient care. Good discharge summaries facilitate continuity between secondary and primary care. The junior doctors' forum led this project to improve the quality of electronic discharge summaries (eDS). Baseline measurement revealed significant room for improvement. We measured the quality of 10 summaries per month (across all inpatient specialties), against 23 indicators from the revised Academy ...[more]

PMID: 26734325

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Project description:Discharge summaries are a vital tool to communicate information from Hospital to Primary Care teams; updating GPs about what happened during an admission, and handing over care detailing any follow up care required. Historically, Discharge Summaries have been posted to hospitals, increasing costs for hospitals, creating administrative work for GP practices receiving the letters, and resulting in some letters being lost or delayed in reaching the GP, with implications for patient safety if follow up requests are not received and acted upon. In an effort to improve patient care, the Clinical Commissioning Group in Surrey drew up a contract with Ashford and St Peter's Foundation Trust, aiming to increase the percentage of discharge summaries sent electronically from the rate of 9% sent within 24 hours, to over 75%. This contract set targets of 50% in May, 65% in June, and 80% in July. Financial penalties would be imposed if targets were not achieved, starting in June 2013. The Trust set up a working group comprising of doctors, IT personnel and ward PAs to devise a multi-pronged solution to achieve this target. The electronic discharge summary system was reviewed and improvements were designed and developed to make the process of signing off letters easier, and transmission of signed off letters became automated rather than requiring manual transmission by ward PAs. Presentations and leaflets to explain the importance of prompt completion and transmission of discharge summaries were given to Doctors to improve compliance using the revised IT system. Figures on transmission rates were automatically emailed to key stakeholders every day (Ward PAs, Divisional Leads) showing performance on each ward. This helped identify areas requiring more intervention. Areas (e.g. Day Surgery) that had not used electronic discharge summaries were engaged with, and persuaded to take part. As a result, transmission rates of Discharge Summaries within 24 hours of patient discharge increased from 9% on May 11th 2013, to 76% by June 29th 2013. This has improved communication with GPs, led to more reliable handover of care, and reduced costs for the Trust (both in processing and postage costs, and by avoiding fines).

Project description:Around 110,000 people spend time in critical care units in England and Wales each year. The transition of care from the intensive care unit to the general ward exposes patients to potential harms from changes in healthcare providers and environment. Nurses working on general wards report anxiety and uncertainty when receiving patients from critical care. An innovative form of enhanced capability critical care outreach called 'iMobile' is being provided at King's College Hospital (KCH). Part of the remit of iMobile is to review patients who have been transferred from critical care to general wards. The iMobile team wished to improve the quality of critical care discharge summaries. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Plan, Do, Study, Act (PDSA) methodology was used. Three PDSA cycles were undertaken. Methods adopted comprised: a scoping literature review to identify relevant guidelines and research evidence to inform all aspects of the quality improvement project; a process mapping exercise; informal focus groups / interviews with staff; patient story-telling work with people who had experienced critical care and subsequent discharge to a general ward; and regular audits of the quality of both medical and nursing critical care discharge summaries. The following behaviour change interventions were adopted, taking into account evidence of effectiveness from published systematic reviews and considering the local context: regular audit and feedback of the quality of discharge summaries, feedback of patient experience, and championing and education delivered by local opinion leaders. The audit results were mixed across the trajectory of the project, demonstrating the difficulty of sustaining positive change. This was particularly important as critical care bed occupancy and through-put fluctuates which then impacts on work-load, with new cohorts of staff regularly passing through critical care. In addition to presenting the results of this quality improvement project, we also reflect on the lessons learned and make suggestions for future projects.

Dataset Information

Improving the quality of discharge summaries: implementing updated Academy of Medical Royal Colleges standards at a district general hospital.

Publications

Improving the quality of discharge summaries: implementing updated Academy of Medical Royal Colleges standards at a district general hospital.

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