Laurel Fick, MD
St. Vincent Indianapolis
Program Size: 31-100 residents
Academic Setting: Community-Based
Clinical Setting: Inpatient wards
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Overview
We have created a Discharge Review evaluation that encompasses 3 components of an inpatient discharge: direct observation of discharge counseling, review of written discharge instructions including detailed follow-up, and a complete medication reconciliation. Ratings are based on a 5-point Likert scale- strongly disagree to strongly agree. The direct observation component asks the evaluator to rate the trainee on completeness, expected course of care (i.e. what to watch for) including follow-up planning, and effective communication skills including use of the teach-back method. The evaluation of written discharge instructions rates trainees on completeness and appropriateness of instructions (including diet, activity, wound care), follow-up- with special attention to complex conditions such as anticoagulation, and communication skills. The medication reconciliation is evaluated for completeness, appropriateness, and lack of errors. The evaluator (internal medicine faculty) is also asked to rate the complexity of the discharge and state the trainee's competency to independently discharge patients of similar complexity. Evaluators are encouraged to include comments or observations following each subsection and at the end of the evaluation. The evaluation is linked to milestones and can be used to help guide if/when a trainee is ready to discharge independently. Discharge summaries (as they are dictated and not immediately available at the time of discharge) are evaluated using a separate tool. We require two completed Discharge Review evaluations by Internal Medicine teaching faculty in the first six months of training, with more required should competency not be achieved. The review process takes approximately twenty minutes. This tool was newly implemented into our curriculum and feedback by faculty and residents on its use has been positive.
Development
The key steps were: a) Determining the important components of the discharge review- patient/family counseling, written instructions including follow-up, and medication reconciliation. b) Determining what were felt to be the most important parts of a successful discharge for each of the above components. c) Asking faculty to rate the level of complexity for the discharge. d) Asking faculty to state competency to independently discharge an similarly-complex patient. The final 2 steps were key to ensuring that competency granted was appropriate only for the level of complexity of the evaluated discharge.
Lessons Learned
Potential pitfalls are: a) using a generic Likert-type scale for every question versus customizing with sample anchors b) stating a trainee has achieved competency in discharging patients of similar complexity does not ensure that the trainee will always complete a safe and appropriate discharge for a similarly-complex patient c) this requirement is a change for our faculty members- buy-in and time taken to complete the review and evaluation will be monitored. In exchange for this implementation we are no longer requiring faculty to formally (written evaluation) review H&Ps or progress notes.
Faculty Development and Training
Our faculty are already familiar with the use of direct observation tools and electronic evaluations within New Innovations. The new evalution is being rolled out for the upcoming academic year and faculty will have had information about the new requirements and demonstrations of the tool at 2 separate faculty meetings (and over email for those not in attendance). Any concerns or problems with the evaluation will be addressed at future faculty meetings once it is in use.
How Used to Inform Decisions about a Learner's Milestone
I have linked the new tool to milestones within the New Innovations software system. The evaluation hits on the following milestones: Medical Knowledge (MK1), Interpersonal Skills and Communication (ICS1), and Systems Based Practice (SBP4)- one of the few tools we have to specifically address this milestone. I envision this evaluation also being customizable to other residency programs (pediatrics, family medicine, obstetrics) and even student rotations, specifically externships.
Contact
For more information, please contact lbfick@stvincent.org