Barnet Hospital Emergency Department Discharge Summary: A Quality Improvement Journey

  • Hospital discharge letters are an essential form of communication between primary and secondary care
  • Emergency departments offer a fast-paced clinical service to large numbers of service users
  • Barnet Hospital treats over 300 service users each day, originating from Barnet, Enfield and Herts Valley Clinical Commisioning Groups
  • Clinical Commissioning Groups (CCGs) had provided feedback on the quality of discharge letters from Barnet A&E
  • A temporary Discharge Summary Working Group was set up and activity was linked to a trust CQUIN
  • The multi-disciplinary team met on a monthly basis for the duration of the improvement work, a total of six times
  • A driver diagram was created on the online Life platform (weblink below) to track the improvement work
  • The driver diagram was modified regularly to reflect the wider stakeholder engagement
  • The overall aim was linked to a trust CQUIN
  • A target of 80% compliance of discharge letters to core clinical information was set
  • Clinical leaders and champions were allocated in the emergency department
  • Examples of poor discharge letters received from local GPs were shared amongst emergency department (ED) clinicians
  • The role of the ED flow co-ordinator was modified to allow monitoring of completed discharge letters, including the utilisation of the IT system
  • Importance of completing good quality letters was reinforced during clinical meetings, such as morning handovers and weekly teaching
  • Baseline data illustrated 50-60% of discharge letters were compliant
  • Prospective daily audits (sample size = 10) were collected to monitor progress and provide individualised feedback to ED clinicians
  • Daily sample audits revealed significant improvements in the quality of discharge summaries
  • The chart below shows a reduction in blank discharge letters generated by the emergency department
  • The second chart below, displayed as a Statistical Process Control chart, illustrates a series of upwards shifts in the mean compliance of discharge letters
  • The chart reveals both an improvement in the mean, and a reduction in variation
  • The most marked improvement was linked to a change in the flow co-ordinator role
  • A report from the CCG illustrated a reduction in GP enquiries to Barnet ED since August 2016, however no significant change since the same time period 1 year ago (see below)
  • The trust CQUIN audit in April 2017 showed 47/50 sampled notes were complaint. This was well above the required 80% target set by the CCG
  • Key to success of the project was linked to the multi-discliplinary and multi-organisational recruitment of the discharge summary working group
  • Frequent data points allowed real-time progress to be monitored throughout the project timeframe
  • Clinical leadership, both in the emergency department and across the CCGs, was central to the improvement work
  • Ongoing leadership, collaboration and data monitoring will ensure sustainability of the improvement work
  • Below is a quote from Rob Eckersley, a medical trainee involved in the project:
"It was great to see all members of the team pulling in the same direction to achieve the goal. And although we implemented a number of PDSA cycles that proved to be effective, I feel it was principally a change in culture in the ED which was most impressive. Receiving the successful results of the CQUIN audit was the cherry on top of the icing"
  • A series of video clips were collected from various members of the team to reflect on their improvement journey

Page by Dr Adnan Raja, Darzi Fellow, Royal Free London NHS Trust

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