E-dischargesummarieslearningresourceprojectFinalreportv1.1
January2019
©RoyalCollegeofPhysicians2019
TheRoyalCollegeofPhysicians
TheRoyalCollegeofPhysicians(RCP)isapatient-centredandclinicallyledmembershiporganisationforphysicians,withover36,000membersworldwide.TheRCPworkstoensurethatphysiciansaretrainedtoprovidehigh-qualitycare,andpromotesevidence-basedpoliciestogovernmenttoencouragehealthylifestylesandreduceillness.Byworkinginpartnershipwithotherhealthorganisations,wepresentapowerfulandunifiedvoicetoimprovehealthandhealthcare.
HealthInformaticsUnit
TheRCPHealthInformaticsUnit(HIU)aimstoimprovepatientcareby:
• providingclinicalleadershipforthedevelopmentandimplementationofstandardsforthestructureandcontentofcarerecordstoachieveinteroperabilitybetweencomputersystemsindifferentcaresettings
• advisingonandpromotingtheimplementationanduseofsafeandeffectivenewtechnologies
• promotingtheprofessionalisationofclinicalinformaticsandthedevelopmentofcareerpathwaysforthosewantingtospecialiseinthisfield.
Novartis
ThedevelopmentofthistoolkithasbeensponsoredbyNovartisPharmaceuticalsUKLimited.
Copyright
Allrightsreserved.Nopartofthispublicationmaybereproducedinanyform(includingphotocopyingorstoringitinanymediumbyelectronicmeansandwhetherornottransientlyorincidentallytosomeotheruseofthispublication)withoutthewrittenpermissionofthecopyrightowner.Applicationsforthecopyrightowner’swrittenpermissiontoreproduceanypartofthispublicationshouldbeaddressedtothepublisher.
Copyright©RoyalCollegeofPhysicians2019
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11StAndrewsPlace,LondonNW14LE
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3
Revisionhistory
Version Date Summaryofchanges
0.1 03.09.2018 DocumentcreatedbyLindsayDytham
0.2 25.10.2018 Firstdraftcompleted
0.3 05.11.2018 DocumentupdatedfollowingfeedbackfromJanHoogewerf
0.4 12.11.2018 DocumentupdatedfollowingfeedbackfromJanHoogewerf
0.5 27.11.2018 EditsmadebyLindsayDytham
1.0 04.12.2018 ReportfinalisedbyLindsayDytham
1.1 15.01.2019 ReportupdatedfollowingfeedbackfromthePRSBandadditionalreviewers
1.2 28.01.2019 UpdatedfollowingeditingforRCPhousestyle
Acknowledgements
Thee-dischargesummarylearningresourceprojectwasverymuchacollaborativeeffort,withexpertiseandadviceprovidedbyawiderangeofpeople,viafocusgroups,surveysandinterviews.
ClinicalleadershipwasprovidedbyDrStephanieStrachan.Stephanie’sexperienceofmedicaleducationprovidedinvaluableknowledgeofwhatistrulyneededtosupportjuniordoctorsandwhatcouldmakethemostimpactonthequalityofcommunicationthroughe-dischargesummaries.Shedevotedmuchtimetoindependentlydevelopthelearningresourcematerialsthatwouldbeusefulandmostengagingtotrainees,alwaystakingaccountofexistingstandardsandtheconsultationresultsthroughtheprojectitself.Anysuccessofthelearningresourcehasbeendriventhankstoherpragmaticclinicalexpertise.
Duringthesetupofthisproject,andthroughout,theRCPEducationDepartmenthaveprovidedongoingsupportandadvicetohelpensurethelearningresourcewouldbefitforpurposeandtheresultsoftheprojectmeaningful.
TheRCPMedicalWorkforceUnitteamprovidedaprofessional,reliableservicetodeveloptheaudittoolandquestionnairesthatformedpartsofthelearningresourceandevaluation.
Forthesixsiteswhotookpartinthepilotofthelearningresource,thanksgotothesupervisorsandadministrativestaffwhocoordinatedthetrainees,andthetraineesthemselvesfortakingpartwithsuchcommitmentandenthusiasmandprovidingsubsequentvaluablefeedback.
©RoyalCollegeofPhysicians2019
Contents
Contents.............................................................................................................................................4
Executivesummary.............................................................................................................................6
1. Backgroundandcontext............................................................................................................8
2. Purpose.......................................................................................................................................8
3. Literaturereview........................................................................................................................8
4. Method.....................................................................................................................................10
4.1. Focusgroup.......................................................................................................................10
4.2. Projectteam.....................................................................................................................10
4.3. Furtherconsultation.........................................................................................................11
Survey.......................................................................................................................................11
Interviews.................................................................................................................................12
4.4. Resourcedevelopment....................................................................................................12
4.5. Evaluation.........................................................................................................................12
5. Learningresource.....................................................................................................................12
5.1. Learningobjectives..........................................................................................................12
5.2. Learningresourceapproach.............................................................................................13
5.3. Beforethelearningactivity...............................................................................................13
Pre-activityaudit.......................................................................................................................13
5.4. Thelearningactivitydetails.............................................................................................14
5.5. Afterthelearningactivity.................................................................................................15
5.6. Evaluationmethod............................................................................................................15
Aims..........................................................................................................................................15
Methods....................................................................................................................................15
6. Pilotresults..............................................................................................................................16
6.1. Participation......................................................................................................................16
6.2. Pre-training......................................................................................................................16
6.3. Post-training.....................................................................................................................17
6.4. Auditchecklist...................................................................................................................18
6.5. Additionalfeedback.........................................................................................................19
Feedbacksessionwithtrainees–EastLancashireHospitalsNHSTrust..................................19
Focusgroupmeetingwithtrainingsupervisors........................................................................20
7. Discussionandconclusions.......................................................................................................20
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7.1. General.............................................................................................................................20
7.2. Pilot...................................................................................................................................20
8. Recommendations....................................................................................................................21
8.1. RecommendationsforRCP...............................................................................................21
Dissemination...........................................................................................................................21
Learningresourcecontent........................................................................................................22
8.2. RecommendationsforNHStrustsandmedicalschools...................................................22
9. Communicationsplan...............................................................................................................22
10. Additionalresources............................................................................................................23
References.......................................................................................................................................24
Appendices.......................................................................................................................................26
AppendixA:Focus-groupmeetingJanuary2018.........................................................................26
AppendixB:Surveyresults...........................................................................................................28
AppendixC:Feedbackfrominterviews-recipientsofdischargesummaries..............................33
AppendixD:Pre-trainingquestionnaireanalysis..........................................................................35
AppendixE:Post-trainingquestionnaireanalysis.........................................................................39
AppendixF:Audittoolresultsanalysis........................................................................................44
©RoyalCollegeofPhysicians2019
Executivesummary
Projectsummary
Dischargesummarieshavehistoricallybeenfoundtobepoorlywrittenandcontaininaccurateandineffectiveinformation.Giventhatthesafetyandeffectivenessofcareislargelydependentuponaccurateandappropriatecommunication,thisisclearlyanimportantissuethatrequiresattention.
Juniordoctorsauthoringdischargesummarieshavelittle,ifany,trainingonhowtowritegooddischargesummaries.Dischargesummarycompletionisacommonplaceactivityforfoundationdoctors,butalsomanyotherrolesincludingphysicianassociates,pharmacistsandadvancedclinicalpractitioners.TheRoyalCollegeofPhysicians(RCP)HealthInformaticsUnit(HIU)carriedoutresearchandconsultationinordertodevelopaninformededucationresourcetoaddressthisissue.
Alearningresourcewascreatedthatwouldbeofpracticalusetoe-dischargesummaryauthors,toimprovetheirunderstandingofthebroadimportanceofe-dischargesummariesasatransferofcarecommunicationtoolandtosupporttheminwritingsummariesthatcanbeusedeffectively.
ThelearningresourcewaspilotedinsixNHStrustsandthepilotevaluated,with39individualstakingpartinthetraining.Thetrainingwasoverseenbyaneducationalsupervisororarelevantseniorclinicianwhounderstoodandchampionedthedischargesummaryasacommunicationtoolbetweensecondaryandprimarycare.Thelearningresourcewaswellreceivedbyparticipantsandtheirsupervisors,andconfidenceinwritinge-dischargesummariestotherequiredstandardincreasedbyameanscoreof2.1(scoreoutof10).
Participantscommentedthatthey‘feelmoreconfidentthaneverwithdischarges’andthat‘thechecklistprovidedformalguidanceonwritingdischargesummaries,whichIhaven’tseenbefore’.Anothercommentedthatitwas‘usefultoseeanexampledischargesummaryaspreviouslyIhadnotbeensureexactlywhatshouldbeincluded’,andanother,‘Iwasabletoimprovemyowncompletionofdischargesummariesasaresultofthislearningactivity’.
WiderdisseminationofthelearningresourcetoallNHStrustsisrecommended.
Methodology
Aliteraturereviewandperiodofconsultation,includingfocusgroupmeeting,surveyandaseriesofindividualandgroupinterviews,wereusedtodevelopalearningresourcethatcouldbepilotedinNHStrusts.Thepilotwasevaluatedandtheresults,conclusionsandrecommendationsarepresentedinthisreport.
Learningresource
Thelearningresourcewasmadeupofatoolkitofmaterialsincludinga‘cribsheet’thatdescribedthekeyfeaturesofthee-dischargesummaryheadingsandhowtheyshouldbewritten;anexampledischargesummaryannotatedtoexplainitsweakandstrongpoints;asetofexamplepatientnotesandblankdischargesummarytopracticecompleting;anexamplecompletionofadischargesummaryforthenotesprovided;aself-assessmentchecklistforusewhenwriting
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e-dischargesummaries;andanaudittoolforcarryingoutamorethoroughassessmentofthequalityofane-dischargesummary.
Conclusions
• Verylittletrainingisprovidedinmedicalschoolsandfoundationtrainingforcompletinge-dischargesummaries,andinwrittencommunication,generally.
• PrioritiesforGPswhenreceivingadischargesummaryare:o thattheongoingplanisclearandeasytoidentify,withanyrequiredactions
apparent,especiallythosethatareurgento thattherationaleforanychanges,especiallytomedications,isclearo thatthepatient’sjourneythroughtheepisodeofcareisconcisebutcompleteand
easytofollow.• Participantsinthepilotofthelearningresourcefoundallthecomponentsuseful,but
especiallytheself-assessmentchecklistandanopportunitytodiscussdischargesummarieswithcolleagues(scored8.6and8.8outof10,respectively).
• Participantsweremoreconfidentinwritingdischargesummariesfollowingthetraining,withtheirscoreoutof10improvingby2.1onaverage.
• Traineeslackedunderstandingoftheactiverolethatapatientmaywishtotakethatcanimprovethedischargeprocess.Thisawarenesswasincreasedfollowingthetraining.
• Dischargesummariesaresometimeswrittenwithexcessiveuseofacronymsandspecialistterminology,whichmaybeobstructivetopatientsandothernon-technicalornon-specialistreadersofasummary.Thiswasimprovedfollowingthetraining.
• Participantsexpressedaninterestinhavingawiderselectionofexampledischargesummariesfordifferentspecialties.
Summaryofrecommendations
• MakethelearningresourceavailabletoallNHStruststofreelytakeupanduse.• Providetrainingfordoctorsinthefinalyearofmedicalschoolandasearlyaspossible
duringthefirstF1placement,ideallybeforetheytakeonresponsibilityforauthoringdischargesummaries.
• Providetrainingduringrelevantinductionperiodsforotherprofessionalsresponsibleforwritingdischargesummaries.
• Delivertraininginagroupsettingforparticipantstobenefitfromdiscussionandthesharedexperiencesofvariedprofessionals.
• Providededicatedtimetocompletetheactivitytoincreaseparticipation.• Developotherexampledischargesummariesfortheemergencydepartment,mental
health,paediatricsandotherspecialties;workwithspecialistsocietiestodoso.• Considerusingthelearningresourceaspartofawiderqualityimprovementprojectin
ordertoassessthelonger-termimpactoftrainingonthequalityoflocale-dischargesummaries.
©RoyalCollegeofPhysicians2019
1. Backgroundandcontext
By1October2018,NHSorganisationswererequiredbytheNHSEnglandStandardContracttobesendingdischargesummariesbydirectelectronictransmissionasstructuredmessagesusingcodeddataandstandardisedclinicalheadings,sothatdatacanbeautomaticallyextractedintoGPrecords(NHSStandardContract2017/18and2018/19TechnicalGuidance,section39.22).1Dischargesummarieshavehistoricallybeenfoundtobepoorlywrittenandcontaininaccurateandineffectiveinformation.2–6Giventhatthesafetyandeffectivenessofcareislargelydependentuponaccurateandappropriatecommunication,thisisclearlyanimportantissuethatrequiresattention.
TheRoyalCollegeofPhysicians(RCP)HealthInformaticsUnit(HIU),withtheProfessionalRecordStandardsBody(PRSB),hasbeeninstrumentalindevelopingthe‘E-dischargesummarystandard’,astandardforthecontentandstructureofdischargesummaries.7Thisstandard,andthePRSBstandardsforthestructureandcontentofhealthandcarerecords,8replacedthe(nowarchived)AcademyofMedicalRoyalColleges(AoMRC)publicationStandardsfortheclinicalstructureandcontentofpatientrecordspublishedin2013.9
Thejuniordoctorsauthoringdischargesummarieshavelittle,ifany,trainingonhowtowritegooddischargesummariesanddonotusuallyreceivefeedbackorsupervisionforthetask;4,5themethodologyandresourcesavailableforwritingdischargesummariesmayvarybothbetweenandwithintrusts.Dischargesummarycompletionisacommonplaceactivityfordoctors,butalsoforotheralliedmedicalprofessionalsincludingphysicianassociates,advancedclinicalpractitionersandpharmacists.
Toachieveaccuracyandconsistencyindischargesummaries,theHIUhascreatedaneducationresourcewhichaimstoimprovetheunderstandingoftheimportanceofcomprehensive,accuratesummaries,andexplainhowthiscanbeachieved.
2. Purpose
Thisdocumentisthefinalreportofthee-dischargesummarieslearningresourceproject.Thereportincludesthemethodsusedtodevelopandpilottheeducationalresourceandtoevaluatethem,thelearningobjectives,andthefindingsfromtheevaluation.Itmakesgeneralrecommendationsabouteducationneedsforthosecompletinge-dischargesummariesandtotheRCPaboutnextstepsforthedisseminationofthelearningresourcethatwasdeveloped.
Thisdocumenthasbeenproducedtoinformdecisionsaboutimplementationoftheeducationalresource.ItsaudiencesincludeNovartisPharmaceuticalsUKLimited(whosponsoredtheproject)andtheRCP,andisalsoprovidedasevidencetothoseintheNHSwhoareconsideringusingtheeducationalresourceintheirowntrust.
3. Literaturereview
Ithasbeenwidelyreportedthatdischargesummariesoftenlackrequiredinformation,foranumberofreasons.2–6Alackoftraininginwritingdischargesummarieshasalsobeenreported,4,6withjuniordoctorsfeelinginadequatelypreparedforwritingdischargesummaries,leadingtoa
9
callforfurthertraining.10SuggestionsfortraininghaveincludedGP-ledadvice,guidanceonappropriatecontentandgoodpracticeexamples.10
Keyproblemareashavebeenrecognisedasdocumentationofinvestigations,medicationchangesandfollow-uparrangements.6Ina2014studyinaUKgeneralhospital,thecharacteristicofdischargesummariesdeemedtobemostimportantbyjuniordoctorsandGPswasaccuracy.Themostimportantcontentiteminthesamestudywasmedicationprescribed.10MedicationchangeswereviewedtobemoreimportantbyGPsthanjuniordoctors,andGPswerelargelydissatisfiedwiththequalityofinformationaboutmedicationchangesprovidedondischargesummaries,suggestingagapinjuniordoctors’educationinthisarea.10
Nationally,therehavebeenmanyCommissioningforQualityandInnovation(CQUIN)targetsfordischargesummariestobecompletedandtransmittedtotheGPwithin24hours,buttherearefewerreportedeffortstoimprovethequalityofdischargesummaries.Interventions,suchasanelectronicpromptingsystem,12havebeenshowntoimprovetheaccuracyandcompletenessofdischargesummaries.
In2018theCareQualityCommission(CQC)reviewed20localhealthandcaresystemstounderstandhowservicesareworkingtogethertomeettheneedsofpeoplewhomovebetweenhealthandcareservices,withafocusonpeopleagedover65.5Thereportusedadischargeinformationflowtool,seekingperspectivesfromprovidersofsocialcareabouttheinformationtheyreceivewhenolderpeoplearedischargedfromhospitalsandintotheircare.
TheCQCreportdescribedpeoplefrequentlybeingdischargedfromhospitaltotheirhomewithoutaccurateorsufficientinformationabouttheirstayinhospitalortheircareneeds.Peoplewerealsoseenreturninghomeorbeingmovedtoanewhomeonlytogetunsafecareand/orgetreadmittedtohospitalbecauseofalackofinformation.Some29%ofregisteredmanagersofsocialcareproviderssaidtheyreceivedischargesummarieslessthanaquarterofthetimewhenapersonisdischargedintotheircare.Also,60%ofregisteredmanagersfromdomiciliarycareservicesreportedthattheyreceivedischargesummarieslessthanaquarterofthetime.Inaddition,nearlyaquarter(23%)ofcareprovidersreportedthatthequalityofdischargeinformationwas‘rarely’or‘never’sufficienttomakedecisionsaboutwhetherornottheycanprovidecaretoapersonbeingdischargedtothem.Informationmentionedaslackingspecificallyincludedhighlightedchangestomedicationsordetailofwhenthepersonhadlasttakentheirmedication.5
Implementingnationalrecordstandardheadingsfore-dischargesummarieshasbeenshowntoreducethetimespentwritingdischargesummariesaswellasthetimetakenbyGPstocontactthetrusttoaskforpotentialmissinginformation;makeresponsibilitiesclearer;andreducethepotentialforomissionofkeyinformation.12,14
AstudyatDoncasterandBassetlawTeachingHospitalsFoundationNHSTrustsin2017–18determinedthatthemajorityofdischargesummarieswereauthoredbyjuniordoctorsandlackedkeyinformationsuchasdiagnosis,pastmedicalhistoryandmedicationchanges.15Throughimplementationofadischargesummarytemplate,withdescriptionsofthetemplateheadings,
©RoyalCollegeofPhysicians2019
therewasasignificantimprovementindischargesummaryquality.Recordingofthediagnosisforthecurrentadmissionincreasedfrom75%to90%completionandpastmedicalhistoryfrom58%to87%complete.About94%ofpatientshaddocumentationofmedicationchanges,withreasonsdocumentedin84%ofpatients,comparedwithjust67%beforetheintervention.Thestudyauthorsrecommendededucationofnewjuniordoctorsandmedicalstudentsinthenewdischargesummarytemplateateveryrotationchangeover.15
4. Method
4.1. Focusgroup
Afocusgroupmeeting,heldon29January2018,broughttogether18healthandcareprofessionalsandpatientswhohaveexperienceofcreating,receivingorengagingwithe-dischargesummariesinavarietyofways.Thisformedthebaselineneedsanalysisforthisreport.Thegroupconsistedofthefollowing:
• twojuniordoctors• onetraineeGP• threeGPs• onesecondarycareconsultant• onepharmacist• twopatients• oneinformationmanager• onehealthcareservicesmanager,privatesector• oneprojectmanagerfromthePRSB• threemembersoftheRCPHIU• oneeducationalistfromtheRCPEducationDepartment.
Duringthemeeting,thegroupwereaskedtoconsiderthefollowing:
• Whatarethecurrentissuesaroundqualityofe-dischargesummaries?• Whichissuescouldbeaddressedbylearningresources?• Whatdoestrainingfore-dischargelooklikeatthemoment?• Howcoulditbebetter?• Whatwouldtheideallearningresourcesbelike?
ConclusionsofthefocusgroupmeetingcanbefoundinAppendixA.
4.2. Projectteam
Followingthefocusgroupmeeting,asmallprojectteamwasestablishedtooverseefutureprojectactivity.Membershipincludedthefollowing:
Name JobtitleDrStephanieStrachan,clinicallead
Criticalcareconsultant,King'sCollegeHospitalNHSTrust;honoraryseniorlecturer,GKTSchoolofMedicalEducationKing’sCollegeLondon
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JanHoogewerf Programmemanager,HIU,RCPLindsayDytham Projectmanager,HIU,RCPDavidParry Deputydirectorofeducation,RCP
4.3. Furtherconsultation
SurveyFollowingthefocusgroupmeeting,basedonthefeedbackreceived,theprojectteamdevelopedapotentialplanforalearningresourcetosupportthewritingofe-dischargesummaries.Asurveywasthendevelopedtoconsultfoundationdoctors,astheprimaryauthorsofdischargesummaries,andtheirsupervisors,onthepotentiallearningactivitymethodandhowitshouldbedelivered.
Theproposedapproachforthissurveywasoutlinedbriefly,asfollows:
• F1teachingactivityduringworkplace-basedassessment• supervisionbyrelevantseniorclinicianwhounderstandsandchampionsdischarge
summaryasacommunicationtoolbetweenprimaryandsecondarycare• F1guidedthroughexamplepatient'scaseandcorrespondingdischargesummary• F1completesadischargesummaryforamorecomplexpatient• peerorself-assessmentwithfurtherfeedbackfromtheeducationalsupervisor
encouraged.
Therewere77responsestothesurvey.Asummaryofthemainlearningpointsarelistedbelow:
• Theactivityshouldlast40–60minutes.• Acombinationofself-assessmentandsupervisorfeedbackwouldbemostbeneficial.A
seniorshouldtakethetimetogothroughajunior'sdischargesummary,andoffercomments,criticismandadvice.
• Trainingneedstobeprovidedasearlyaspossibleinadoctor’scareer,ideallybeforetheystarttowritedischargesummaries(eginshadowingorinductionperiodsorinanearlyF1teachingsession)andthenrepeatedthroughfoundationtraining(writinggooddischargesummarieswasdescribedasan‘iterative’process).
• Thevastmajorityofrespondentsfeltthistrainingwouldbebestdeliveredinahospitalsetting.
• Respondentswereasked‘Towhatextentdoyoufeelthatthislearningactivitycouldhelptoimprovethequalityofdischargesummariesproducedbyjuniordoctors?’Onascalefrom1to100,themeanforseniordoctorsrespondingwas74andforjuniordoctorsitwas58.
FullresultsofthesurveycanbeseeninAppendixB.
©RoyalCollegeofPhysicians2019
InterviewsAseriesofgroupandindividualinterviewswereheldwithvariousrecipientsofdischargesummariestogatherfurtheropinionaboutwhatmakesaqualitydischargesummarythatisfitforpurposeandwhetherthedraftlearningresourcemightbeappropriate.IntervieweesincludedGPs,aGPregistrar,pharmacistsandapatient.Thefeedbackfromthesesessionswasusedtodevelopandrefinethematerialsthatformedthelearningresource(seeAppendixC).
4.4. Resourcedevelopment
AllelementsofthelearningresourcewerecreatedbystudyingthePRSBe-dischargesummarystandard(lookingatwhichheadingsaremandatory,requiredoroptional)andusinginformationgainedthroughtheliteraturereview.Feedbackgatheredfromthefocusgroup,surveyandinterviews(whichhelpedtodeterminewhatthemostimportantpartsofthedischargesummaryareforthosethatusethemandhowtheseshouldbewritten)wasalsoused.
Thefollowingmaterialswereplannedbytheprojectteamtoformpartofthelearningresourcetoolkit:
1. guidancenotesforsupervisors2. dischargesummarytemplateoutliningheadingsincludedinthegenericdischargesummaryfor
thepurposeofthetraining3. dischargesummary‘cribsheet’describingwhatshouldbeincludedineachoftheheadings4. anexampledischargesummaryannotatedtodescribegoodandbadpoints5. clinicalnotesofanexamplepatient*6. dischargesummarytocompletefortheexamplepatient7. examplecompletionofdischargesummaryforexamplepatient8. self-assessmentchecklistforusebytraineeswhenwritingdischargesummary9. audittoolforassessingthequalityofarealdischargesummary,whichwouldalsohelptrainees
tofurtherconsiderwhatthekeyareasofimportancearewithinadischargesummary.
*Theclinicalnotesofanexamplepatientweredevelopedbytakingananonymisedsetofpatientnotesandeditingthesetomeetthelearningneedsfortheactivity.
4.5. Evaluation
Seesection5.6belowforadescriptionoftheevaluationmethods.
5. Learningresource
5.1. Learningobjectives
Bycompletingthelearningresource,itwasintendedthatparticipantswouldbeableto:
• understandwhotherecipientsofe-dischargesummariesare,howtheyusethedischargesummaryandtheinformationthattheyneed
• describethepurposeandimportanceofe-dischargesummaries
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• befamiliarwiththePRSBe-dischargesummarystandardheadingsandunderstandtheinformationthatisappropriatetorecordundereachheading
• gainconfidenceinwritingqualitydischargesummariesthatareusefultoallrecipients• writethedetailsine-dischargesummarieswithclarityandtoanappropriatelevelofdetail• identifyanddiscussgoodandbadpointsofcompletede-dischargesummarieswith
multiprofessionalcolleagues• obtaintakeawaymaterialstoprovideongoingsupportwhenwritinge-discharge
summaries.
5.2. Learningresourceapproach
Thelearningresourcetoolkitofmaterialsincludedthefollowing:
• guidancenotesdocumentforsupervisorsofthelearningactivity• agenericdischargesummarytemplatealignedwiththePRSBe-dischargesummary
standard.Thiswasnotintendedtobeadefinitivetemplatebutincludesthemainclinicalheadingsforeducationalpurposestohelppeopletowriteaqualitydischargesummary
• cribsheet–notestoguidewritingadischargesummary• anexamplepatientdischargesummaryannotatedtoexplainpointsofimportance• exampleclinicalnoteswithaccompanyingblankandcompleteddischargesummaries• self-assessmentchecklisttoenableself-orpeer-reviewandguidedreflectionofthe
completedpracticedischargesummary.• onlineaudittooltoassessthequalityofane-dischargesummary.
5.3. Beforethelearningactivity
Priortorunningthelearningactivitywithtrainees,supervisorswereaskedtofamiliarisethemselveswiththecontentsoftheresourcepackandtoreviewthemostrecentPRSBguidanceone-dischargesummaries.
Supervisorswereaskedtofamiliarisethemselveswiththeprovidedgenericdischargesummarytemplate.Thetemplatewascreatedasa‘bestpractice’examplefromthePRSBstandardandthroughdiscussionswithavarietyofstakeholdersincludinghospitaldoctors,GPs,pharmacists,andpatients.Asthetemplatewouldbeunlikelytobeidenticaltothesystemusedintrusts,supervisorswereaskedtocompareandcontrasttheirowntrust’sdischargesummarytemplatewiththegenericdischargesummarytemplateinthelearningresourcetoolkit.Thisexerciseaimedtohighlightanyfieldsthatarenotspecificallyincludedintrusts’individualtemplates,suchthat,followingthelearningactivity,thetraineescouldbesignpostedtothetrustdocumentandtolearnwheretheymayincludebestpracticeelementsifspecificfieldsforthemareabsent.
Pre-activityauditPilotsiteswereencouragedtoreviewthestandardofdischargesummariesintheirtrustpriortodeliveringthelearningactivity.Theonlineaudittoolpreparedaspartoftheresourcepackenabledanaudittobetakenbothbeforeandafterthelearningactivitytoassesstheimpactofthelearningactivityonthequalityofdischargesummariesineachpilotorganisationthatchosetotakepart.
©RoyalCollegeofPhysicians2019
5.4. Thelearningactivitydetails
Setup
Thelearningactivityissuitableforanyhealthcareprofessionalthatauthorsdischargesummariestoprimaryhealthcareteamsfromasecondarycaresetting;however,theexampleprovidedforthepracticedischargesummarywasbasedonamedicalepisodeforanadultpatient.Forthepurposesofthepilot,itwassuggestedtodeliverthelearningactivityusingmethodologydescribedbelowtotraineedoctorsduringtheirF1year,aspartofclassroomteachingand/oraworkplace-basedassessment(WPBA).Otherhealthcareprofessionalsthatauthordischargesummariestookpartinthetraininginsomeofthepilotsites.Theactivitywasdesignedtotakeupto1hourtocomplete.Thiswouldnotincludethepre-activityaudit,whichshouldbecompletedbeforethetrainingiscarriedout.
Foundationdoctorshavebeenidentifiedasfrequentauthorsofdischargesummaries,butmanyotherrolesmaybeinvolved,includingphysicianassociates,pharmacists,advancedclinicalpractitionersetc.Whentheseclinicalprofessionalsarenewtowritingdischargesummaries,theymaynotbewhollyfamiliarwithhowe-dischargesummariescanbecreatedtomaximisetheirbenefittomultiplestakeholders.Duringexperientiallearningofthetasktherearecommonpitfallsencounteredthatmaybeavoided,whichitishopedwouldbehighlightedthroughthistraining.ThislearningactivityalsofamiliariseshealthcareprofessionalswiththePRSBstandard.
Thelearningactivitycouldbedonebyeitherindividualsorgroupsoftrainees,supervisedbyaneducationalsupervisororarelevantseniorclinicianwhounderstandsandchampionsthedischargesummaryasacommunicationtoolbetweenprimaryandsecondarycare.
Fortrainingprovidedtoasupervisedgroup,itwouldideallybedeliveredinanITsuitefacilitywithenoughcomputersforeachtraineeoreachpair.Thesupervisorwouldalsoneedaccesstoacomputerand,ideally,aprojector,sothatalltraineescouldseethesupervisor’sscreenatonetimeforthepurposesofdiscussion.Therecommendedgroupsizewouldbe8–10traineesatonetime,buttrainingcouldbedeliveredtolargergroupsiftheequipmentandspaceavailablecouldcaterforthis.Iftraineeswereabletobringlaptopsandwereprovidedwiththelearningresourcetoolkitinadvance,thiswouldhelptoaccommodatelargergroupsizesforthetraining.Ifitwasnotpossibleforthetraineestobesuperviseddirectlyduringtheactivity,itcouldbecarriedoutindependently,asindividualsorsmallgroups,butthisislesspreferable.
Methodology
1. Thetraineeswereinitiallyaskedtoreviewandcritiqueanexampledischargesummary.Thesupervisorledadiscussionaroundthepurposeofdischargesummaries,theiraudience,problemsandpitfallsandbestpractice,aidedbytheannotatedpointsandthecribsheetnotes,toguidewritingadischargesummary.ThisexercisealsointroducedthegenericexampletemplatetothetraineesandthePRSBe-dischargesummarystandard,aswellashighlightingtheimportanceofgoodwrittendocumentation.
15
2. Thetraineesthencompletedadischargesummaryforanexamplepatient.Theyhadtheguidancematerialavailabletothem(‘Dischargesummarytemplatecribsheet’)tousealongsidewritingthesummary.
3. Thecompleteddischargesummarywastheneitherpeer-orself-assessedusingtheone-pageself-assessmentchecklist,supportedbytheireducationalsupervisororotherseniorclinician.Acompleteddischargesummarywasincludedtoaidthediscussion,ifrequired(‘Activity-practicedischargesummaryexamplecompletion’).
Traineesmaythenhavebeensignpostedtowardadditionaltrainingorsupportasrequiredfortheirindividualneeds.
5.5. Afterthelearningactivity
Allparticipantswereaskedtoreviewatleastonerealdischargesummarybythemselvesoranotherparticipatingtraineethatwaswrittenaftercompletingthetraining.Theyusedtheonlineaudittooltodothis.
5.6. Evaluationmethod
AimsTheevaluationaimedtoassesswhetherthelearningresourcemetthelearningobjectivesoutlined(seesection5.1)andiftheresourcewasableto:
a)helptraineestounderstandhowtocreateaqualitydischargesummary
b)improvethequalityofthedischargesummariestheycreated
c)bedeliveredwithappropriatetiming
d)featurecontentthatwasconsideredappropriatebythoseusingtheresource.
MethodsDataweregatheredbythefollowingmeans:
1.pre-trainingquestionnairefortrainees(includingquantitativeandqualitativedata)
2.post-trainingquestionnairefortrainees(includingquantitativeandqualitativedata)
3.auditofdischargesummarieswrittenbytraineesbeforeandafterreceivingthetraining(self-completed)
4.groupfeedbacksessionwithtrainingparticipants(RoyalBlackburnHospital)
5.groupfeedbacksessionwithtrainingactivitysupervisors(viateleconference).
©RoyalCollegeofPhysicians2019
6. Pilotresults
6.1. Participation
Thepilotofthee-dischargesummarylearningresourceengagedsixUKNHStrusts.Thesesiteswereengagedprimarilythroughparticipationintheconsultationsurvey.
Therewere74individualssigneduptothetraining,eitherthroughexpressinganinterestthemselvesorbeingrecommendedbytheirsupervisorormedicaldirector(Table1).Therewasahighdrop-outrateintwoofthepilotsites,whichisattributedtothemethodofsignupinthesetwolocations–whereF1swereaskedtooptoutiftheydidnotwishtotakepart,ratherthanvoluntarilysigningupinitially.Traineeswhoparticipatedindependently(ratherthanwithdirectsupervision)werenotgivenprotected,dedicatedtimetocompletethelearningactivity,sowouldhavebeenlikelytofindithardertofindtimetocompletethetasksinadditiontotheirexistingclinicalduties–anotherreasonfordrop-out.
Table1.Summaryofpilotparticipation
Organisation Numbersignedup
Numberwhocompletedlearningactivity
Participationthroughgroupteachingsessionorindependentuseoflearningresource?
BlackpoolTeachingHospitalsNHSTrust
9 8 Independent
EastLancashireHospitalsNHSTrust
11 9 Groupsession(multiprofessional)
EpsomandStHelierNHSTrust 17 4 IndependentSouthendUniversityHospitalNHSFoundationTrust
8 7 Groupsession
UniversityCollegeLondonHospitalsNHSTrust
2 2 Groupsession
WestSuffolkNHSFoundationTrust
27 8 Independent
TOTAL 74 38
6.2. Pre-training
Participantsinthelearningactivitywereaskedtocompleteaquestionnairepriortotakingpart.Therewere62respondentsintotal.Ofthese,97%hadwrittendischargesummariesbefore,but31%hadreceivednotrainingofanysortinthetask.Forthemajorityofthosewhohadreceivedtraining,thiswasintheformofatalkorlecture(84%).Trainingwasmostlyreceivedatmedicalschool(40%),atF1induction(32%)orinaF1teachingsession(24%).Whenaskedifthetimingthattrainingwasreceivedwasappropriate,themeanscoreofresponseswas7.8(where10=highlyappropriate).
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Respondentswereaskedtoconsiderwhoreceivedcompleteddischargesummaries.Of59peoplewhoansweredthisquestion,57peoplementionedtheGPand50peoplethepatient.Severalotherrecipientswerelisted(egcarers,clinicalcoders),butwithonly26mentionsintotal.
Weaskedrespondentstoconsiderwhyitisimportanttobeclearandconcisewhenwritingadischargesummary.ThemostcommonthemeamongresponseswasfortheawarenessoftheGP/specialists/othersinvolvedincare.Othercommonresponsesincluded:forpatient’sunderstanding/forpatienttoactionfollow-upplans;forfollow-upplanstobeactioned;andfortheGPtoplan/identifytasks.
Whenasked‘Whatisyourunderstandingofthepatient’srolewithinthedischargesummaryprocess?’themajorityofrespondents(63%,n=62)answeredthattheysimplyreceiveit/itisfortheirrecordsorsotheyareawareoftheplan.
Ofthosewhohadwrittendischargesummariespreviously,51%hadreceivednofeedbackonthequalityofthese.Thirty-twopercenthadreceivedfeedbackrelatedtotheirwrittencommunication(egtoobrief/toolengthy).
Finally,respondentswereaskedtoscorehowconfidenttheyfeltincompletingdischargesummariestothestandardrequiredbythePRSB,where10=veryconfident,1=unconfident.Themeanscoreforthiswas6.1(n=59,standarddeviation(SD)=1.34).
CompleteresultsofthisquestionnairecanbefoundinAppendixD.
6.3. Post-training
Followingthetraining,participantswereaskedtocompleteafinalquestionnairetoreflectontheirexperienceandlearning.Therewasatotalof31returnsofthequestionnaire.
Allbutoneelementofthelearningresourcetoolkitwererankedabove8/10.Thehighestrankedfeature(8.8/10)ofthetrainingwashavinganopportunitytodiscussdischargesummarieswithcolleagues.Thissupportsthedeliveryofthetrainingthroughgroupsessionsasopposedtothroughindependentlearning.Thelowestrankedtask(7.6/10)wasuseoftheonlineaudittool.Commentsinlaterquestionssuggestthisrelatestosomeconfusionoverwheninthetrainingthetoolshouldbeusedandhow–thiscouldbeimprovedbyprovidingclearerinstructionstosupervisorsandbyprovidingadditionalwritteninstructionsfortrainees.
Whenaskedtodescribethepositiveaspectsofthelearningactivity,themostfrequentresponsesincludedthefollowing:
• examplesofcompleteddischargesummariestoviewandcompareto• learningwhatisrequiredofagooddischargesummary(includingPRSBstandard)• groupwork/discussion/multiprofessionalworking• learninghowtocommunicatetheinformationinadischargesummary–eglevelofdetail
required• self-assessmentchecklisttoolvaluabletousealongsidewritingdischargesummaries.
©RoyalCollegeofPhysicians2019
Traineeswerealsoaskedwhatcouldbeimprovedaboutthelearningactivity/training.Theaspectsmentionedmostweretoprovidemoreexamplesofdifferentdischargesummariesforadditionalspecialitiesorscenarios,egsurgicalorA&E.Itwasalsonotedthatcompletingthe‘Medications’sectionwasoverlyarduous,notsufficientlysimilartohowthisisdoneinrealdischargesummariesandnotapointofsignificantlearning.
ThescoreofconfidencewithcompletingdischargesummariestothestandardrequiredbythePRSBhadameanof8.2,comparedwithascoreof6.1forthesamequestionaskedbeforetakingpartinthetraining.
Themajorityofrespondents(45%)feltthatthetrainingwouldhavebeenmoreappropriateifcarriedoutduringtheirinductionperiod,orbeforetheyfirststartwritingdischargesummaries.Quitealargegroup(35%)oftraineesfeltthatthetimingofthepilottraining(inthefirst1–2monthsofF1sstartingtheirfirstplacement)wasappropriate,however.
Theparticipantswerethenaskedtoagainconsiderthesamefourquestionstheywereaskedbeforethetrainingwithrelationtothecontentofdischargesummaries.Therewasa12%increaseinthenumberofrespondentswhorecognisedthatthepatientwasarecipientofadischargesummary.Therewasalsoalargeincreasefrom5%to24%ofrespondentswholisteddistrictnurseasapossiblerecipientandalsoanincreasefrom2%to17%wholistedcommunitypharmacists.Slightlyfewerpeople(areductionof5%)mentionedcarersorcarehomes,however.
Whenaskedwhyitisimportanttobeclearandconcisewhencompletingdischargesummaries,itwaspleasingtoseeashiftfromthedischargesummarybeingpurelyarecordforGPs(from49%downto34%)towarditbeinganimportantwaytoidentifyfollow-upplans(from25%to31%)andforGPstobeabletoworkmoreefficiently(15%upto34%).Therewasalsoanincreasedmentionoftheimportanceofcontinuityofcare(from11%to24%).
Therewasanequallypositiveresultintermsofanimprovedunderstandingoftheroleofapatientinthedischargeprocess.Therewereseveralrespondents(7%)whofeltthatpatientshadnoroleinthedischargeprocessbeforethetraining,buttherewerenorespondentsafterthetraining.Therewasalsoashiftofdescriptionsawayfrompatientshavingapassiverole,simplyreceivingthedischargesummary(from64%downto52%),towardbeingactiveparticipantswhoseconcernsandwishesshouldbediscussedandrecorded(from5%to24%)andwhoshouldbefullyinvolved(from2%upto12%).
Mostrespondents(84%)feltthattheydidnothaveanyadditionaltrainingneedsfollowingthislearningactivity,withjustacoupleoftraineesmentioningthattheywantedtohavemorepractice.Tworespondents,anadvancednursepractitionerandaphysicianassociate,alsomentionedthattheywouldliketospreadthetrainingtotheircolleagues.
Completeresultsofthepost-trainingquestionnairecanbefoundinAppendixE.
6.4. Auditchecklist
Theonlineaudittoolwascompletedfor40e-dischargesummaries.Ofthese,25werecompletedfordischargesummarieswrittenbeforethetrainingand15forthosewrittenafter.Therewasa
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smallnumberofpairedexamples(n=6),whereindividualscompletedtheauditfordischargesummariestheyhadwrittenbothbeforeandthenaftercompletingthistraining.
Severalareasofweaknesswerehighlightedfromthecompletedauditforms.Ofthe40returns,40%didnotagreethatpatientand/orcarerconcerns,expectationsorwisheshadbeenincludedinthedischargesummary.Inaddition,38%didnotagreethatthedischargesummaryindicatedwherethepatienthadbeeninvolvedinplanningandmonitoringtheirowncare.Whenaskedifthedischargesummaryindicatedwherethepatienthadbeeninvolvedinplanningandmonitoringtheirowncare,38%disagreed.In30%ofresponses,thedischargesummarydidnotincludeinformationaboutsocialcarepackages.Also,in30%ofcases,respondentsdisagreedthatthedischargesummarywasdiscussedwiththepatientpriortodischarge.
Fromanalysingthesixpairedresponses,theareaswhichdemonstratedthemostimprovementine-dischargesummarieswrittenbeforeandafterthetrainingwereasfollows(theresponsesforthesequestionswere‘Stronglydisagree’,‘Disagree’,‘Neitheragreenordisagree’,‘Agree’,and‘Stronglyagree’,andascorewasgivenbasedonhowfarupordownthisscaletheanswersmoved):
• Thepatient’smedicationondischargeisfullydocumentedwithchangeshighlighted(+1.7).• Patientand/orcarerconcerns,expectationsorwishesareincluded(+1.5).• Thedischargesummaryindicateswherethepatienthasbeeninvolvedinplanningand
monitoringtheirowncare(+1.3).• Anysecondarydiagnosesareaccuratelydocumented(+1.2).• Thedischargesummaryhasconsideredthepatientholistically(+1.2).
Itshouldhoweverbenotedthattherewasaverysmallsample(n=6)forthesebefore/afteranalyses.
CompleteresultsoftheauditchecklistcanbefoundinAppendixF.
6.5. Additionalfeedback
Reflectionsofthelearningresourcewerealsocollatedviatwogroupfeedbacksessions.
Feedbacksessionwithtrainees–EastLancashireHospitalsNHSTrustThroughattendingagroupfeedbacksessionwiththesupervisorandparticipantsofthegrouptrainingsessionrunattheRoyalBlackburnHospital,thefollowinglearningpointswereidentified.
Traininghelpedto:
• makethenarrativeine-dischargesummariesmorefocused
• considerwhattheGPalreadyknowsandwhattheyneedtoknow
• knowwhatinformationshouldbeinthedischargesummary
• appreciatetheneedtoavoiduseofabbreviationsandmedicaljargon
©RoyalCollegeofPhysicians2019
• allowabetterappreciationoftheinvolvementofpatientsinthedischargeprocess.
Havinganinteractivetrainingsession,withdiscussionbetweendifferentmembersofthemultiprofessionalteam,wasalsoemphasisedasakeybenefit.
FocusgroupmeetingwithtrainingsupervisorsSupervisorswereinterviewedfollowingdeliveryofthetrainingtogathertheirperspectivesontheusefulnessofthetraining.Responseswereverypositiveand,althoughitwasrecognisedthatagroupsessionwasthepreferableapproach,deliveringthetrainingatlargerscale,egtoallF1satinduction,wouldmakethislogisticallydifficult,duetotherequirementforITfacilitiesforthetraineesduringthesession.
Thegroupexpressedastrongopinionthate-dischargesummarytrainingshouldbeprovidedtoundergraduatemedicaltraineesinthefinalyearofmedicalschool,and/orbeforedoctorsbegintheirF1placement,withlaterfollowupstorefreshandreinforcelearning.
7. Discussionandconclusions
7.1. General
• Adischargesummaryisanimportanthandovertool,apieceofmedicalhistoryusedinfuturecareencountersandavaluablerecordforpatientsoftheirepisodeofcare.Itisespeciallyimportantforpatientsaspeopleareoftenveryvulnerablewheninhospitalandmaynotbefullyabletoretainorunderstandallinformationthatisgiventothemverbally.Italsoprovidespatientswithanopportunitytoseekfurtherinformation,ifrequired.
• Juniordoctorsaretheprimaryauthorsofdischargesummaries,buttheyarealsowrittenbyotherprofessionals,includingpharmacists,advancednursepractitioners,physicianassociatesandconsultants.
• Juniordoctorsreceiveverylittletrainingincompletinge-dischargesummariesandinwrittencommunication,generally.Themajorityoftrainingthathadbeenreceivedwasviaatalkorlecture,ratherthanthroughapracticaltask,whichwasrare.
• Theinductionperiodforjuniordoctorsisanintenseperiodoftrainingandthusadifficulttimetotakeinandretainadditionalnewinformation.Thereisalsoafeelingthatthereisasaturationoftrainingviaane-learningroute,sothiswouldnotbeaproductivemethodbywhichtoprovidetraininginwritinge-dischargesummaries.
• PrioritiesforGPswhenreceivingadischargesummaryare:o thattheongoingplanisclearandeasytoidentify,withanyrequiredactions
apparent,especiallythosethatareurgento thattherationaleforanychanges,especiallytomedications,isclearo thatthepatient’sjourneythroughtheepisodeofcareisconcisebutcompleteand
easytofollow.
7.2. Pilot
• Participantsfoundthecribsheet(descriptionsofdischargesummaryheadings),annotatedexampledischargesummary,self-assessmentchecklist,practiceofwritingamock
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dischargesummaryandcomparingtoacompletedexampleandanopportunitytodiscussdischargesummarieswithcolleaguesthemostusefulaspectsofthetraining(allrated>8/10).
• Participantsweremoreconfidentinwritingdischargesummariesfollowingthetraining,withtheirscoreoutof10improvingby2.1onaverage.
• Traineesinvolvedinthepilotgenerallylackedunderstandingoftheactiveroleapatientmaywishtotakeinthedischargeprocess.Patientand/orcarerconcerns,expectationsorwisheswereexcludedfrom40%ofauditeddischargesummariesinthepilot.Thiswasimprovedthroughthetraining,attributedto,forexample,trainingthathighlightedareasofthedischargesummarythatareparticularlyrelevanttothepatientandimportanttobeincluded(seeAppendixE–F).
• Dischargesummariesaresometimeswrittenwithexcessiveuseofacronymsandspecialistterminology(in23%ofthoseauditedinthepilot)whichmaybeobstructivetopatientsandothernon-technicalornon-specialistreadersofasummary.Animprovementinthiswasseenbysomeparticipantsinthepilot(seeAppendixF).
• Participantsexplainedthatadditionalexampledischargesummaries,fordifferentspecialties,wouldbeuseful.
• Organisationswhousepaperpatientnotesaremorelikelytohavedischargesummariesthatlackinformationwhereasthosewhouseelectronicpatientnotesaremorelikelytoincludeexcessivedetailduetouseofcut-and-pastefunctions.
• Thenumbersoftraineeswhocompletedallthetrainingtaskswassmallcomparedwiththenumbersignedupinsomeofthepilotlocations,whichisattributedtotheirmethodofsignup(requiringanoptouttonottakepartratherthanthroughvoluntarysignup)andtotheirlackofdedicatedtimetocompletetheactivity.
• Thenumberoftrainingparticipantswhosedischargesummarieswereauditedbothbeforeandafterthetrainingwastoosmall(n=6)todrawrobustconclusionsaboutanyimprovementsinquality.
8. Recommendations
8.1. RecommendationsfortheRCP
Dissemination• MakethelearningresourceavailabletoallNHStruststofreelytakeupanduse.• Followthecommunicationsplanprovidedwiththisreporttooptimisedisseminationofthe
report’sfindingsanddetailsofhowtoaccessthelearningresource,andtoensureallrelevantstakeholdersareinvolved.Seesection9.
• Considerusingthelearningresourceaspartofawiderqualityimprovement(QI)project.Forexample,theAbertaweBroMorgannwgUniversityHealthBoard(ABMUHB)hasbeenworkingonaQIapproachtoimprovingdischargesummariesandthereisthepotentialtolinkthislearningresourceintothisworkoranotherQIproject.Suchalinkcouldfacilitatethelonger-termanalysisofdischargesummariestoidentifywhetherimprovedqualityofcareandefficienciescouldbeidentifiedfollowingdeliveryofthetraining.
©RoyalCollegeofPhysicians2019
Learningresourcecontent• Produceanadditionalsetoflearningresourceinstructionsfortraineessoitisclearhow
theyshouldundertakethetasks.Thisisespeciallyimportantiftheycarryoutthelearningactivityindependently.Focusonhowandwhentousetheaudittool,asthiswasataskthatwasreportedtocauseconfusion.
• Thecontentofthepracticedischargesummaryandpatientnoteswasintendedtobegenericbutwasbasedonasurgicalepisodeforanadultpatient.Otherexamplesfortheemergencydepartment,mentalhealth,paediatricsandotherspecialtieswouldbehelpfuladditions.Workwithspecialistsocietiestodeveloptheseadditionalexamples.
• Editthemedicationssectionofthepracticedischargesummarytasktomorecloselymaptrustsystemsforrecordingthisinformation(ieincludemoreauto-populatedfieldsandfocusontheneedtorecordandhighlightrationaleforanychanges).
• Labelthedocumentswithinthelearningresourcetoolkitmoreclearlyandconsistently(matchedtotheinstructionsprovided)tomakeiteasiertonavigatethedocumentsrequiredforeachtask.
• Considerdevelopmentoftheannotateddischargesummaryintoanalternativesoftwarepackageforbettereaseofreadingtheannotationsaboutweakandstrongpointswithinthesummary.
8.2. RecommendationsforNHStrustsandmedicalschools
• ProvidetrainingfordoctorsinthefinalyearofmedicalschoolandasearlyaspossibleduringthefirstF1placement,ideallybeforetheytakeonresponsibilityforauthoringdischargesummaries.
• Providetrainingduringrelevantinductionperiodsforotherprofessionalsresponsibleforwritingdischargesummaries.
• Delivertraininginagroupsettingforparticipantstobenefitfromdiscussionandthesharedexperiencesofvariedprofessionals.
• Thepracticalitiesofagroupsettingmustbeconsidered.DuetotherequirementforITfacilities,itmaynotbepossibletoruntheactivitywithlargegroups.Participantscouldbeaskedtobringapersonallaptop,wherepossible,tohelpalleviatethispotentialissue.
• Providededicatedtimetocompletetheactivitytoincreaseparticipation.
9. Communicationsplan
Acommunicationsplanisprovidedalongsidethisreportwhichoutlinesthekeymessagesfromthisprojectandproposedmethodsfordisseminationofitslearningandthelearningresourcematerialsproduced.ThisplanalsoexplainstheactivityrequiredduetotheclosureoftheHIUatendofMarch2019.
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10. Additionalresources
Duringthisproject,severalrelevantmaterialswereidentifiedthatwouldbeofusetoanyoneinterestedinimprovingtheirtrust’sdischargeprocess.Theseresourcesarelinkedtoanddescribedbelow:
1. Quickguide:dischargetoassess
Thisquickguideaimstosupportlocalhealthandsocialcaresystemstoreducethetimepeoplespendinhospital,atthepointthattheynolongerneedacutecare.Itprovidespracticaltipsandadvicetocommissionersandprovidersondischargetoassess(D2A)models,includingbestpracticefromacrossthecountry.
www.nhs.uk/NHSEngland/keogh-review/Documents/quick-guides/Quick-Guide-discharge-to-access.pdf[accessedNovember2018].2. QuickguidetoimplementingPRSBeDischargesummaryheadings
ThisquickguideprovidesanoutlineapproachformanagersleadingtheimplementationofthePRSBheadingsineDischargesummariesinlightofthenewstandard.https://digital.nhs.uk/binaries/content/assets/legacy/pdf/l/3/edischarge_quick_guide.pdf[accessedNovember2018].
3. Hospitaldischargesummaryaudittool
TooltoauditdischargesummariesagainsttheAoMRCrecordstandards,developedtosupportpatientsafetyandqualityofcare,professionalbestpracticeandassistcompliancewithinformationgovernance.TheAoMRCstandardheadingswerepublishedpriortothecurrentPRSBheadingsbuttheyaresufficientlysimilartostillbeuseful.www.rcplondon.ac.uk/projects/outputs/record-keeping-audit-tools[accessedNovember2018].4. Casestudies
LearnhowtwohospitalshavesuccessfullyimplementedheadingsintheireDischargesummariestoensureconsistentrecordingofinformation,toimprovethequalityofinformationsharedwithGPsandtoenhanceauditdata.PapworthHospitalcasestudyhttps://digital.nhs.uk/services/transfer-of-care-initiative/edischarge-summaries/papworth-hospital-case-study[accessedNovember2018].
OxleasNHSFoundationTrustcasestudyhttps://digital.nhs.uk/services/transfer-of-care-initiative/edischarge-summaries/oxleas-nhs-foundation-trust-case-study[accessedNovember2018].
©RoyalCollegeofPhysicians2019
5. Actnow–planfordischargeearly
Partof‘Calltoaction’:aseriesofpracticalresourcestosupporthealthandsocialcarestafftoreducedelayedtransfersofcare.Theseguidesareaimedtohelphealthandsocialcarecolleaguestotakepromptpracticalactionsanduseeveryopportunitiestopreventdelayedtransfersofcare.Throughusingtheseguides,healthandsocialcarestaffcanaddresstheevidencethatstayinginhospitalforlongerthanrequireddrivesadverseoutcomesforpatients.
www.england.nhs.uk/publication/call-to-action-a-series-of-practical-resources-to-support-health-and-social-care-staff-to-reduce-delayed-transfers-of-care/[accessedNovember2018].
References
1. NHSEngland.NHSStandardContract2017/18and2018/19TechnicalGuidance.London;2016.www.england.nhs.uk/wp-content/uploads/2016/11/7-contract-tech-guid.pdf[Accessed30October2018].
2. CareQualityCommission.Managingpatients’medicinesafterdischargefromhospital.London:CareQualityCommission;2009.http://webarchive.nationalarchives.gov.uk/20101122140156/http:/www.cqc.org.uk/_db/_documents/Managing_patients_medicines_after_discharge_from_hospital.pdf[Accessed21August2018].
3. MooreC,WisniveskyJ,WilliamsS,McGinnT.Medicalerrorsrelatedtodiscontinuityofcarefromaninpatienttoanoutpatientsetting.JournalofGeneralInternalMedicine2003;18(8):646-51.
4. May-MillerH,HayterJ,LoewenthalLetal.Improvingthequalityofdischargesummaries:implementingupdatedAcademyofMedicalRoyalCollegesstandardsatadistrictgeneralhospital.BMJOpenQuality2015;4(1):u207268.w2918
5. CareQualityCommission.Beyondbarriers:howolderpeoplemovebetweenhealthandcareinEngland.London:CareQualityCommission;2018.www.cqc.org.uk/publications/themed-work/beyond-barriers-how-older-people-move-between-health-care-england[Accessed21August18].
6. vanWalravenCandWeinbergAL.Qualityassessmentofadischargesummarysystem.CanadianMedicalAssociationJournal1995;152(9):1437-42.
7. ProfessionalRecordStandardsBody.E-dischargesummarystandard.London;2018.https://theprsb.org/standards/edischargesummary/[Accessed25October2018].
8. ProfessionalRecordStandardsBody.StandardsfortheStructureandContentofHealthandCareRecords.London;2018.https://theprsb.org/standards/healthandcarerecords/[Accessed10December2018].
9. AcademyofMedicalRoyalColleges.StandardsfortheclinicalstructureandcontentofpatientrecordsAoMRCstandard.London;2013.www.aomrc.org.uk/wp-content/uploads/2016/05/Standards_for_the_Clinical_Structure_and_Content_of_Patient_Records_0713.pdf[Accessed25October2018].
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10. YemmR,BhattacharyaD,WrightDandPolandF.Whatconstitutesahighqualitydischargesummary?Acomparisonbetweentheviewsofsecondaryandprimarycaredoctors.InternationalJournalofMedicalEducation2014;5:125-31.
11. MauriceAP,ChanS,WPollardCetal.Improvingthequalityofhospitaldischargesummariesutilisinganelectronicpromptingsystem.BMJOpenQuality2014;3:u200548.w2201.
12. NHSDigital.OxleasNHSFoundationTrustcasestudy:UsingtheAcademyofMedicalRoyalCollegesheadingsineDischargesummaries.Leeds;2017.https://digital.nhs.uk/services/transfer-of-care-initiative/edischarge-summaries/oxleas-nhs-foundation-trust-case-study[Accessed25October2018].
13. NHSDigital.PapworthHospitalcasestudy:UsingtheAcademyofMedicalRoyalCollegesheadingsineDischargesummaries.Leeds;2017.https://digital.nhs.uk/services/transfer-of-care-initiative/edischarge-summaries/papworth-hospital-case-study[Accessed25October2018].
14. GoonooMS,Al-TalibI,HammoudNandChaturvediP.Qualityofe-dischargesummariesatadistrictgeneralhospital.Posterpresentedat:InnovationinMedicine2018:RCPannualconference;2018Jun25–26;London,UK.
©RoyalCollegeofPhysicians2019
Appendices
AppendixA:Focus-groupmeetingJanuary2018
Thefollowingconclusionscouldbedrawnfromthediscussionsheldatthefocusgroupmeeting.
Reasonsforpoorqualityofe-dischargesummaries
• Timeandresourcesarelimited,especiallybecausetherearepressurestodischargepatientstoincreasethenumberofbedsavailable.
• Juniordoctorsarethepredominantauthorsofe-dischargesummariesbutreceivelittletraininginhowtocompletethemeffectivelytoensuretheircontentcanbeofthebestusetotherecipients.
• Juniordoctorsreceiveinsufficienttrainingintheskillofwrittencommunication(incomparisontothetrainingtheyreceiveinface-to-facecommunication)atundergraduatelevelandintheirfoundationyears.
• Juniordoctorsareoftenrequiredtowritedischargesummariesforpatientstheyhavenotpersonallytreatedorevenseenduetochangeoverofshifts.
• Wouldthequalitybeimprovedifconsultantsreviewede-dischargesummaries,allowingthemtoprovidefeedbacktojuniordoctors?ThissystemisbeingtrialledatWestSuffolkHospital.Inotherunits,consultantssign-offalldischargesummariesbeforetheyaresent,alsoallowingscopetoprovidefeedbacktotheauthor.Althoughthesewouldbeadditionaltaskrequirementsforconsultants,theycouldbefactoredintojobplansiftheybecameestablishedasstandardprotocolandmaysavetimeinthelongrun.
Contentofalearningresource
• Thereareseveralpossibleaudiencesforthelearningresource.Juniordoctorsaretheprimaryauthors,butotherprofessionalsalsoassistinwritingdischargesummaries(egpharmacistsandnurses)andmoreseniorstaffcouldalsoplayapartinhelpingstafftoimprovetheirquality.
• HowtousethehospitalITsystemstoproducedischargesummariesisnotrelevant–theseinstructionswilldifferineachtrust.Thefocusshouldbeonprinciplesandgoodpracticearoundcommunicating.
• Timeandresourcemanagementtrainingformedicalstudentswouldbehelpful–teachingtheabilitytosummarise,writtencommunications,writinglettersetc.
• Lookingatgoodandpoorexamplesofe-dischargesummariesmaybeausefulapproach.
Formatofalearningresource
• Juniordoctorshaveverypoorengagementwithe-learningmodulesduetoanexcessofeducationviathismethodalreadyandalackoftimetoaccessthematerialandlearnfullyfromitscontent.
• Aone-offeducationalmodulewouldbeunlikelytoberetained.• Aposterthatcouldserveasanaidememoirmaybeofusewhencompletinge-discharge
summaries.
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• Interactivelearningresources,withpracticalactivities,wouldbebetterreceived.• Duringtheinductionperiodorduringawork-basedassessmentmaybeappropriatetimes
todeliverthelearningresource.Itshouldbedeliveredatatimethathasbeenspecificallysetasideforthispurposeandisaprotectedtime.
Generalfeedbackfromfocusgroupdiscussions
• Thedischargesummaryisanimportanthandoverandcommunicationtool.Itisadirectedletterforaspecificpurpose.
• Juniorscompletingdischargesummariesneedtoreceivefeedbackonthequalityoftheircompletioninordertolearnandimprove.
• Anytasks,actionsortimeframeswithinadischargesummaryshouldbemadecleartotheGPor,insomecases,apracticeadministrator,whomaybeabletocarryoutsomeactionsindependentlyoftheGP,whichmayreducewaitingtimesforpatientsandnegatetheneedforanadditionalconsultation.
• Otherhealthprofessionalscancompletesectionsofthedischargesummary–solefocusdoesnotnecessarilyneedtobeonadoctorforcompletion.
• GPsarenottheonlyrecipientsofadischargesummary.Patients,communitypharmacists,socialcareorganisationsetc,alsomakeuseofthecontent.Thedischargesummaryisoftenalsousedasahistoricaldocumentwithinapatient’srecord,whichcanprovidemuchinsighttoinformtheircare.
• Patientsmaynotbeveryreceptivetoverbalinformationwheninhospital,atthisvulnerabletime.Thedischargesummaryisthereforeanimportantwrittendocumentthatcanbereferencedtosupportappropriateself-care.Ittellsthepatientwhattoexpectandwhen.
• Aculturechangeisrequiredsothatthosecompletinge-dischargesummariesunderstandtheirimportanceandrelevance.
©RoyalCollegeofPhysicians2019
AppendixB:Surveyresults
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(Minutes)
(Minutes)
©RoyalCollegeofPhysicians2019
Proposedlearningactivityapproach:
• F1teachingactivityduringworkplace-basedassessment• supervisionbyrelevantseniorclinicianwhounderstandsandchampionsdischarge
summaryasacommunicationtoolbetweenprimaryandsecondarycare• F1guidedthroughexamplepatient'scaseandcorrespondingdischargesummary• F1completesadischargesummaryforamorecomplexpatient• peer-orself-assessmentwithfurtherfeedbackfromtheeducationalsupervisor
encouraged.
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AppendixC:Feedbackfrominterviews–recipientsofdischargesummaries
Keypointsofprioritytoidentifyinadischargesummary:
• Whatistheplanforthepatient?HowshouldtheGPandpatientmanagethenextsteps?Highlightingactionsfortheimmediate,shortandlongterm.
• Whatwasthejourneytogettothatstage?• Beconciseandhighlightactionpointsandurgentmatters(within2weeks).• Highlightwhathaschanged.• Rememberthatitwillalsobereadandactedonbynon-clinicianstoo.• Personcompletingtherecordisimportant–toavoidrecipientshavingtomakemany
phonecallstoidentifytheauthor.• Mostrecentbloodtestresultsarepertinenttocarryoutmedicinesoptimisation.
Additionalfeedback:
• Corequestionstoconsiderwhenwritingdischargesummary:- WhyamIwritingthis?- Whoisitrelevantto?- Whatwillhappenifthispatientisreadmittedandthedischargesummaryistobe
used?• Theinherentproblemistheenvironmentthatjuniordoctorsareworkingin:apatientthat
isgoinghomeisnotclinicallyurgent.• Thereisnofeedbackloopfordischargesummaries.• Thereare22headingsindischargesummaries(fromPRSBstandard).Realistically,adoctor
maylookatfiveorsixofthesewhenwritingadischargesummary.• Thereisn’tasinglemostimportantpartofadischargesummary.• Levelofdetail?
- Therecanbetoomuchdetailindischargesummariessoitishardtoidentifywhatismostrelevant.
- Ontheotherhand,askingajuniordoctortoconsiderwhatis/isnotimportantcouldberisky–theymaynotyetbeinagoodpositiontodeterminewhatcanbeleftout.
- Pharmacistsdoappreciatedetailinthedischargesummarytoassistmedicinesoptimisation.
• Biggestbarrierstoqualitydischargesummariesarelackoftimeandwritingthemaboutpatientsyouhaven'tseen.Thesecan’tbeaddressedthroughthiswork,sowhereshouldwefocusefforts?
• Non-clinicalstaffandpatientswillalsoneedtousethedischargesummary.Peoplecanlookthingsupiftheydon’tunderstandthembutatleastwithacleardischargesummarytheyhavetheopportunitytodothat.
• Importantthatenoughmedicineisprovidedattimeofdischarge–aminimumof2weeksofsupply.Thisisespeciallyimportantfor‘red’classifieddrugs,whicharesolelyforsecondaryortertiarycareinitiationandlong-termmaintenanceofprescribing,and‘amber’drugswhichareappropriatetobeinitiatedandstabilisedbyaspecialistinsecondaryortertiarycare,butoncestabilisedthedrugmaybeappropriateforresponsibilitytobetransferredfromsecondarytoprimarycarewiththeagreementofaGPandaformal‘sharedcare’agreement.
• Pharmacistinvolvementindischargesummaryinhospitalsettingsshouldbeencouraged.
©RoyalCollegeofPhysicians2019
• Shouldencouragecommunicationwithpharmacyteamandconversationswiththepatient/family/carersduringdischarge.
• Patientsappreciatedetailedreviewthattakesabroadviewofthepersonasawhole,includinganymultipleconditions.
• Patientsappreciateavoidanceofobstructiveterminologybutappreciatethatthelanguagewouldbeappropriatelyclinicalandarewillingtolookupinformationtodecodeifnecessary.Thisisespeciallytrueifcontenthasbeenverballycommunicatedatthetimeofdischarge.
35
AppendixD:Pre-trainingquestionnaireanalysis
Organisationparticipation:
Organisation Frequency Numbersignedup Percentagereturn
BlackpoolTeachingHospitalsNHSTrust
8 9 89%
CroydonUniversityHospitalNHSTrust
3 3 100%
EastLancashireHospitalsNHSTrust
9 11 82%
EpsomandStHelierNHSTrust
16 17 94%
SouthendUniversityHospitalNHSFoundationTrust
7 8 88%
UniversityCollegeLondonHospitalsNHSTrust
1 2 50%
WestSuffolkNHSFoundationTrust
18 27 67%
Haveyouwrittenanydischargesummaries?
Yes:60/6297% No:2/623%
Haveyoureceivedanykindoftraininginwritingdischargesummaries?
Yes:43/6269% No:19/6231%
Pleasedescribeanytrainingyouhavereceivedregardingthecompletionofdischargesummaries:
Theme Frequency(n=19)Directverbaladvice 3Talk/lecture/teachingsession 16Learningactivity/task 4
Whodeliveredthedischargesummariestraining?
Trainer Frequency Percentageoftotalwhorespondedtothisquestion
Educationalsupervisor 0 0%
©RoyalCollegeofPhysicians2019
Clinicalsupervisor 1 4%Otherconsultant 8 33%Specialtyregistrar 0 0%Foundationdoctor 5 21%Generalpractitioner 3 13%Universitylecturer 6 25%Other(pleasespecify):Educationalfellows
1 4%
Atwhatstageofyourcareerwasthetrainingcarriedout?(Morethanoneresponsecouldbeselected)
Stage Frequency Percentageoftotalwhorespondedtothisquestion
Wasthetimingappropriate?*(Mean;10=highlyappropriate)
Medicalschool 10 40% 8.5SupervisedpracticepriortostartingFY1
2 8% N/A
Trustinduction 6 24% 9F1teachingsession 8 32% 6.25Other(pleasespecify):MScadvancedpracticebutwithinthehospitalsetting
1 4% 8
*Forresponseswheretrainingwasonlyatthiscareerstage(notmultiplestages).
Wasthetimingofthetrainingappropriate?(Where10=highlyappropriate)
Mean=7.8(n=19)
Whoreceivescompleteddischargesummaries?(n=59;respondentslistedoneormorerecipient)
0
1
2
3
4
5
6
7
4 5 6 7 8 9 10
Freq
uency
Meanscore
37
Recipient FrequencyGP 57Patient 50Carers/carehome 9Coder/dischargesecretary 6Districtnurses 3Specialistdoctors 2Wardclerk 2Anyonewhowishestoaccessapatient’srecord 2Families 1Communitypharmacy 1
Whyisitimportanttobeclearandconcisewhencompletingdischargesummaries?(n=61)
Theme FrequencyForawarenessofGP/specialists/othersinvolvedincare 30Forpatient’sunderstanding/forpatienttoactionfollow-upplans 17Forfollow-upplans 15ForGPtoplan/identifytasks 11Toease/speedupGPconsultations;saveGPtime;avoidsmissingimportantinformation
9
Forcontinuityofcare 7Forreadmission/topreventreadmission 5Forcoding 3Formedicalhistory 2Forlegalpurposes 2Toavoidconfusion 2Codingaffectspricing 1Forqualityofcare 1
Whatisyourunderstandingofthepatient’srolewithinthedischargesummaryprocess?(n=62)
Theme FrequencyTheyreceiveit/itistheirrecord/theyknowtheongoingplan(passiveonly) 39Tobeabletocarryoutfollow-upinstructions/knowtheirresponsibilities 8Notsure 6Theycanuseitiftheyhaveanyqueries/concerns 4Tobeinvolvedincheckingtheinformationandmakinganychangesneededforongoingcare/makingdecisionsaboutongoingcare
4
Norole/nomajorrole/couldmakerequestswhichmightbeconsidered 4TohelpcommunicateinformationtoGP/communitycare 3Asourceofinformation/tobeabletoexpresstheirconcerns/expectations 3Itscontentisdevelopedthroughcommunicationwithpatient 1Tobe‘fullyinvolved’ 1
©RoyalCollegeofPhysicians2019
Pleasedescribeanyfeedbackyouhavereceivedregardingyourcompletionofdischargesummaries:
Theme FrequencyNofeedback 29Communicationskills(egtoolengthy/brief) 18I’mwritinggood/adequatesummaries 2FeedbackfromOSCE 2Superfluousinformation 1Adviceaboutmedications 1Errorshighlighted 1Mixedfeedback–it’ssubjective 1Tobemoreholistic 1Examples:‘Somemiddlegradesconsidermyrefusaltouseacronymsandcomplexmedicallanguageintheclinicalsummaryalittleoverthetop,asmostpatients“don'tcare”or“won'tunderstandanyway”.IhavebeenpraisedformyprofessionallanguageandcommunicationwiththeGPregardingtasksrequiredofthem.’‘Ihavenotyetreceivedanyfeedbackonmydischargesummaries–generallytheteamiscontentthattheyhavebeencompleted.’‘DuringmyfirstweekasanF1mydischargesummarieswerenotsuccinctenough,iewereinclusiveofirrelevantdetails,anddidnotfollowaclearandeasilyreproduciblestructure.IhavesinceadoptedsubheadingsandhavemadeuseofthedefaulttemplatesavailableontheICEsystem.’
ICE=integratedclinicalsystem;OSCE=objectivestructuredclinicalexamination.
HowconfidentareyouincompletingdischargesummariestothestandardrequiredbythePRSB?(Where10=veryconfident,1=unconfident)
Mean=6.1
SD=1.34
n=59
39
AppendixE:Post-trainingquestionnaireanalysis
Total:31responses
Organisation Frequency Numbersignedup Percentagereturn
BlackpoolTeachingHospitalsNHSTrust
6 9 67%
CroydonUniversityHospitalNHSTrust
0 3 0%
EastLancashireHospitalsNHSTrust
9 11 81%
EpsomandStHelierNHSTrust
3 17 18%
SouthendUniversityHospitalNHSFoundationTrust
6 8 75%
UniversityCollegeLondonHospitalsNHSTrust
2 2 100%
WestSuffolkNHSFoundationTrust
5 27 19%
Howusefuldidyoufindthefollowingaspectsofthelearningactivity(Where1=notveryusefuland10=veryuseful)
Item Meanscore(n=7)Cribsheet(descriptionsofdischargesummaryheadings) 8.0Annotatedexampledischargesummary 8.1Self-assessmentchecklist 8.6Practiceofwritingamockdischargesummaryandcomparingtoacompletedexample
8.0
Anopportunitytodiscussdischargesummarieswithcolleagues 8.8Onlineaudittool 7.6
Pleasedescribewhatyouperceivedasthepositiveaspectsofthelearningactivity
Theme FrequencyExampledischargesummaries 10Toknowwhatisrequiredofagooddischargesummary(includingPRSBstandard)
10
Groupwork/discussion/multiprofessionalworking 10Learninghowtocommunicatetheinformationinadischargesummary–levelofdetailrequired
6
Self-assessmentchecklisttoolvaluabletousealongsidewritingdischargesummaries
5
Havingaformalised,uniformapproachwithastandardisedstructure 2
©RoyalCollegeofPhysicians2019
Practisingwritingadischargesummaryusingnotes 2Cribsheet 1Examples:‘Ifeelmoreconfidentthaneverwithdischarges.’‘Ihavedefinitelylearnedandthishashelpedenormously!’‘Iwasabletoimprovemyowncompletionofdischargesummariesasaresultofthislearningactivity.’‘Chancetodevelopskillsinanappliedway.’
Whatdoyouthinkcouldbeimprovedaboutthelearningactivity/training?
Theme FrequencyMoreexampledischargesummariesfromdifferentspecialties/withdifferentfocus,egsurgical,A&E
5
Completingthemedicationssectionwasunrealistic/arduous 5Makethelearningresourceavailableearlierintraining 4Differencesbetweengenerictemplatefortheactivityandthetrusttemplate
4
Highlightcommonerrors/mistakestoavoid 3Moretimeallocatedforsession 3Difficultyofusingtheonlineaudittool/clarityoverwhentouse 2Clearerinstructionsforstudents 1Moreguidance/trainingonwritingaclinicalsummary 1Bringcompleteddischargesummariestothetrainingsession 1Morepracticeofwritingmockexamples 1Examples:‘Perhapsalinktoalibraryofvaried'model'dischargesummarieswouldbeausefulresource.’‘Whilstworkinginabusyenvironmenttheonlineaudittoolwasmoredifficulttousflippingbetweeneachscreenandwritingthedischargeletter.’‘Includetheclinicalcodersinthemeetings!Theyseethemostdischargelettersandwouldbeabletohighlightcommonpitfallsetc,astheirjobistomakesurethelettersareascomprehensiveaspossibleandmajorchunksarenotmissing.’‘Perhapsannotatingthemedicalnoteswithimportantinformation,notjustthedischargesummary.’
HowconfidentareyounowincompletingdischargesummariestothestandardrequiredbythePRSB?
Mean=8.2
(n=31)
41
(Meanbeforetrainingwas6.1)
Althoughthemeanscoreofconfidenceincreasedbyascoreof2,tworespondentsgavealowerscoreaftertrainingcomparedwithbefore.Itshouldbenotedthat,insomecases,traineesself-judgedmeasureofconfidencemayhavebeenhighbeforetraining,andactuallylookinginmoredetailedattherequirementsofane-dischargesummarywillhavemadethemrealisetheywerelessconfidentthantheyhadoriginallyfelt.Alonger-termdeterminationoftrainee’sconfidencewouldberequiredtoseeifthisdipwouldberesolvedinthefuture.
Wasthispointinyourcareeranappropriatetimetocarryoutthislearningactivity?(Where1=veryinappropriateand10=veryappropriate)
Mean=8.3
(n=31)
Theme FrequencyDuringinductionwouldbemoreuseful/atstartofwritingdischargesummaries(forotherprofessionals)
14
Thisisanappropriatetime–atstartofF1 11Infinalyearofmedicalschool 2InsummerbeforestartingF1 1Justafterinductionweek 1
Howmuchdirectcontactdidyouhavewithasupervisororseniorclinicianduringthisactivity?(Where1=nocontactand10=fullysupported)
Mean=5.8
SD=3.4
(n=31)
Thelargespreadofdataforthisquestionindicatesthepolaritybetweenpilotsiteswhodeliveredtheirtrainingasagroupsession,andthosethataskedtraineestocompletethetasksindependently.
Forty-eightpercentoftraineesgaveascoreof10forthisquestion;29%ofrespondentsgaveascoreof1–3forthisquestion.
Beforethetraining,weaskedyousomequestionsaboutthecontentofdischargesummaries.Pleasenowconsiderwhatnewordifferentideasyouhavelearntaboutthefollowing:
Whoreceivescompleteddischargesummaries?
©RoyalCollegeofPhysicians2019
Recipient Percentagebeforetraining(n=59)
Percentageaftertraining(n=29)
GP 97% 97%Patient 85% 97%↑Carers/carehome 15% 10%↓Coder/dischargesecretary 10% 14%↑Districtnurses 5% 24%↑Specialistdoctors 3% 3%Anyonewhowishestoaccessapatient’srecord
3% 3%
Wardclerk 3% 0%↓Families 2% 0%↓Communitypharmacy 2% 17%↑
Whyisitimportanttobeclearandconcisewhencompletingdischargesummaries?
Theme Percentagebeforetraining(n=61)
Percentageaftertraining(n=29)
ForawarenessofGP/specialists/othersinvolvedincare
49% 34%↓
Forpatient’sunderstanding/forpatienttoactionfollow-upplans
28% 21%↓
Forfollow-upplans 25% 31%↑ForGPtoplan/identifytasks 18% 10%↓Toease/speedupGPconsultations;saveGPtime;avoidsmissingimportantinformation
15% 34%↑
Forcontinuityofcare 11% 24%↑Forreadmission/topreventreadmission 8% 7%↓Forcoding 5% 0%↓Formedicalhistory 3% 10%↑Forlegalpurposes 3% 3%Toavoidconfusion 3% 3%Codingaffectspricing 2% 0%↓Forqualityofcare 2% 0%↓Torecordpatientthoughtsandwishesandrationale
0% 3%↑
Toprovideappropriateholisticpatient-centredcare
0% 3%↑
Whatisyourunderstandingofthepatient’srolewithinthedischargesummaryprocess?
Theme Percentagebeforetraining(n=61)
Percentageaftertraining(n=25)
Theyreceiveit/itistheirrecord/theyknowtheongoingplan(passiveonly)
64% 52%↓
Tobeabletocarryoutfollow-upinstructions/knowtheirresponsibilities
13% 16%↑
Notsure 10% 0%↓Theycanuseitiftheyhaveanyqueries/ 7% 8%↑
43
concernsTobeinvolvedincheckingtheinformationandmakinganychangesneededforongoingcare/makingdecisionsaboutongoingcare
7% 8%↑
Norole/nomajorrole/couldmakerequestswhichmightbeconsidered
7% 0%↓
TohelpcommunicateinformationtoGP/communitycare
5% 0%↓
Asourceofinformation/tobeabletoexpresstheirconcerns/expectations
5% 24%↑
Itscontentisdevelopedthroughcommunicationwithpatient
2% 0%↓
Tobe‘fullyinvolved' 2% 12%↑
Doyoufeelyouhaveanyadditionaltrainingneedsregardinge-dischargesummaries?Pleaseprovidedetailsbelow.(n=25)
Response FrequencyNo 21Yes–repeatedatalaterdate 3Nojustwanttohavemorepractice/experience 2Iwanttosharethetrainingwithcolleagues 2
Ifyouhaveanyadditionalcommentsaboutthistraining,pleaseincludethesebelow
‘ThistraininghasbeenincrediblyhelpfulandIamverygratefulfortheopportunity’‘Excellentinitiativeaddressinganimportantandpreviouslyoverlookedissue.Keepupthegoodwork!’‘Thistrainingwasveryusefulandhopefuturejuniordoctorscanparticipateinthesekindoftraining.’‘Veryusefuloverall.Ifeelitwouldbeveryusefultobeincludedintrustinductionfornewdoctors/physicianassociates/associatenursepractitioners.’‘Didn'treallyhaveenoughtimeinthesessiontoachievemoreconfidence.’
©RoyalCollegeofPhysicians2019
AppendixF:Audittoolresultsanalysis
n=40
Areasofweakness:
• patientand/orcarerconcerns,expectationsorwishesareincluded(40%disagree)• thedischargesummaryindicateswherethepatienthasbeeninvolvedinplanningand
monitoringtheirowncare(38%disagree)• themultidisciplinaryteam(MDT)contributedtothedischargesummary(33%disagree)• thedischargesummaryincludesinformationaboutsocialcarepackages(30%disagree)• thedischargesummarywasdiscussedwiththepatientpriortodischarge(30%disagree)• itiscleartodeterminehowtoseekadditionalinformationifrequired(28%disagree)• dischargedetailsandfollow-upplan(25%feltthiswasnotcompletelysatisfactorily
completed)• allergiesandadversereactions(25%feltthiswasnotcompletelysatisfactorilycompleted)• patient’srelevantpastmedicalhistoryisclearlyandconciselyrecorded(23%didnot
agree)• thereisminimaluseofacronymsandspecialistterminology(23%disagree)• thedischargesummarywasdiscussedwiththecarehome,ifrelevant,priortodischarge
(23%disagree)• theinpatientjourneyisclearandconcise(20%didnotagree)• thehospitalconsultantcanbeeasilyidentified(20%didnotagree)• anychangestomobilityorcognitivefunctioninghavebeennoted(20%disagree)• anysecondarydiagnosesareaccuratelydocumented(18%didnotagree)• thedischargesummaryhasconsideredthepatientholistically(15%disagree).
Comparativedatabefore/afterthetraining:
n=6
Areaswheretherewerenoteworthydifferencesbeforeandafterthetraining:
Thepatient’srelevantpastmedicalhistoryisclearlyandconciselyrecordedResponse Beforetraining Aftertraining Score1 Stronglyagree Stronglyagree 02 Disagree Agree +23 Neitheragreenordisagree Agree +14 Agree Stronglyagree +15 Neitheragreenordisagree Stronglyagree +26 Agree Agree 0 Averagescore +1
45
Thepatient’smedicationondischargeisfullydocumentedwithchangeshighlightedResponse Beforetraining Aftertraining Score1 Disagree Stronglyagree +32 Disagree Agree +23 Agree Agree 04 Agree Stronglyagree +25 Agree Stronglyagree +16 Neitheragreenordisagree Stronglyagree +2 Averagescore +1.7
AnysecondarydiagnosesareaccuratelydocumentedResponse Beforetraining Aftertraining Score1 Stronglyagree Stronglyagree 02 Neitheragreeordisagree Agree +23 Agree Stronglyagree +14 Agree Stronglyagree +15 Agree Stronglyagree +16 Neitheragreenordisagree Stronglyagree +2 Averagescore +1.2
Patientand/orcarerconcerns,expectationsorwishesareincludedResponse Beforetraining Aftertraining Score1 Disagree Stronglyagree +32 Neitheragreeordisagree Agree +13 Agree Stronglyagree +14 Disagree Stronglyagree +35 Neitheragreenordisagree Disagree -16 Neitheragreenordisagree Stronglyagree +2 Averagescore +1.5
TheMDTcontributedtothedischargesummaryResponse Beforetraining Aftertraining Score1 Notapplicable Stronglyagree -2 Neitheragreeordisagree Disagree -13 Agree Stronglyagree +14 Disagree Stronglyagree +35 Neitheragreenordisagree Neitheragreeordisagree 06 Disagree Agree +2 Averagescore +1MDT=multidisciplinaryteam.
©RoyalCollegeofPhysicians2019
ThereisminimaluseofacronymsandspecialistterminologyResponse Beforetraining Aftertraining Score1 Disagree Stronglyagree +32 Disagree Agree +23 Agree Agree 04 Stronglyagree Stronglyagree 05 Agree Agree 06 Agree Stronglyagree +1 Averagescore +1
ThedischargesummaryindicateswherethepatienthasbeeninvolvedinplanningandmonitoringtheirowncareResponse Beforetraining Aftertraining Score1 Disagree Agree +22 Disagree Agree +23 Agree Agree 04 Neitheragreenordisagree Stronglyagree +25 Neitheragreenordisagree Disagree -16 Disagree Stronglyagree +3 Averagescore +1.3
ThedischargesummaryhasconsideredthepatientholisticallyResponse Beforetraining Aftertraining Score1 Disagree Agree +22 Agree Agree 03 Agree Stronglyagree +14 Neitheragreenordisagree Stronglyagree +25 Neitheragreenordisagree Neitheragreenordisagree 06 Neitheragreenordisagree Stronglyagree +2 Averagescore +1.2
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