Background: The ongoing challenge for hospitalists in the era of value based care is how to provide high quality care without compromising efficiency.   In 2013, the Department of Medicine at Massachusetts General Hospital asked each division to designate important quality goals.    The Hospital Medicine Division chose two quality measures:  prenoon discharge rate and discharge summary completion timeliness.  For prenoon discharges the target rate was 20 percent or more, and for discharge summary, the goal was 85% completion rate or more within 24 hours of discharge.  The measurement period took place from July through September, in 2013. 

Purpose: To improve the operational performance of a large academic hospitalist group of 70 hospitalists on multiple medical services including teaching teams over a three month period of time.

Description:

 #1) Group Alert Emails:  To improve performance in these measures, monthly alert emails were sent to the entire Hospital Medicine Unit (HMU).  These emails emphasized the targets, reported the group’s current performance, and then predicted performance needed to meet target levels.  This intervention led to an improvement in the Hospital Medicine Unit discharge summary completion rate from 89.1% to 94.8%.  When compared to the discharge summary rate of the Department of Medicine (non-Hospitalist Divisions) over July and August (who did not receive emails), which remained at 86% – 88%, the improvement is even more impressive.  The same improvement was not be seen in the prenoon discharge rate over July and August.   The HMU prenoon discharge rate declined from 18.2% to 16.0% from July to August.

 #2) Individual Alert Emails:  Given the lack of improvement seen in prenoon discharge rates, a new intervention was initiated at the beginning of September.  Individual emails were sent to every attending whose individual prenoon discharge rate and discharge summary completion rate were below target levels.   These individual emails lead to a dramatic improvement in prenoon discharge rate across the HMU.  The prenoon discharge rate for HMU was 25.6% in September.  At the completion of the three month period, the ≥85% target level for discharge summary completion rate was met by the HMU with a reported average completion rate of 92.6%.   The ≥20% target level for prenoon discharge rate was nearly met by the Unit with a reported average rate of 19.5%.  Pre-intervention and post-intervention rates highlight the improvement.  The pre-intervention prenoon discharge rate for the HMU was 17.7%, and the post-intervention rate was 19.5%.   The discharge summary completion rate increased from 87.9% to 92.6%

Conclusions: Alert emails highlighting the importance of an operational measure provided a simple and effective intervention to achieve quality improvement.  The greatest improvement in prenoon discharge rate was achieved by targeting emails to individual hospitalists, which suggests the importance of detailing individual performance.  Periodic individual email alerts that make individual performance transparent may prove to be the most effective way to achieve quality improvement in operational measures important to the Department.  Group and individual email alerts will again be used to improve HCAHPs score for the Department in January – March 2015. The most effective frequency and volume of alerts are not known and could be assessed in future studies.