Development of a quality scoring tool to assess quality of discharge summaries

Abstract

Introduction:Timely, precise, and relevant communication between hospital-based clinicians and primary care physicians post-discharge (DC) ensures quality transitions, thereby reducing patient safety incidents and preventing readmission. At the present time there is limited knowledge of elements of quality or methods to score the quality criteria in the context of DC summaries. The Nova Scotia Health Authority, a provincial health system responsible for the delivery of services in a small Canadian province, embarked on a system-level approach to the standardization of DC summaries in an effort to improve quality and safety at care transitions from hospital to primary care.Materials and Methods:A comprehensive literature review to retrieve items relevant to quality in DC summaries, retrospective audit of charts, a consensus development process, and, finally, validation of a scoring tool were conducted in order to develop a quality scoring tool for DC summaries.Results:Relevant items were identified through the literature review and consensus development process. Corresponding definitions that were established assisted the development of the quality criteria, which were subsequently used to score the quality of DC summaries in our organization.Conclusion:The scoring tool developed through this work will be applied to help us gain a more in-depth understanding of quality in DC summaries and support the development of suitable education and quality processes in the health authority that can best support safe care transitions for patients.

The Quality of Discharge Summaries After Acute Kidney Injury

“…Also, the discharge summary elements included in our composite score have not been formally validated by nephrologists or PCPs nor shown to be predictors of short-term and long-term outcomes; however, the items selected are consistent with previous literature examining discharge summary quality in both AKI and non-AKI populations. 13,[15][16][17][18]23,[32][33][34][35][36][37] The single-center study design limits generalizability, as other centers may have unique discharge summary tools (eg, electronic templates) that allow easier inclusion of AKI-relevant elements (eg., baseline serum Cr). However, our results are consistent with other literature from the United Kingdom and the United States, suggesting low discharge summary quality in patients with AKI persists across different health care settings and infrastructures.…”

Usability of Electronic Health Record–Generated Discharge Summaries: Heuristic Evaluation

“…Australia and the United Kingdom have developed national standards for electronic DSs [ 18 , 28 ], and Canadian researchers have explored standardizing DSs in Nova Scotia [ 29 ]. In contrast, most US research aimed at increasing patient safety during care transitions focuses upon improving discharge planning processes (eg, training clinicians to generate more useful discharge documentation [ 30 , 31 ] or involving patients and caregivers in discharge planning [ 31 , 32 ]).…”

Supporting SURgery with GEriatric Co-Management and AI (SURGE-Ahead): A study protocol for the development of a digital geriatrician

“…After discharge, final data from the hospital information system data will be recorded, especially adverse events and complications. The medical discharge report will be critically assessed in terms of completeness and quality (time independent) [53]. A telephone follow-up will be performed with participants and general practitioners to evaluate COC decisions on discharge from surgery 90 days (± 7 days) after discharge (T6).…”