Best‐practice checklists may help reduce medical errors during patient discharge. However, current paper checklists have poor physician support and limited integration with clinical workflows. No previous study has evaluated the impact of using a checklist on physicians’ discharge workflow and productivity.
To develop a best‐practice discharge checklist for hospital patients using the Electronic Medical Record (EMR) (EPIC, Verona, WI), and evaluate its usage, user‐satisfaction, and impact on physicians’ workflow.
We reviewed the literature and consulted with physician‐leaders at our academic medical center to develop a checklist. An online survey was used to identify physicians’ perceived usefulness of checklists, current methods of remembering discharge tasks, and interest in an EMR discharge checklist. Over a four‐month period from July to November 2013, 2 teams of 3 physicians each month were randomized to using a paper checklist, and 3 teams to using the EMR checklist. Online surveys were used to assess physicians’ usage and satisfaction. Checklist usage was self‐reported on a scale of 1 to 100, corresponding to a percent of discharges completed using the checklist. On a scale of 1 to 100, users evaluated the checklist on its integration in the workflow, and usefulness in reminding to complete discharge tasks, increase confidence, and increase efficiency.
The checklist comprised 15 items categorized by tasks on admission, during hospitalization, and discharge planning. Survey results (n=76) showed currently used methods for remembering discharge tasks were memory (54.0%) and paper (18.4%). Perceived usefulness of checklists and interest in using an EMR checklist were reported from 1 to 100 and had a mean of 66.4 ± 21.2 (IQR 52, 81), and 64.5 ± 26.6 (IQR 50, 88), respectively. Both variables were significantly correlated (r = 0.60, p<0.001). The checklist was incorporated into a keyword, or “smart phrase” tool in the EMR, allowing physician‐users to automatically insert the checklist into progress notes. Of the 60 physicians in the four‐month trial, response rate was 58.3%. EMR checklist users reported significantly higher checklist usage than paper (28.5 vs. 7.67, p=0.019). Integration of checklist in the workflow was perceived as being significantly higher among EMR users than paper (22.6 vs. 1.67, p=0.014). Usefulness of checklist in reminding to complete tasks was significantly higher among EMR users (33.7 vs. 8.92, p=0.041), as was confidence in discharge (30.8 vs. 5.00, p=0.029), and efficiency of discharge (25.5 vs. 6.67, p=0.056). Increasing use of EMR checklist was significantly correlated with increased usefulness of checklist in reminding to complete tasks (r=0.846, p<0.001), confidence (r=0.813, p<0.001), and efficiency (r=0.870, p<0.001).
This is the first study to evaluate the utility of a checklist in improving the patient discharge process. Using an EMR checklist improves physicians’ confidence in discharge, reminds them to complete necessary discharge tasks, and increases the efficiency of the discharge process. Future studies are needed to evaluate the impact of checklists on clinical outcomes.