“Learning by Doing”—Resident Perspectives on Developing Competency in High-Quality Discharge Care

Abstract

BACKGROUND: Reducing readmissions and post-discharge adverse events by improving the quality of discharge care has become a national priority, yet we have limited understanding about how physicians learn to provide high-quality discharge care. METHODS: We conducted in-depth, in-person interviews with housestaff physicians with qualitative analysis by a multi-disciplinary team using the constant comparative method to explore learning about highquality discharge care as a systems-based practice and to identify opportunities to improve training around these concepts. RESULTS: We analyzed interview transcripts from 29 internal medicine residents: 17 (59 %) were interns (PGY-2 or PGY-3), 12 (41 %) seniors, and 17 (59 %) were female. We identified a recurrent theme of lack of formal training about the discharge process, substantial peerto-peer instruction, and "learning by doing" on the wards. Within this theme, we identified five specific concepts related to systems-based practice and highquality discharge care which residents learned during residency: (1) teamwork and the interdisciplinary nature of discharge planning; (2) advanced planning strategies to anticipate challenges in the discharge process; (3) patient safety and the concept of a "safe discharge;" (4) patient continuity of care and learning from post-discharge outcomes and; (5) documentation of discharge plans as a valuable skill. CONCLUSIONS: Discharge care is an overlooked opportunity to teach concepts of systems-based practice explicitly as learning about discharge care is unstructured and individual experiences may vary considerably. Educational interventions to standardize learning about discharge care may improve the development of systems-based practice during residency and help improve the overall quality of discharge care at teaching hospitals.KEY WORDS: discharge care; quality of care; core competencies; residency education.

Medical Residents and Interprofessional Interactions in Discharge: An Ethnographic Exploration of Factors That Affect Negotiation

“…18 Strategies to address this balance include further attention to education about discharge and alternative interprofessional approaches for discharge, particularly given the turnover of medical attendings and residents. Greysen et al 26 outline several ways to improve residency training in discharge, such as the development of educational goals and activities as part of the formal curriculum; incorporating key concepts embedded in high-quality discharge, such as interprofessional care, patient safety and patient communication, into broader themes of systems-based practice training; and the use of innovative approaches to evaluation. In addition to education, various interprofessional arrangements for discharge are being examined, such as embedding a discharge facilitator in a resident team.…”

“…This finding reflects researchers' calls to include other healthcare professionals in educating residents and providing feedback on their performance, and the need for medical staff training in relation to discharge processes. 3,26 While individual efforts are laudable, it is important to create environments conducive to interprofessional interactions and to maximize the contributions of different professionals to care rather than relying on the benevolence of individuals. 35 The creation of an effective workplace learning culture was identified as another priority area in a survey of medical education research.…”

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

“…Discharge planning in general internal medicine (GIM) units is particularly complex given the multifaceted and challenging nature of patients' health and social care needs, and the varied discharge destinations of this patient group (Szecket, Wong, Wu, Berman, & Morra, 2012). Policies on hospital discharge have identified the importance of interprofessional collaboration, however, recent research has described limitations with teamwork and collaboration in this clinical context (Greysen, Schiliro, Curry, Bradley, & Horwitz, 2012a;Toronto Central LHIN Discharge Planning Steering Group, 2011).…”

Interprofessional Communication Patterns During Patient Discharges: A Social Network Analysis

“…[1][2][3][4][5] Policies and hospital-based strategies to improve the quality of discharge care following a patient's admission and discharge from the hospital have been implemented. 1,[6][7][8] Transitions of care initiatives, such as the Better Outcomes for Older Adults through Safe Transitions, and quality collaboratives, such as the State Action on Avoidable Rehospitalization initiative, provide approaches and strategies at the unit level to improve this process. [9][10][11] A prerequisite for these initiatives, however, is high-quality communication and collaboration between the myriad of providers and patient involved in the discharge process.…”