The Effect of Workload Reduction on the Quality of Residents’ Discharge Summaries

Abstract

BACKGROUND:The completeness of hospital discharge summaries may reflect the overall quality of interprofessional 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. Firstyear 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.KEY WORDS: discharge summary; residency design; work hours.

Predicting and Communicating Risk of Clinical Deterioration: An Observational Cohort Study of Internal Medicine Residents

“…Resident workload has been shown to have an influence on resident performance and patient outcomes. [14][15][16][17] Additionally, a recent study of physician handoff practices showed that larger numbers of patient care handoffs were associated with a greater number of interruptions during handoff. 18 These interruptions are associated with increased opportunity for overlooked or omitted patient information, and may explain the greater level of discordance between PGY-3 giver and receiver.…”

Provider Characteristics, Clinical-Work Processes and Their Relationship to Discharge Summary Quality for Sub-Acute Care Patients

“…Increased levels of workload and work-burden can be associated with poorer discharge documentation quality. 26 Third, we do not attempt to assess the accuracy of the provider documentation, only the presence/ absence of specific components. It is possible that some components included within study summaries were inaccurate and may have affected patient safety because of a communication error.…”

“Learning by Doing”—Resident Perspectives on Developing Competency in High-Quality Discharge Care

“…19 Beyond these traditional approaches, some programs have already introduced innovative approaches to teach specific discharge components such as documentation in discharge instructions and summaries. 31,32 Second, underlying concepts of teamwork, advanced planning, patient safety, and patient communication that are embedded in high-quality discharge care should be integrated into broader themes of training for competency in systems-based practice. These efforts, in turn, should be tied to specific outcomes such as adverse events or readmissions.…”