Dishonourably Discharged?Improving timely sending of discharge summaries at the Royal Devon & Exeter (RD&E) Hospital

Royal Devon & Exeter Hospital: Dr Luke Glover, Dr Simon Brackley, Dr Lucy Andrews, Dr Georgia Wright,Dr Lauren Eddy,Dr Miles Edwards,Dr Riordan Deehan Jackson, Dr Smruthy Chakka

Understanding the Problem & Setting our Aim

Discharge summaries are vital for ongoing patient care and often contain important tasks for GPs ( Abrashkin et al 2012)

Delayedsending creates additional workload for GPs, hospitaldoctors and administrative staff and risks patient safety ( Kripilani et al 2007)

At our hospital, we have had numerouscomplaints regarding the impact of delayed discharge summaries on patient care

We aimed to increase the percentage of discharge summaries sent to GPs within 2 working daysto 90% across all departments by 14th July 20 22

Setting up Measurements

22.6% of discharge summaries (12965/57367) were not sent within 2 working days

0) to present

We stratified these unsent summaries by location, specialty, discharge method, day of week and hour of day in order to target our tests of change

Discharges as Deceased

Cycle 1: Creating a "culture of completion" Intervention We engaged the medical problem, issued them a poster and asked that they encourage junior doctors to send RIP summaries at the time of writing death certificates

Result -6 week increase incompletion within 2 working days of deceased discharge from 50- 80% (run chart below -intervention at red line)

Patient Lists

Cycle 1: Colorectal

Intervention -Changinguse of "lists" by colorectal doctors to include discharged patients with unsent paperwork within 30 days

Result - We realised our initial data collectiondidn't allow sole measurement of colorectal discharges. We also had poor take - up. We were grateful for starting on a small scale and learnt from this for our next cycle

Cycle 2: Respiratory

Intervention Learning from cycle 1, we targeted a respiratory ward (where our data allowed measurement) and engaged all doctors on the ward

Result -Though we now had 100% uptake, the intervention has as of now had no effect (run chart below change at red line)

Automated Sending

75% of delayed summaries are signed but waiting for the final administrative step of clicking send

It represents the largest potential area of improvement

What we learnt - with the right approach there is the capacity to meet our target. "Soft interventions" like posters have temporary effects as their initial impact diminishes

Plan for Cycle 2: Our next intervention must be more robust. We plan to practically automate creation of deceased discharge summaries and have begun discussions with the ME's team

Discussion and Next Steps

What we learnt - We asked therespiratory doctors who were ambivalent about using the changed list. We must make sure our next intervention is not perceived to increase work. Our cycle also coincided with changeover of doctors to different teams

Engaging with Trust

Plan -Implement trust- wide changes to our EPR so summaries automatically send to the GP when signed

Result -We thought this was in process, but meetingthe trust's digital fellow, found that little progress had been made

What we learnt - Implementing change is difficult, with multiple factors at play. Early MDT support is critical

Engaging Stakeholders

Intervention -We attended two trust taskforce meetings where we presented our data & reasoning for the change

Result - We have the support of significant members of the medical staff and consultant body

Future plan: Pushing change requires careful thought about who is affected (patients and staff). After further consultation we hope to make this software change and measure its effect on a day- by- day basis

Our major advantage in this project is the extremely detailed continuous measurement we have managed to create and analyse

By engaging with stakeholders , we can combine the subjective feedback with the above data to target our tests of change

It is a big problem to tackle. Our parallel approaches to target different aspects, combined with small tests of change and learning from previous cycles gives us confidence in achieving our aim

There are multiple considerations for future cycles that we have learnt: the rotation of healthcare staff during testing (and later implementation), the balancing measures that need to be considered (e.g. workload in midst of a pandemic) and the importance of early MDT involvement and co mmu nication

Our Pareto chart suggests our most powerful change may be through targeting the signed unsent summaries, with the potential to exceed our target.We are currently in discussion with groups across the trust to make this happen