Want to Improve the Patient Experience? Let’s Start With Discharge Planning.

Derick Alison
Derick Alison
8 Min Read

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    Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

Communication is key.

How many times through the course of the day, doing what we do in healthcare, does communication between every member of the team prove itself to be critical to the success of almost everything we do in our clinical lives? From the moment we arrive at work in the morning, until we finish our last notes late in the evening, getting the right information at the right time really matters.

That includes communication between every member of the team involved in taking care of the patient in the office, from the security guard downstairs to the greeters at our check-in desk, to the medical assistants who bring our patients into the room and measure their vital signs, to the nurses who educate patients and administer vaccines, and to the patients as we communicate with them during our brief time together.

And there’s even more communication that goes on, including communication to and from the outside world — results from labs and imaging, reports from consultants, and data from remote patient monitoring. The information comes from faxes, telephone calls, emails, and online chats. Sometimes it can seem overwhelming, but most of the time it can be invaluable.

So often through the course of our days and weeks, a clinical situation arises that is suddenly going to demand a lot of communication, coordination, and resources: a new diagnosis, a new medical mystery, a deteriorating clinical condition. Suddenly communication needs to kick into high gear — arranging blood tests, imaging, specialty consultations, biopsies, treatments, infusions, and surgeries; getting approval from insurance companies; and coordinating appointments and schedules. Sometimes these things have to happen in just the right order, at just the right time, and with very little margin for error.

Figuring out the right balance of email, messaging within the electronic medical record, chat features, and phone calls can prove to be a challenge, but it’s often so rewarding when it all works. Wasn’t it George Peppard’s character John “Hannibal” Smith of the “A-Team” who said, “I love it when a plan comes together“?

Obviously, in healthcare, things often take unexpected turns, and the best-laid plans sometimes need to be corrected mid-course. But sometimes we get it right, and when we do, it feels just right, and we wish this could happen every time.

Take, for example, a patient going home from the hospital. Something happened that led to them being admitted, requiring some level of intensive inpatient treatment, either a procedure or surgery, intravenous antibiotics or some other treatments, and they’ve gone along and things have gotten better, and they are now ready to go home. This critical juncture is the perfect time for communication to happen, when all the moving parts need to come together at the right place, at the right time.

As an inpatient hospitalist team or a surgical team finishes up managing an inpatient admission, this is the time for reaching out to those who are going to assume the ongoing care of the patient once they go home. What are the tasks that need attending to, what loose ends need to be tied up, and what do we need to do that just couldn’t get done while the patient was lying there in the hospital bed?

We’ve all read discharge summaries that have been huge cut-and-paste jobs, endless amounts of data brought together into one lengthy document the doesn’t offer much insight into what happened during the admission. I understand why people feel the need to do this, but, like a good progress note, a discharge summary should really be about communicating what happened during the inpatient time, what needs to happen next, and making sure that everyone knows their future roles and responsibilities. And patients themselves need to be involved in this process, to have it clearly explained to them what’s happened to them and what’s going to need to happen in the days and weeks ahead.

How often have patients come to you after they were admitted to an outside hospital and slid across the counter an envelope containing a huge sheaf of papers that have page after page of out-of-context data, and after reading this you find yourself no closer to knowing what the heck happened, and what has to happen next? And the patient will often look at you blankly and say, “It’s all in there; they told me it was all in there. I don’t know what happened to me in the hospital nor what I’m supposed to do next.”

Perhaps it’s time we stop kidding ourselves in thinking that these discharge summaries as they are written now are the be-all and end-all of the truth of an admission. Let’s come up with a better way to plan for this important and delicate transition, because when it’s done poorly, bad things tend to happen.

I love the idea of getting everybody together, a day or two before discharge, connecting everyone by chat, Zoom, or a phone call, and let everybody talk it out in a free-form kind way. That way we are all on the same page. I know what you were thinking, you know what you want me to do, and the patient understands the imperative things they need to do to continue getting healthier. This could create an ideal closure, a model of collaboration and communication that would undoubtedly improve the discharge process, and make sure that badness does not fall through the cracks.

This will take some commitment, a lot of resources, some changing of the mindsets of a lot of people, but perhaps if we stop, breathe, and take the time to get this right, we’ll all be better off.

Better a few minutes of quality communication than endless drivel that does no one any good, and has the potential to cause a lot of harm.

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