The transition from hospital to home or to another care site is a high-risk period for the patient for a number of reasons, as we have discussed in The Hospitalist this year. Ineffective communication with the patient and between healthcare practitioners at discharge is common. In addition, primary care providers increasingly delegate inpatient care to hospitalists. This delegation of care can lead to gaps in knowledge that present risks to patient safety.
Further, information transfer among healthcare practitioners—whether they be primary care providers or hospitalists—and their patients is often compromised by record inaccuracies, omissions, illegibility, information never delivered, and delays in generation or transmission.
The Agency for Healthcare Research and Quality (AHRQ) has identified recall error, increased clinician workloads, interface failures between physicians and clerical staff, and inadequate training of physicians to respect the discharge process as the root causes of deficiencies in the current process of information transfer at discharge. While an interoperable health information technology infrastructure for the nation could effectively address many issues related to discharge planning, such a solution is certainly many years away.
Given the fact that a nationwide, interoperable health information technology infrastructure is not yet a reality, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is exploring multiple approaches for improving communication with patients and among practitioners in the discharge planning process. This article details those strategies and is meant to stimulate discussion and elicit suggestions for future approaches.
If you have any suggestions for improving the discharge planning process, e-mail us at [email protected]. We’ll publish the most effective and intriguing responses in a future issue of The Hospitalist.
Discharge Planning Standards
Patients may be discharged from the hospital entirely or transferred to another level of care, treatment, and services; they may be reassigned to different professionals or settings for continued services. JCAHO standards require that the hospital’s processes for transfer or discharge be based on the patient’s assessed needs. To facilitate discharge or transfer, the hospital should assess the patient’s needs, plan for discharge or transfer, facilitate the discharge or transfer process, and help to ensure that continuity of care, treatment, and services is maintained.
These standards (found in the Provision of Care (PC), Ethics, Rights and Responsibilities (RI), and Management of Information (IM) chapters of the hospital accreditation manual) will be updated in July 2007. The changes include both new language and new requirements meant to improve communication with patients and among providers during the discharge planning process. Rather than a significant overhaul, these changes can be viewed as refinements to the existing standards that will help hospitals ensure that the intent of each standard is actually carried out to benefit patients. For example, an element of performance for standard PC.4.10 that addresses development of a plan of care now specifies that this process should be individualized to the patient’s needs. Another example is standard IM.6.20, for which an element of performance will require that the medical record contain medications dispensed or prescribed at discharge.
It is also important to note that JCAHO standards underscore the importance of the patient retaining information. Today, JCAHO requires—through its National Patient Safety Goals—that a list of current medications be provided to the patient at discharge. For patients who have been treated by a hospitalist, this requirement is especially important when they return to their primary care physicians for follow-up treatment.
Discharge Planning During the On-Site Survey
JCAHO began more closely examining discharge planning in 2005 by piloting a new process that surveyors used to evaluate standards compliance in 2006. The first option tested is a concurrent review in which surveyors observe the discharge instructions as they are being taught to the patient and then interview the patient about the content. The second option is a retrospective review and entails calling patients 24 to 48 hours after discharge to ascertain their understanding of the medication regimen and other instructions provided. Both options are used by JCAHO surveyors to understand how practitioners, nurses, and other caregivers carry out the hospital’s policies.