Faculty Bibliography

Background: Hospital discharge is a critical transition in care, yet recent data show much room for improvement: 1 in 5 patients experiences an adverse event or readmission within 30 days of discharge. Presently, metrics for the quality of discharge care are limited, and little is known about factors affecting the quality of hospital discharge from the perspective of physicians. Residents' perceptions are particularly important given their unique viewpoint of the discharge process as trainees and their role as primary care givers at teaching hospitals, which collectively provide 20% of all hospital care in the United States. Methods: We employed qualitative methods to describe the dischargeprocess from the resident's perspective and generate hypotheses about quality-limiting factors and key strategies for improvement through in-depth in-person interviews. We developed a purposeful sample of participants with attention to postgraduate year and experience in different hospital settings. Our study design included 2 internal medicine training programs-Yale and New York University (NYU)-to ensure a wide breadth of experiences. To date, we have completed 17 interviews with Yale residents and have begun enrollment at NYU. Interviews were professionally transcribed and independently coded by 2 investigators, and discrepancies were resolved by consensus. Thematic analysis was performed by a diverse research team using the constant comparative method. Results: We have analyzed interviews with 17 Yale residents to date: 10 (59%) were seniors (PGY-2 or PGY-3), 7 were interns (41%), and 10 were female (59%). Based on these interviews, we have identified 5 unifying themes representing factors perceived to limit the quality of discharge care: (1) competing priorities of timely versus thorough discharge, (2) lack of communication between discharge team members, (3) uncertainty about provider roles and patient readiness for discharge, (4) lack of standardization in discharge procedures, and (5) poor patient communication and postdischarge feedback. Representative excerpts from interview transcripts will be presented to illustrate conceptual variations of these quality-limiting factors as well as to support the overall consistency and robustness of each theme above. Conclusions: Quality-limiting factors identified by residents may generate hypotheses to develop novel quantitative measures of quality that are grounded in the experiences of physicians providing discharge care. Residents' insights on this topic may also help shape training and practice to improve the quality of discharge care at teaching hospitals

BACKGROUND: Patient satisfaction is typically measured by quantitative surveys using predetermined domains. However, dissatisfaction may be an entity distinct from satisfaction, may have different determinants, and may better reflect problems in healthcare delivery. OBJECTIVE: The aim of this study was to describe domains of dissatisfaction experienced by patients during hospitalization. SETTING: The setting was a U.S. urban academic medical center. PATIENTS: The patients were adults discharged between July 1, 2007 and June 30, 2008 INTERVENTION: The intervention was a postdischarge telephone interview: "If there was one thing we could have done to improve your experience in the hospital, what would it have been?" MEASUREMENTS: The measurements were standard qualitative analysis of suggestions for improvement. RESULTS: We randomly selected 976 of 9,764 interviews. A total of 439/976 (45.0%) included at least one suggestion for improvement. We identified six major domains of dissatisfaction: ineptitude (7.7%), disrespect (6.1%), waits (15.8%), ineffective communication (7.4%), lack of environmental control (15.6%), and substandard amenities (6.9%). These domains corresponded to six implicit expectations for quality hospital care: safety, treatment with respect and dignity, minimized wait times, effective communication, control over physical surroundings, and high-quality amenities. Some of these expectations, such as for safe care, effective communication between providers, and lack of disrespect, may not be adequately captured in existing patient satisfaction assessments. CONCLUSIONS: The results represent patient-generated priorities for quality improvement in healthcare. These priorities are not all consistently represented in standard patient satisfaction surveys and quality improvement initiatives. Patient input is critical to assessing the quality of hospital care and to identifying areas for improvement.

STUDY OBJECTIVE: Prolonged emergency department (ED) wait time and length of visit reduce quality of care and increase adverse events. Previous studies have not examined hospital-level performance on ED wait time and visit length in the United States. The purpose of this study is to describe hospital-level performance on ED wait time and visit length. METHODS: We conducted a retrospective cross-sectional study of a stratified random sampling of 35,849 patient visits to 364 nonfederal US hospital EDs in 2006, weighted to represent 119,191,528 visits to 4,654 EDs. Measures included EDs' median wait times and visit lengths, EDs' median proportion of patients treated by a physician within the time recommended at triage, and EDs' median proportion of patients dispositioned within 4 or 6 hours. RESULTS: In the median ED, 78% (interquartile range [IQR], 63% to 90%) of all patients and 67% (IQR, 52% to 82%) of patients who were triaged to be treated within 1 hour were treated by a physician within the target triage time. A total of 31% of EDs achieved the triage target for more than 90% of their patients; 14% of EDs achieved the triage target for 90% or more of patients triaged to be treated within an hour. In the median ED, 76% (IQR 54% to 94%) of patients were admitted within 6 hours. A total of 48% of EDs admitted more than 90% of their patients within 6 hours, but only 25% of EDs admitted more than 90% of their patients within 4 hours. CONCLUSION: A minority of hospitals consistently achieved recommended wait times for all ED patients, and fewer than half of hospitals consistently admitted their ED patients within 6 hours.

AIM: The Observed Simulated Hand-off Experience (OSHE) was created to evaluate medical students' sign-out skills using a real-time assessment tool, the Hand-off CEX. SETTING: Thirty-two 4th year medical students participated as part of an elective course. PROGRAM DESCRIPTION: One week following an interactive workshop where students learned effective hand-off strategies, students participated in an experience in which they performed a hand-off of a mock patient using simulated history and physical examination data and a brief video. PROGRAM EVALUATION: Internal medicine residents served as standardized hand-off receivers and were trained on expectations. Students were provided feedback using a newly developed Hand-off CEX, based on the "Mini-CEX," which rates overall hand-off performance and its components on a 9-point Likert-type scale. Outcomes included performance ratings and pre- and post-student self-assessments of hand-off preparedness. Data were analyzed using Wilcoxon signed-rank tests and descriptive statistics. Resident receivers rated overall student performance with a mean score of 6.75 (range 4-9, maximum 9). Statistically significant improvement was observed in self-perceived preparedness for performing an effective hand-off (67% post- vs. 27% pre-reporting 'well-prepared,' p<0.009). DISCUSSION: This brief, standardized hand-off training exercise improved students' confidence and was rated highly by trained observers. Future work focuses on formal validation of the Hand-off CEX instrument. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11606-009-1170-y) contains supplementary material, which is available to authorized users.