But, she says, hospitals "that are serious about this, like ours is now," want to make these processes standard and specific, defining who is responsible for what. That way, the transition process will be done more effectively and efficiently. No pieces will be missed, and nothing will be done three or four times in different ways by different caregivers.
So in recent months, Yale-New Haven has staffed people "to literally follow doctors and nurses around, literally 24/7, including weekends, to write down everything providers do that seems related to discharge care, including how much time it takes," Horwitz says. In this way, "we can get a clear sense of how effectively that work gets done during the course of a hospitalization."
The project includes, for example, the half-hour that an intern might spend on hold with a doctor's office trying to schedule a follow-up appointment. "Is that a good use of the intern's time? We want to reorganize that work to make it more effective."
Horwitz's recent paper in JAMA Internal Medicine described a survey of patients at her hospital during 12 months ending in April 2010. The survey found that only one-third of patients got a follow-up appointment with a physician before their discharge, and less than two-thirds of patients with heart failure were advised to limit salt intake.
Perhaps most important, one-quarter of the discharge instructions did not use "intelligible language to describe the reason for hospitalization" and one-third of patients could not clearly describe their diagnoses.
HCAHPS and transition planning
Starting soon, three questions dealing just with the discharge process will be added to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, first for reporting purposes only. However, they are candidates that may eventually be used to influence payment in the value-based purchasing incentive program.
- During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left
- When I left the hospital, I had a good understanding of the things I was responsible for in managing my health
- When I left the hospital, I clearly understood the purpose for taking each of my medications
And when those answers start coming in, White says, "we'll start to know whether the patients feel these efforts are helping, but we don't yet have a good measurement system in place to look at that."
White says that hospital teams "still have a lot to learn about which readmissions are avoidable and which are not. Readmissions to some extent are a marker of poor quality of care." And by preventing them, she says, "we know we are delivering higher-quality care."
This article appears in the December 2014 issue of HealthLeaders magazine.