Problem

Our SMART (specific, measurable, attainable, relevant, time-bound) objective was to improve patient understanding of the discharge domains of diagnosis, medication changes, follow-up care, return instructions and patients knowing who their consultant was in the short stay unit (SSU) by attaining a score of at least 4 (near-complete understanding) on all questionnaire domains in 90% of the patients by April 2021. Previous studies have shown that patient understanding on discharge from hospital is limited1–5 and that this is associated with poor outcomes including increased risk of readmission to hospital.5–8

The SSU at Ninewells Hospital in Dundee, Scotland, receives adult patients from the Acute Medical Admissions Unit who require an additional 24–72 hours care.9 After this period, they are either discharged home or transferred to a specialty ward. The team involves acute care consultants, doctors in training, nursing staff, healthcare support workers, a pharmacist and administrative staff.

The SSU team had identified improving patient information as an important organisational aim,10 but had no data about the extent of the problem in the SSU. The project focused on the improvement aims of being patient-centred and efficient.11 The aim of this approach was to improve understanding on the discharge domains of diagnosis, medication changes, follow-up care, return instructions and patients knowing who their consultant was in the SSU.

During pre-intervention data collection it was shown that the patients had a poor understanding of their discharge domains. One out of five patients had no comparative understanding of their diagnosis with 31% responding neither agree nor disagree or lower for understanding their diagnosis, 17% did not know symptoms that would prompt them to revisit a doctor, 69% did not know who their consultant was and 42% of the patients had only partial concordance or lower for understanding instructions to take their medications.

In addition, average patient understanding varied greatly based on day of discharge, which could suggest different clinical teams were more effective at conveying patient understanding than others due to time constraints or other external environment factors. Furthermore, the gap between patient self-rated understanding and comparative understanding increased with age displaying that the older patients are the more likely they are to over-estimate their understanding.

During the study and planning period, there were changes to standard practice for the discharge of patients. In the planning phase, discharged patients had only verbal instructions and a copy of their electronic discharge document (EDD) was sent to their general practitioner (GP). Occasionally on patient request, their EDD would be printed out and given to them. A week prior to pre-intervention data collection, a new EDD format was introduced with no prior training to staff. Then, after 1 week of pre-intervention data collection, hospital policy changed so that nursing staff were requested to give a copy of the EDD to all discharged patients. Hence, pre-intervention data collection includes 1 week of previous standard practice of solely verbal instructions and 1 week of new standard practice of giving patients a copy of their EDD. The intervention included adaptation of the EDD format in response to feedback from patients.

Background

Previous studies have shown that patient understanding is limited on discharge.1–4 12–14 Potential causes include: time constraints,2 5 13 15 16 limited capacity for staff to convey complicated important information,1 7 17 poor patient health literacy13 16 18 19 and patient culture of not asking or clarifying questions.2 5 The result is that the patients and their families are frequently unable to properly understand key medical information, for example, knowing their diagnosis,7 any changes to their medications,7 20 plans for follow-up and instructions for return.7 20 21

To make improvements in a system you must understand it well ‘Without understanding, there could be a focus on changes that do not lead to improvements and might even make things worse’.22 We applied the SEIPS (Systems Engineering in Patient Safety) V.2.0 human factors model to understand the work system for discharge from the SSU and to identify opportunities for collaboration and communication between clinicians and the patient.23

The SSU is fast paced to meet high flow of incoming patients, with the potential to cause the discharge process to be rushed in response to external environment pressures.7 13 15–17 Patient understanding about discharge plans is dependent on the people in the working system, who are the patients as well as the clinicians.23 Challenges for the clinicians include pitching information at the patient education level or health literacy,3 7 18 avoiding medical jargon4 6 20 and managing the large amount of information that must be given at once.1 7 Moreover, patients are likely to be fatigued and stressed at the time of discharge.7 8 17 24 These are all barriers to understanding, especially if information is only conveyed verbally.

The EDD provides an opportunity to give written information to patients. This is a summary document sent to patient’s GP on their hospital stay. However, this is likely to be written in medical language that is typically above patient’s reading age,6 20 which in the UK has been estimated at 9 years old.25 Our intervention involved collaborative work between staff and patients to improve the format of written information from the EDD. In addition to collecting information about self-reported understanding we assessed patients’ knowledge, because previous studies have shown that they may overestimate their understanding.3 4 14 Some studies report that only 20% of the patients are aware of their comprehension deficit.5 26

Measurement

Process measures:

1. Percentage of patients receiving an EDD on discharge from hospital

2. Percentage of patients receiving an EDD in patient-friendly language on discharge from hospital.

Outcome measures:

1. Primary: Patient understanding of discharge domains was measured by telephone questionnaire. This assessed both self-rated understanding and actual understanding in comparison with the EDD. A dual assessment was undertaken as literature highlighted self-rated understanding was greater than actual.3–5 The questionnaire was adapted from two validated tools from the Picker Institute (the Picker Patient Experience Questionnaire)27 and Emergency Department Consumer Assessment of Healthcare Providers and Systems (ED CAHPS).28

2. Secondary: Patient confidence in managing their condition with information received while in hospital; measured on a Likert scale at the end of the telephone questionnaire. To assess whether improved information is giving increased confidence.

Balancing measures:

1. Staff survey about time pressures and satisfaction with communication assessed by a paper questionnaire given on the ward, with both Likert responses and a free text box. This was to help the sustainability of the change by monitoring any negative staff impact.

Design

A 4-week pre-interventional and post-interventional study in the form of telephone questionnaires evaluated the effect of giving a patient a copy of their adapted EDD on the understanding of five discharge domains: diagnosis, medication changes, follow-up plans, return instructions and who their consultant was. The design of the intervention was informed by previous interventions (see Background). Improving patient experience and information is a priority for NHS Tayside.

The improvement team included acute care consultants, senior charge nurse, foundation year doctor, ward admin and office admin staff.

Patients were first involved by asking what their preference for receiving written information was which then informed the design of the patient-friendly discharge document. Many Plan-Do-Study-Act (PDSA) cycles were then conducted (table 1) on structuring questions and documenting responses by telephone questionnaire. The outcome measures were chosen to assess how to best help patients understand more about their hospital stay.

We anticipated that recruitment of representative patients would be challenging and would require clear, prespecified inclusion and exclusion criteria informed by other studies. Inclusion criteria: Patients discharged from the SSU, >18 years, fluent in English, cognitively capable, being discharged back to their home and not a secondary care facility and gave informed consent to participate in the study.5 8 29–32 In addition, post-intervention we only included patients who had received a copy of their EDD.5 8 29–31 Exclusion criteria included receiving treatment for alcohol misuse,2 5 in isolation on ward for COVID-19 or had a standing warning for violence. As patients had to be consented before accessing their notes, some were excluded after consented.

The intervention was based on available literature, adapted to changing COVID-19 restrictions and informed by healthcare team and patient opinion collected through multiple PDSA cycles (table 1).

The healthcare team’s main concern with change ideas were time taken to complete them, hence the change idea was integrated into tasks already undertaken. The change idea was to restructure the ‘Correspondence to the GP’ section of the EDD to be written in simple terms to the patient. This is a summary document sent to patient’s GP on their hospital stay. The patient-friendly structure was informed by patient preference using signposting, spacing information out and avoiding jargon, as tested in a PDSA cycle. Prior to implementation, a PowerPoint teaching session was delivered to doctor staff5 explaining how to structure this document along with a summary document (online supplemental appendix 1). The suggested template for the patient-friendly document was laminated and put in the doctor’s room where EDDs were written. Previous success in similar settings was achieved with printed materials3 33 34 for patients and this change idea coincided with staff preference for time-effectiveness, hence was expected to succeed. In addition, as this task was integrated into existing systems the change was thought to be sustainable.

Foundation doctors were encouraged to signpost verbal information to the patient to increase the likelihood of patient understanding34 and to use the teach-back method in a nurturing way.5 This combination of verbal information bridges the gap of health literacy in patients and is preferred by patients.5 34 35

The period was chosen to coincide with deadlines and likelihood of yielding a substantial sample size as informed by observations. Telephone questionnaires/interviews were a common data collecting technique used in patient understanding studies3 5 12 26 32 33 36–38 and with COVID-19, the safest way to collect data. The questionnaire was administered verbally to not disadvantage39 40 patients with a low literacy. Likewise, a written questionnaire was likely to be incomplete and disadvantage those with poor literacy or vision.

The likely problem to encounter was yielding a suitable sample due to poor telephone questionnaire respondence, this was attempted to be overcome by consenting all possible patients. Likewise, another problem to overcome was habit, attempting to get staff to undertake a task they had previously done differently. This was attempted to be overcome by reminding staff each morning/afternoon of the change and putting up posters on the ward as reminders.

Strategy

The method uses the model for improvement41 which includes addressing the following questions: What are we trying to accomplish?, How will we know a change is improvement? and What changes can we make that will result in an improvement? In addition to using PDSA cycles which were undertaken to inform the structure of the project which demonstrate fidelity to the theory. These small tests of change were either adopted, adapted or abandoned.42 Prior to the use of PDSA cycles an observation period was conducted to see the current working system.

Four-week observations were undertaken including shadowing various healthcare staff and creation of system process maps, hierarchal task analysis,43–45 cause and effect diagram and driver diagrams (online supplemental appendix 1) to understand the system and generate change ideas.

We completed a total of 17 PDSA cycles (table 1), which were grouped around three categories surrounding the project aim: measurements (n=9), developing a change idea (n=3) and documentation of results (n=5).

The measurements PDSA cycles revolved around the development of the patient and staff questionnaires, developing a change idea cycles to assess the feasibility of the change idea and to ensure it worked and documentation pertaining to the development of consent and information forms and results from the data collection.

The measurement cycles (1.1–1.9) developed both the patient and staff questionnaires. Both were adapted many times due to investigation of: Appropriate content of the patient questionnaires, rewording of questions, removal of questions, changing of the structure of questionnaire and creation of an understanding scoring system.

The patient questionnaires derived from a merger of two pre-existing non-specific to the SSU or discharge domain questionnaires one of which was UK based27 and the other USA.28 The staff questionnaire was comprised solely of a few selected questions from the NHS National Staff Survey.46

The change idea cycles (2.1–2.3) were developed from initial observations in the Acute Medical Unit then the SSU. Feedback gathered from the driver diagram (online supplemental appendix 1) facilitated potential change ideas. Facilitators to patient understanding were identified as staff willingness to help patients, repetition of information to patients and the use of a discharge summary. Barriers to potential change ideas were time constraints, patients disinterest in self-management, staff confidence conveying medical information and over-estimation of perceived patient understanding: ‘Teach back is helpful but we can usually gauge understanding of patient so don’t feel like we need to do this’—Registrar on SSU.

Educational materials were designed and given to doctors including an interactive PowerPoint, poster for the ward and a summary document (online supplemental appendix 1).

The structure of the adapted EDD was informed by literature and patient preference: using spaced out information, signposting and avoiding jargon.

The documentation cycles (3.1–3.5) developed patient consent forms, information sheets and results of patient questionnaires. The information sheets maintained mainly original content. A spreadsheet was developed to easily document patient questionnaire responses from the telephone interviews.