e-discharge summaries learning resource project

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

RoyalCollegeofPhysicians

11StAndrewsPlace,LondonNW14LE

www.rcplondon.ac.uk

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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.


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


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.


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

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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,


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.


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.


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.

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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).


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.


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


• 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.


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].


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.


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.


AppendixB:Surveyresults

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(Minutes)

(Minutes)


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.


• Shouldencouragecommunicationwithpharmacyteamandconversationswiththepatient/family/carersduringdischarge.

• Patientsappreciatedetailedreviewthattakesabroadviewofthepersonasawhole,includinganymultipleconditions.

• Patientsappreciateavoidanceofobstructiveterminologybutappreciatethatthelanguagewouldbeappropriatelyclinicalandarewillingtolookupinformationtodecodeifnecessary.Thisisespeciallytrueifcontenthasbeenverballycommunicatedatthetimeofdischarge.

35

AppendixD:Pre-trainingquestionnaireanalysis

Organisationparticipation:

Organisation Frequency Numbersignedup Percentagereturn


8 9 89%

CroydonUniversityHospitalNHSTrust

3 3 100%


9 11 82%

EpsomandStHelierNHSTrust

16 17 94%

SouthendUniversityHospitalNHSFoundationTrust

7 8 88%


1 2 50%


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%


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


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


6 9 67%

CroydonUniversityHospitalNHSTrust

0 3 0%


9 11 81%

EpsomandStHelierNHSTrust

3 17 18%

SouthendUniversityHospitalNHSFoundationTrust

6 8 75%


2 2 100%


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


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?


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)


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)


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.’


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.


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