Does Increased Clinical Workload Lead To Poorer Performance On Quality Improvement Indicators?

DOES INCREASED CLINICAL WORKLOAD LEAD TO POORER PERFORMANCE ON QUALITY IMPROVEMENT INDICATORS?

Nicole Van Groningen, MD^*¹;Dr. Margaret C. Fang, MD, MPH²;Nader Najafi, MD³;Raman Khanna, MD, MAS¹;Alvin R. Rajkomar, MD¹ and Priya Prasad, PhD³, (1)UCSF, San Francisco, CA, (2)University of California, San Francisco, San Francisco, CA, (3)University of California San Francisco, San Francisco, CA

Meeting: Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.

Abstract Number: 223

Category: Research

Sub-Category: Quality Improvement

Keywords: Discharge, Patient Safety, Quality Improvement, Quality Metrics and Workload

Background: A “safe” hospitalist workload – that is, the point at which caring for too many patients leads to poorer outcomes for each individual patient – has not been defined. We sought to understand whether the workload of a resident-run inpatient team, measured by number of orders entered into the electronic medical record, was associated with adherence to two quality metrics: completion of a high-quality after visit summary (AVS) at discharge (Figure 1), and completion of timely discharge summary. We hypothesized that as workload increased, completion rate of these metrics would decline.

Methods: In this retrospective observational study, we identified all admissions to the general medicine teaching service at UCSF Medical Center between May 1, 2015 and September 30, 2016, and determined which specific team each patient was on. Based on data collected for quality improvement purposes, we identified whether each patient received a high-quality AVS on discharge and whether a discharge summary was completed within 24 hours of discharge. Our proxy measure of clinical workload was the total number of orders entered by a given medical team both on day of discharge and the day prior to discharge. Based on order volume, we calculated the odds that a patient discharged on a given day would receive a high-quality AVS and a timely discharge summary, adjusting for the mean 3M APR-DRG Severity of Illness (obtained from billing data) of patients cared for by the team.

Results: We identified 5,829 patients cared for by 8 different resident teams. The median number of orders per team per day was 343 (IQR 261, 446). Of the 5,829 patients discharged during the study period, 4,181 (71.7%) received a high quality AVS on discharge. Of the 4,277 patients for which discharge summary status was available, 3,856 (91.2%) had a discharge summary completed within 24 hours. After controlling for 3M APR-DRG Severity of Illness, there was no statistically significant association between total orders placed by the team on a patient’s day of discharge and odds of receiving a high quality AVS (OR 0.96, 95% CI 0.92, 1.01) or receiving a timely discharge summary (OR 0.95 95% CI 0.88, 1.02), nor was there a statistically significant association between team orders placed the day prior to a patient’s discharge and odds of receiving a high quality AVS (OR 0.97, 95% CI 0.93 – 1.02). However, patients were 12% less likely to receive a timely discharge summary for every 100 extra orders the team placed on the day prior to discharge (OR 0.88, 95% CI 0.82, 0.95).

Conclusions: The lack of association between team workload and the likelihood that a patient would receive a high-quality AVS suggests that adherence to this quality metric is independent of workload, possibly because it is targeted by quality improvement initiatives at UCSF and therefore prioritized by residents. The finding that patients were less likely to receive a timely discharge summary when workload was high prior to day of discharge indicates that with higher workload, adherence with some quality metrics may decline.