Download Teaching Accountability at Transitions

Exercises for Teaching Accountability at Discharge
Jeff Greenwald, MD
Boston Medical Center
Boston Association of Academic Hospitalists in Medicine
Objectives:
By the end of these exercises, the learner should:
1. Understand the difference between patient-centered and physician-centered
policies regarding continuity of care.
2. Appreciate the frequency and type of problems that a patient may face after
discharge.
3. Be able to prospectively identify and address problems that a patient may face
after discharge.
4. Identify systems issues that promote adverse events after discharge.
5. Be able to improve his/her own skills at communicating key issues to the patient
and future care providers at discharge.
6. Recognize the importance of personally taking accountability for the controllable
and foreseeable issues surrounding discharge.
7. Understanding issues surrounding accountability to the patient and to colleagues –
both inpatient and outpatient – surrounding the transition to outpatient care at
discharge.
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Table of Contents
1. Bounce back policies reconsidered
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'Bounceback' policies may prevent patients from being readmitted to
providers who know them well. This is a 45 minute small group (> 10
people) exercise where two or more groups take opposing viewpoints on
local bounceback policies. Emphasizes thoughtful evaluation of policies,
systems learning patient care and communication.
2. Trainee phone calls to patients after discharge at 48-72 hours
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20-25% of medicine patients experience an iatrogenic post discharge
adverse event. Using a structured format trainees call 1 patient and
PCP/week to determine outcomes after discharge. This is followed by an
attending rounds discussion on outcomes and review of discharge
literature. Emphasizes personal accountability, medical knowledge,
personal practice and systems changes to mitigate adverse outcomes.
3. House Officer offers gives his/her own contact information to
patient for use prior to first follow-up visit
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Advanced trainees ask selected patients to call them post-discharge with
questions until they see their PCP in follow-up. This is followed by either
individual debriefing or an attending rounds discussion on outcomes and
review of discharge literature. Emphasizes personal accountability,
communication, personal practice and systems changes to mitigate adverse
outcomes.
4. Simplified FMEA on a discharge – what could go wrong?
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30-60 minute team exercise using a QI tool to evaluate a patient BEFORE
discharge to proactively identify and address post-discharge issues.
Emphasizes learning a process improvement tool, systems learning and
patient care.
5. Simplified RCA on a readmission – what did go wrong?
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30-60 minute team exercise using a QI tool to evaluate a readmitted patient
AFTER discharge to identify and address post-discharge issues.
Emphasizes learning a process improvement tool, practice-based learning,
systems learning and patient care.
6. Discharge Handoffs: Documentation and Beyond
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Two exercises. 20-30 minute team exercise where interns review each
other's actual discharge summaries and give feedback. Alternatively, review
de-identified summaries as a group. In second exercise have one intern
accept into his/her clinic a new, unassigned patient of the other intern after
discharge. Emphasizes accountability, communication and patient care
Disclaimer:
Not all of the following exercises are appropriate for all training programs. Issues differ
from program to program so it is important that local issues and politics be considered in
the selection of which exercise(s) to utilize.
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1. An exercise: Bounce back policies: from doctor-centered to patient-centered care
Goals of this exercise:
a. Create an environment where policy discussions can occur openly
b. Understand the impact of bounce policies on house officers and patients.
c. Discuss continuity of care and its effect on patient care.
Background for facilitator:
Many institutions have a policy that patients who are readmitted to the hospital
after, for example, >48 hours, do not return to the team previously taking care of
them. Bounce back policies like this are often developed to protect the house
officers from patients who are frequently readmitted. This patient population is
often challenging or even frustrating to work with. Nevertheless, by sheer
randomness, most clinicians will eventually encounter them and the scorecard
will balance out.
Inherent in such bounce back policies is the need for new providers to assess the
patients anew with each re-admission. This is comparable to what would happen
if we disbanded the primary care model and asked patients always to see the doc
of the day. These types of policies nullify the benefits of getting to know a patient
over time. As the literature shows, the risk of readmission is highest in patients
who have had multiple prior admissions. Bounce back policies complicate
communications issues exacerbated by lack of continuity of care.
The exercise (30-45 minutes):
In a group of at least 10 physicians, ask the group: “How many people think the
bounce back policy (review it with group if need be) makes sense (or is a “good”
policy)?” Leave the question vague and let the doctors decide for themselves
what that means.
Hopefully, you will get at least some people saying it does not make sense.
Divide the group by their answer and physically separate the groups. If you have
a larger group (>15), consider dividing each side into 2 or more subgroups for the
purpose of generating small group discussions. If you identified no one above to
answer that the bounce back policy does not make sense, pick at least 5 people
(more in larger groups) to represent this view for the purposes of discussion.
Identify a group scribe to take notes. Ask each group to adopt the OPPOSITE
opinion and generate key arguments that support this opposite view. Allow the
small groups to have 10-15 minutes for discussion.
Ask the scribes to read off the arguments and the facilitator should compile a
visible master list. Begin with the groups defending the current bounce policy
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and then go to the opposing side. After all groups have given their arguments,
open the floor to discussion and challenge the doctors’ views by posing the
opposing arguments identified. Encourage inter-group respectful debate.
At the end of this discussion, ask participants to return to their original positions
on the topic and see if they would like to add any additional comments about the
arguments now that they no longer have to “play” the opposing argument. Also
determine if anyone has changed views on the topic.
At the end of 15-20 minutes, identify the conclusions that have been reached,
making sure that the key points in the background above have been noted. If no
conclusion is possible, highlight the fact that questions remain about the current
policy and encourage ongoing thought and debate at later times.
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2. An exercise: Trainee phone calls to patients and PCPs after discharge
Goals of this exercise:
a. To foster the development of a sense of accountability towards patients
after discharge
b. To explore the complications and difficulties patients experience shortly
after discharge
c. To identify ways to mitigate predictable or anticipatable issues after
discharge in the future
d. To understand the system issues that can lead to a patient having an
adverse event after discharge
Background for facilitator:
To foster the development of a sense of accountability towards patients after
discharge, it is first necessary to expose the trainees to the types of problems and
challenges patients face during that transition. Hearing from the patients, in their
words, may make the lesson hit home more clearly. One tool that may be useful is
to ask each house officer (and student) to call one patient each week, 48-72 hours
after discharge. Talking with the patient’s PCP after the first post-discharge visit
may also help trainees realize the information required for the next provider of
care and also provides additional insight into the issues present after discharge.
While in will be beneficial to speak to the patient and that patient’s PCP, your
trainees may choose or only be able to reach one or the other. This single call
will still have educational value.
The exercise:
Part I: The patient call
At the beginning of your time with the trainees, inform them that you would like
to expose them to the issues associated with successful transitions from hospital to
home. Ask each trainee to pick one patient who they have cared for that week
and call them 2-3 days after discharge to find out how they are doing. Encourage
them to select more complicated patients, either medically or socially, who they
are worried about falling through the discharge cracks. During these calls, the
team member should inquire about:
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How is the medical condition(s) that was addressed during the
hospitalization (worse/better/new developments)?
Address disease specific issues (e.g. weight in patients with heart failure;
peak flows in patients with asthma).
How are they doing with their medications? Were they able to get their
medications? Are they adherent? Any side effects or other problems? If
so, what did they do about it? Look for discrepancies with the discharge
list and what they are taking at home.
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Were they able to understand the discharge instructions received at
discharge? If not, what specific areas were unclear?
Were all of their questions answered at the time of discharge?
Did they encounter any difficulties arranging follow-up with their PCP or
specialists? Or for outpatient testing?
Do they have any suggestions about how the discharge process could be
improved?
Remind the patient about upcoming appointments and tests.
Find out if they have any questions or concerns.
Part II: The PCP call:
The house officer or student should call the PCP after the first scheduled postdischarge follow-up visit. Questions to ask include:
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Was it clear to you at the time of follow-up what happened during the
hospitalization, diagnostically and therapeutically?
Did you feel your patient understood what happened?
Did you have the information you needed to provide adequate care of your
patient after discharge?
If the above three questions were not all answered in the affirmative,
inquire about what was missing and how the discharge process could have
been improved.
If there were studies or results pending at discharge: Did you know about
the studies/results that were pending at discharge and were you able to
obtain their results?
Are you aware of any adverse events, medication related or otherwise,
which occurred after discharge?
Did the patient have any difficulties in getting the care or medications they
needed?
How were you notified of the patient’s discharge?
Do you have any specific recommendations on how to make the discharge
process more effective?
These calls may take 10-15 minutes to make. Then, at attending rounds, review
each team member’s experience and apply the literature on discharge to their
findings (see references and slide show provided separately). With 3-5 people
presenting their calls, there should be ample fodder for discussion. Make sure that
if any significant changes are noted or instituted by the team member, that the
primary care physician or other appropriate individual is notified.
As the attending reviews the calls with the team, make sure they understand how
systems issues and miscommunications/misunderstanding contributed to the
issues identified. Explicitly, help the trainees understand what can be done to
reduce the chances of these complications from occurring in the future.
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Variations:
You may choose to have only the medical students make these calls due to time
constraints, however, everyone should participate in the discussion of the
findings. Students will need to be closely supervised during the phone call.
Additionally, the attending physician may choose to make the calls to the PCP
instead of the trainees. This may foster more honest feedback but requires that
the attending share the direct feedback with the trainees.
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3. An exercise for advanced trainees only: House officers taking calls from the
patients (instead of the PCP) until first follow-up visit
Goals of this exercise:
a. To foster the development of a sense of accountability towards patients
after discharge
b. To explore the complications and difficulties patients experience shortly
after discharge
c. To experience direct responsibility for issues that arise after discharge
d. To appreciate how difficult it is to address issues after the patient leaves
the hospital and how much more difficult these issues would be if the PCP
is not well informed of the events of the hospitalization
e. To improve communication skills with PCPs after discharge regarding
post-discharge issues which arise
Background for facilitator:
Most residents have limited experience being the Primary Care Physician fpr a
recently discharged patient.. Understanding the difficulty of fielding questions
from patients after discharge from hospitalizations in which the PCP was not
directly involved is challenging. This exercise will illuminate some of the issues
that PCPs have to address with discharged patients and will also highlight the
importance of good communications with the PCPs or other care providers.
Additionally, as with the previous exercise, this experience will illustrate some of
the problems that patients encounter after discharge and make it clearer to the
trainee what needs to be done around discharge (i.e. take accountability) to
ensure a safe and effective discharge.
It is important to discuss this exercise with the primary care physicians of the
patients who are involved in this exercise so all care givers are agreeable to the
house officers taking on this additional role. As such, we recommend using this
exercise with advanced trainees only. There are real skills associated with phone
medicine and they need to understand that all recommendations or therapeutic
suggestions need to be discussed with you, communicated to the PCP and
documented.
Alternatively, this exercise could be used with patients who do not have a primary
care doctor prior to the admission. In this way, the student would learn about
post-discharge issues while simultaneously providing a real safety net to a new
patient to the system.
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The exercise:
Encourage your team to tell selected discharged patients that they should call the
team (e.g. the responsible resident) with any questions or problems that arise until
they see their PCP in follow-up. Remind the team that they know more about the
patient’s course than the PCP will, in most cases, and that this transitional
continuity will help protect the patient and assist the PCP.
To do this effectively, one must instruct the team to discuss any significant issues
with you in real time should a a problem arise. Additionally, as above, any postdischarge changes of significance need to be communicated to the PCP prior to
follow-up and documented. Debriefing these interactions, either individually or
with the team, will offer the attending another opportunity to identify any systems
failures or communication gaps that can be ameliorated in the future.
For patients without an assigned PCP, highlight how much more important it is
for a patient to have a connection to the system, recognizing that without one, the
chances are greater that the patient will return to the emergency room as they have
no more appropriate entrée into the medical system.
It is recognized that patients may never call the residents during the period of this
exercise. What should be discussed with them after a week or two of the exercise,
in addition to any patient interactions that do occur by phone, is what they feel
they did differently to prepare the patient for discharge knowing that they,
themselves, were going to get the call if things went wrong. Prompt the
discussion by asking whether they did additional documentation, patient
education, coordinating with ancillary staff, VNA, etc… Hopefully, this exercise
will be done in conjunction with the RCA or FMEA exercises included in this tool
box and this discussion can augment those.
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4. An exercise: Perform a “mini FMEA” on a discharge
Goals of this exercise:
a. To learn the basics of this process improvement method
b. To explore the complications and difficulties patients experience shortly
after discharge
c. To identify ways to anticipate and proactively address issues that may
occur after discharge
Background for facilitators:
Failure Mode and Effects Analysis (FMEA) is a quality improvement technique
which, simply put, asks the question: what could go wrong at each step along the
process and what can we do, preemptively, to prevent this from occurring? There
are many steps to the process which have been substantially simplified for the
purposes of this exercise. Nonetheless, the basic concepts will be illustrated. For
further reading on FMEA, see: http://www.patientsafety.gov/PSC/RCA.html
The exercise (30-60 minutes):
This exercise begins by identifying a patient for whom there are complex
discharge issues anticipated. Sit down with the patient’s record and discharge
planning information. If possible, invite the patient’s nurse or case manager to
join the exercise.
By prospectively identifying areas of the discharge which may cause problems to
the patient, one may be better able to prepare the discharge and the patient to
avoid them and make the patient better aware of how to handle them should they
arise after discharge.
Step 1: Dissect the discharge by explicitly asking the following questions:
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What happened to this patient? That is, how did they present; what was
found on exam and from diagnostic testing; what was the final diagnosis; how
were they treated: how did they respond to treatment: how are they on
discharge (not just “stable,” but specifics like their exercise tolerance and
mental status)? What does the discharge summary need to include about the
course so subsequent care givers reading it will understand the salient events?
On what medications will the patient be leaving? How do they differ from the
admitting medications? What education will the patient need about the new
or changed medications? That is, get the team to reconcile the medications.
What are the pending issues at the time of discharge? Include the clinical
issues (e.g. resolution of the cellulitis), laboratory issues (e.g. final status of
the blood culture), and social issues (e.g. going to AA meeting) that remain
unresolved.
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What are the follow-up plans after discharge? Include any scheduled tests or
appointments and what your goals are for those appointments. Consider
issues surrounding transportation.
What general barriers might impede this patient’s successful transition to
outpatient care. Consider issues surrounding language and literacy (both
health and reading/writing), substance abuse, housing, care giver issues, etc.
Step 2: Get to the root causes of the identified problems
Using the results of these questions, look for potential barriers which may
impede the patient. Ask “what if” questions, review the answers you have
developed above and look for predictable problems (e.g. What if the patient
does not have the money to pay for his medications? What if the patient’s
sister cannot drive him to his follow-up? What if he develops diarrhea from
the antibiotics?). Then, develop contingency plans for those issues, preferably
looking to system fixes rather than individual fixes, where possible.
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5. An exercise: Perform a “mini RCA” on a readmission
Goals of this exercise:
a. To learn the basics of this process improvement method
b. To explore the complications and difficulties patients experience shortly
after discharge
c. To identify ways to anticipate and proactively address issues that may
occur after discharge
Background for facilitator:
A root cause analysis (RCA) is a multidisciplinary and systematic approach to
reviewing an adverse outcome that has occurred in an effort to uncover the layers
of systems problems that may have existed to permit the end result. Take
advantage of an unscheduled readmission to do a mini RCA – mini because you
may not have the ability to convene a multi-disciplinary group and do all the
formal steps of the process. Nonetheless, bear in mind that it is important to
review the events, looking at them from the perspectives of the patient and all the
involved care givers.
Emphasize that the purpose of the experience is not to blame anyone but to look
for system holes that permitted the events to occur as they did. Individual
culpability is not the point of the exercise. Remember, in complex systems like
hospitals, there is almost never a single reason that explains an adverse event
completely. For additional information on RCA, see:
http://www.patientsafety.gov/PSC/RCA.html.
The exercise (30-60 minutes):
Begin by naming the problem or problems as specifically as possible that led to
the readmission; that is: “What happened?” Then start asking the question: “Why
did this occur?” Generate a list of direct and indirect/contributing reasons. Think
broadly. For each reason identified, think in turn about “What system issues
permitted that to occur?” By doing this iterative process, one eventually gets to
the roots of the systems that need addressing. Identify these issues and then
strategize with the team how to prevent them from recurring. If you wish, you
may use the worksheet available at
http://www.patientsafety.gov/PSC/Alternative_Education_Formats/PtSafety_Case
_Conference_Format/PSCaseConferenceCard.pdf to identify what issues need to
be addressed a systems levels so the problems identified do not recur. More
information about RCA and the worksheet may be found at
http://www.patientsafety.gov/PSC/CaseConf.html.
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6. A double exercise: Discharge handoffs: documentation and beyond
Goals of these exercises:
a. Reinforce the issue of accountability at transitions not only to oneself and
one’s patients, but also to one’s colleagues
b. Give and receive feedback on communications and care provided around
discharge
Background for facilitators:
Below are two exercises that reinforce the issue of accountability at transitions
not only to oneself and one’s patients, but also to one’s colleagues. It begins with
a paper-based feedback exercise on discharge summary content and clarity but
concludes with actual referral of a patient after discharge to a close colleague.
Both must be done in a non-threatening environment so feedback may be given
and taken in a constructive fashion. The choice of appropriate cases for each
exercise is important and moderate to complex cases will be preferable so
questions will arise.
By way of review for this exercise, recall that feedback1 should be:
a. specific rather than general with the use of examples
b. based on decisions made by learners not an interpretation of their motives
c. non-judgmental
Exercise 1 (20-30 minutes): Improving discharge documentation
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Have one intern on the team review a discharge summary of the other intern
and give feedback as if he or she were the receiving PCP. Highlight what was
missing or what was unclear. Then review it again as if the intern receiving it
were the patient. You may choose to add in copies of other paperwork
normally given to the patient at the time of discharge to reproduce more
faithfully what the patient’s experience might have been like. In this case,
consider how clearly stated the medication lists are, whether they clarify what
medications are new, changed, or discontinued (remembering that the nurses
may use this list to teach the patient at the time of discharge). Additionally,
consider the follow-up appointments and pending issues from the patient’s
perspective and give feedback. Then give the authoring intern the opportunity
to correct the discharge summary based on the feedback received. Finish the
exercise by having the interns switch roles and repeat.
1
Branch WT Jr. Paranjape A. Feedback and reflection: teaching methods for clinical settings. Acad Med
2002: 77(12 Pt 1):1185-8.
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Variation:
If this exercise feels too threatening to the trainees, de-identified discharge
summaries could be used with similar effect. Such materials will have the
same content issues but will raise fewer accountability issues as they represent
“somebody else’s work.”
This exercise could also be done during “intern report,” presenting examples
of real, de-identified well and poorly constructed discharge summaries,
encouraging group discussions of what is good and bad about each one and
having interns, in groups of 3-4, re-write the summaries and present them to
the group.
Exercise 2: Collegial handoffs
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Have one intern accept into his/her clinic a new unassigned patient of the
other intern after discharge. Have the receiving intern give feedback after
seeing the patient in clinic regarding the post-discharge period for the patient,
the documentation quality, and any other issues that may have arisen. Repeat
the process with the second intern sending a patient to follow up with the first.
This process will generally need to be begun early on in the rotation so
enough time for follow-up of the patient in the clinic can pass while the
interns are still on the service. Debrief the two experiences with both interns
together, addressing the same general issues as outlined in Exercise 1 above.
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