The completeness of hospital discharge summaries may reflect the overall quality of inter-professional communications. This study demonstrates that a programmatic change that reduces workload can improve processes of care, as measured by discharge summary quality.
Residents consistently report that high-quality summaries are time consuming and report a conflict between quality and exigency12,19
. Few studies have directly addressed the discharge summary and communication with PCPs in the context of the typical residents’ workload. A survey of senior residents in Britain revealed a lack of priority placed on discharge summary quality, attributable to reduced prioritization from attendings15
. The discharge summaries evaluated for this study were of low overall quality, demonstrating that efforts to improve these documents are warranted. While the causes of the poor quality are unknown, this study indicates that reduced workload and improved supervision may lead to improved communication quality.
There is increased research interest in how the ACGME-mandated limitations on time may affect the quality of patient care and resident education20–22
. Reducing duty hours without workload reductions would be predicted to result in poorer communication. This study was conducted to test the impact of reducing workload within the constraints of duty-hour restrictions. The intervention and control groups worked a similar number of hours per week despite a lower patient census, leaving only the distribution of this time as a variable. Since discharge summaries generated by house staff within the revised rotation were of higher quality than those produced by teams following the traditional schedule and workload, our findings suggest that given a constrained number of hours to conduct clinical care and education, reducing resident workload may contribute to an overall improvement in task performance.
There are several factors that may explain higher quality discharge summaries on the intervention team. The decreased patient load may have allowed for more protected time to dictate these documents, in addition to allowing for more reflection and thorough preparation. Increased opportunity for reflection regarding daily patient care may have improved the residents’ attention to relevant details: the greatest difference in aggregate mean between the control and intervention teams was found in the section on discharge planning. The difference in completion rate may be attributable to interruptions during dictation, supporting the hypothesis that the house staff on the intervention teams produced higher quality discharge summaries because of reduced time constraints. Through the combination of additional reflective time and greater time for faculty interaction, residents on the intervention team may have gained a fuller appreciation of the natural history of common medical conditions and therefore were cognizant of the specific requirements of follow-up management.
The differences are unlikely to be explained by variability in resident competency since the discharge summaries evaluated were produced by 61 different residents over three 4-week rotations; there was no difference in case mix between patients randomized to each service. Interventions to improve discharge summaries most frequently focus explicitly on discharge summary production and delivery process. While this approach does allow for better control of confounding variables in research design, this study broadens the intervention opportunities and quantifies the effect that could be expected from programmatic change.
Our study was limited by several factors. To maintain reviewer blinding, it was necessary to assume that whatever information was included in the discharge summary was accurate. Additionally, the results are limited by their specificity to our single center and evaluation tool, as well as the constrained time period. The discharge summaries evaluated were dictated rather than produced using the templated, computer-based systems that are increasingly common. Consequently, our findings should be replicated at other centers and for other types of programs to enhance its validity.
Though the practical purpose of discharge summaries is readily apparent, they may have a broader function in graduate medical education. The process of creating a discharge summary may, for example, encourage reflection and analysis on the part of the resident, leading to the synthesis of new knowledge. Discharge summaries necessitate that the writer reflect on the next steps for the patient and may augment the attention given to continuity of care and the importance of inter-professional communication. Further research into the value of this documentation in training physicians is warranted.
The results indicate that attention to resident workload may have important implications for overall quality of discharge summaries, resident performance, and potentially for patient care. The findings also reveal significant opportunities for improved education in effectively managing communication during transitions in care for all trainees.