Improving communication to GPs at hospital discharge: a systems approach

Problem

Good communication at hospital discharge is critical for patient safety and continuity of care. Recipient GPs rely almost exclusively on discharge summaries that are usually written by the most junior doctors; these are error prone and may lack insight into community care. Previous quality improvement efforts have largely focused on adherence of discharge summaries to standardised templates, which may be less suited to meet the needs of GPs, especially for more complex patients. Communication-related patient harm continues to occur and the limited progress of improvement has led to recognition of the need for a wider and deeper understanding of this complex issue, as the population becomes increasingly aged and multiply-comorbid.

Approach

Multiple literatures support the exploration of complex problems through structured qualitative enquiry, including Operational Research, Design, and Systems Engineering. Our study adopts a qualitative methodology situated in the ‘systems approach’ recently defined for healthcare by the Royal Academy of Engineering, Royal College of Physicians and Academy of Medical Sciences in their 2017 publication Engineering Better Care. Its set of 13 'driving questions' provided a framework to address the research question of "How can communication to GPs at hospital discharge be improved?". One focus group and twenty semi structured interviews were conducted with key clinical and administrative stakeholders across the primary-secondary care interface of a large tertiary hospital in England, and thematically analysed.

Findings

Data analysis suggests that the system of discharge communication becomes more complex, and incurs greater risks, as a patient’s clinical needs increases. This complexity was identified as a key barrier to communication quality, alongside others across the primary-secondary care interface, including time pressures and a lack of insight on the part of discharge summary authors into the nuances of recipient GP needs. Participants reported that system performance was highly variable, with significant negative consequences for both patients and staff attributed specifically to communication quality. Current standardised forms of communication were reported to hinder system performance for many patients. Solutions were identified that would enable GPs to 'close the open loop' of the largely one-way system of communication from hospital to general practice, to support patient safety and continuity of care.

Consequences

We suggest that a far more collaborative design of this system may improve the quality of care at hospital discharge. More open lines of communication, shared medical records and GP-led teaching sessions for junior doctors are needed to improve stakeholders’ insights into the needs of other system users, facilitate a more operant improvement process and reinforce the shared responsibility of all parties in this critical and vulnerable phase of transition of care. Further research is required to verify and validate any changes before widespread implementation into clinical practice.