Discussion:
Timely post-hospitalization follow-up has been shown to significantly reduce hospital readmission rates 1,4-6. Transition of patient care from the inpatient to the outpatient setting can lead to missed test results, medical errors, and both patient and provider dissatisfaction in the discharge process 7-9,17-19. Our initial baseline resident survey identified areas of resident dissatisfaction with the discharge planning process to include: confusion about the residents’ role, difficulty in communication, and lack of a standardized process for establishing PCP follow-up. We conducted a prospective quality improvement initiative to improve resident physician satisfaction with establishing post-hospitalization PCP follow-up.
In an effort to elicit unbiased responses all survey responses were anonymous without the ability to retrospectively link resident responses with identifying information. For the first two surveys, our team was able to achieve acceptable resident response rates, with 45% and 65% of all internal medicine residents responding, respectively. Although there was a statistically significant increase in resident satisfaction rates from the initial survey to the last survey, the response rate to the last survey was significantly lower than the prior two surveys with only 24% of residents responding. Response rates to the final survey may be attributed to alert or email fatigue, as this was a longitudinal process requiring resident participation throughout the length of nearly an entire academic year 20-22.
Our team was able to utilize our current hospital and clinic infrastructure and work within the technological confines of our current EMR to develop a standardized and streamlined process for establishing post hospitalization PCP follow-up. This process also included pathways to augment follow-up with both PCPs within our clinic system and PCPs at outside institutions. Through the use of two simple interventions focused on provider education, we were able to implement this new method at no additional cost to our institution. However, the ongoing use of this standardized process will require continued efforts from our quality improvement team or additional support from our institution. As current trainees graduate and new trainees enter into the residency program each year, there will need to be annual educational sessions to inform new residents of this process. Additionally, each resident will need to be provided the instructional pockets cards, whether via e-mail or in print, each year and the pocket cards at resident work-stations will need to be maintained.
Although this initiative was able to show an improvement in resident physician satisfaction, the intervention and analysis were limited to a small subset of resident physicians within one department and at only one academic medical center. This project did not evaluate if senior physicians and faculty or providers in other specialties encounter the same baseline dissatisfaction with establishing post-hospitalization follow-up. In addition, the trainees involved in this quality improvement project have time each day designated for education, making our interventions of provider education easier to implement. It is unclear whether this initiative, if expanded hospital wide, would have as high a yield of participation and therefore, as significant an impact on overall provider satisfaction. However, the consolidated process that we identified relied highly on tools already built into the EMR, so it is likely that this process could be more easily generalized to other services and departments at our institution or others hospitals.
Conclusion: This quality improvement initiative identified factors contributing to resident dissatisfaction with the process of establishing post-hospitalization PCP follow-up. The implementation of a standard and streamlined process resulted in a statistically significant increase in resident satisfaction with establishing PCP follow-up at the time of hospital discharge without an increase in perceived workload burden. Further efforts are required to continue the utilization of this process and to assess if this same process can increase provider satisfaction across all levels of training and specialties.