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.