Abstract
Background
The completeness of hospital discharge summaries may reflect the overall quality of inter-professional communications. The effect of reducing resident workload on clinical performance is largely unknown.
Objective
We examined the impact of reducing housestaff workload on the quality of discharge summaries, an indicator of clinical performance, as compared to discharge summaries created by trainees on a team with a more typical workload.
Design
Patients admitted to a medicine service at a community teaching hospital affiliated with an academic medical center were alternately allocated between a control and intervention care team of residents. First-year residents on the intervention team carried an average census of 3.5 patients compared with 6.6 patients for peers on the control team. A random selection of 142 discharge summaries from a 3-month period were blindly evaluated using a structured tool based on professional documentation standards.
Participants
61 internal medicine residents.
Main Results
Inter-rater reliability of discharge summary quality was 0.9. Discharge summaries produced by residents on the intervention team with a reduced workload had significantly more of the required elements (74 vs 65%, p < 0.001). Intervention team summaries were more frequently complete and contained significantly more of the required elements describing the patient history (65.7% vs 36.1%, p = 0.0005), the inpatient narrative (47.1% vs 22.2%, p = 0.003), discharge planning (20.0% vs 5.5%, p = 0.012), and continuity of care (24.3% vs 6.9%, p = 0.005). Fewer than a quarter of the summaries reviewed included discharge instructions, information on follow-up care, or a discharge medication list.
Conclusions
Reducing resident workload can significantly improve discharge summary quality, a measure of resident performance.
Similar content being viewed by others
References
Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–651.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167.
Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323.
O'Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Baker DW. Outpatient physicians' satisfaction with discharge summaries and perceived need for an electronic discharge summary. J Hosp Med. 2006;1(5):317–320.
Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. Feb 28 2007;297(8):831-841.
Balla JI, Jamieson WE. Improving the continuity of care between general practitioners and public hospitals. Med J Aust. Dec 5-19 1994;161(11-12):656-659.
Wilson S, Ruscoe W, Chapman M, Miller R. General practitioner-hospital communications: a review of discharge summaries. J Qual Clin Pract. 2001;21(4):104–108.
van Walraven C, Weinberg AL. Quality assessment of a discharge summary system. CMAJ. May 1 1995;152(9):1437-1442.
Myers JS, Jaipaul CK, Kogan JR, Krekun S, Bellini LM, Shea JA. Are discharge summaries teachable? The effects of a discharge summary curriculum on the quality of discharge summaries in an internal medicine residency program. Acad Med. 2006;81(10 Suppl):S5–8.
Rao P, Andrei A, Fried A, Gonzalez D, Shine D. Assessing quality and efficiency of discharge summaries. Am J Med Qual. 2005;20(6):337–343.
Haney EM, Nicolaidis C, Hunter A, Chan BK, Cooney TG, Bowen JL. Relationship between resident workload and self-perceived learning on inpatient medicine wards: a longitudinal study. BMC Med Educ. 2006;6:35.
Accreditation Council for Graduate Medical Education. Policies and Procedures. http://www.acgme.org/acWebsite/about/ab_ACGMEPoliciesProcedures.pdf. Accessed July 15th 2010.
Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: Institute of Medicine; 2008.
Standard IM 6.10: Hospital Accreditation Standards. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2006:338-340.
van Walraven C, Rokosh E. What is necessary for high-quality discharge summaries? Am J Med Qual. Jul-Aug. 1999;14(4):160–169.
Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med. Dec 21 2001;111(9B):15S-20S.
McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. Apr 8;362(14):1304-1311.
Accreditation Council for Graduate Medical Education. ACGME Program Requirements for Residency Education in Internal Medicine 2007.
Frain JP, Frain AE, Carr PH. Experience of medical senior house officers in preparing discharge summaries. BMJ. Feb 10 1996;312(7027):350.
Horwitz LI, Kosiborod M, Lin Z, Krumholz HM. Changes in outcomes for internal medicine inpatients after work-hour regulations. Ann Intern Med. Jul 17 2007;147(2):97-103.
Ogden PE, Sibbitt S, Howell M, et al. Complying with ACGME resident duty hours restrictions: restructuring the 80-h workweek to enhance education and patient safety at Texas A&M/Scott & White Memorial Hospital. Acad Med. 2006;81(12):1026–1031.
Fletcher KE, Davis SQ, Underwood W, Mangrulkar RS, McMahon LF, Jr., Saint S. Systematic review: effects of resident work hours on patient safety. Ann Intern Med. Dec 7 2004;141(11):851-857.
Acknowledgments
We thank Mary Thorndike, MD; Bruce Levy, MD; Joseph Loscalzo, MD, PhD; Maia Laing; members of the Residency Redesign Committee, the medical residents, and the medical, nursing and health information staff at the Faulkner Hospital. The study was supported by internal funding from the Brigham and Women’s Hospital Department of Medicine.
Conflict of Interest
None disclosed.
Author information
Authors and Affiliations
Corresponding author
ELECTRONIC SUPPLEMENTARY MATERIAL
Below is the link to the electronic supplementary material.
ESM 1
(PDF 33 kb)
Rights and permissions
About this article
Cite this article
Coit, M.H., Katz, J.T. & McMahon, G.T. The Effect of Workload Reduction on the Quality of Residents’ Discharge Summaries. J GEN INTERN MED 26, 28–32 (2011). https://doi.org/10.1007/s11606-010-1465-z
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-010-1465-z