The effect of workload reduction on the quality of residents' discharge summaries.

Abstract

The completeness of hospital discharge summaries may reflect the overall quality of inter-professional communications. The effect of reducing resident workload on clinical performance is largely unknown. We examined the impact of reducing housestaff workload on the quality of discharge summaries, an indicator of clinical performance, as compared to discharge summaries created by trainees on a team with a more typical workload. Patients admitted to a medicine service at a community teaching hospital affiliated with an academic medical center were alternately allocated between a control and intervention care team of residents. First-year residents on the intervention team carried an average census of 3.5 patients compared with 6.6 patients for peers on the control team. A random selection of 142 discharge summaries from a 3-month period were blindly evaluated using a structured tool based on professional documentation standards. 61 internal medicine residents. Inter-rater reliability of discharge summary quality was 0.9. Discharge summaries produced by residents on the intervention team with a reduced workload had significantly more of the required elements (74 vs 65%, p<0.001). Intervention team summaries were more frequently complete and contained significantly more of the required elements describing the patient history (65.7% vs 36.1%, p=0.0005), the inpatient narrative (47.1% vs 22.2%, p=0.003), discharge planning (20.0% vs 5.5%, p=0.012), and continuity of care (24.3% vs 6.9%, p=0.005). Fewer than a quarter of the summaries reviewed included discharge instructions, information on follow-up care, or a discharge medication list. Reducing resident workload can significantly improve discharge summary quality, a measure of resident performance.