Background: As hospitalists, our continuum of care extends beyond a patient’s hospital stay and includes a safe transition to home or a care facility. Improving discharge planning, including the patient’s paperwork, eases this transition. In an effort to improve the discharge process two important concepts were adopted––the use of checklists and enabling teach–back for providers. [...]

Background: Effectively transitioning patients from the hospital to home is an important priority for many hospitals and health care providers. Increasingly, reports have highlighted gaps in the quality of care that arise during and after hospital discharge. Also, external pressures to measure and report on the patients’ hospital care experience, and potential financial penalties for [...]

Background: Hospital discharge documentation are the primary documents communicating a patient’s care plan to the post–hospital care team. Usually, it is the only form of communication that accompanies a patient to the next setting of care; often serves as initial care orders at a post acute care (PAC) facility. There is variability in the documentation [...]

Background: Discharging a patient from the hospital is a complex and high–risk task. Patients require clear and understandable instructions from their discharging providers in order to successfully transition from the hospital back to the home setting. Several prominent projects on this subject, such as Project BOOST, have established best practice standards for what should be [...]

Background: Preventable rehospitalizations are disconcerting for patients, contribute to high costs, and are partly due to deficiencies in patients’ ability to execute post–discharge care plans. Increasing patient engagement and self–empowerment through use of an evidence–based coaching model can improve adherence to the post–discharge care plan and may reduce preventable rehospitalizations. Purpose: To assess the feasibility [...]

Background: The immediate post–discharge period is a vulnerable time both for patients and their care providers. Several studies have been published highlighting safety issues identified during the immediate post–discharge period. To address these problems, we designed a program to provide clinically high risk patients with physician post–discharge follow–up at the resident continuity practice “X.” Purpose: [...]

Background: Since the advent of resident hour restrictions in 2003, hand–offs between providers have become increasingly prevalent. The process of hand–offs can require a substantial amount of time depending on the number of patients being discussed, whether the hand–off is in person, via telephone, or, by some other method. And while hand–offs are occurring, other [...]

Background: The July 2011 ACGME guidelines mandate that residency programs monitor and ensure resident competency in patient handoffs. The guidelines’ concomitant restrictions on resident duty hours are likely to increase both the volume and complexity of handoffs. The new duty hours will also likely change resident teams’ structures in ways that will necessitate handoffs to [...]

Background: Every handoff of patient care between physicians poses a risk for error. New duty hours have increased the number of handoffs occurring between residents. Residents must be trained to deliver accurate, consistent, and efficient handoffs. Studies have shown that handoffs are most effective when performed face to face with minimal interruptions, incorporate contingency plans, [...]

Background: Handoffs of hospitalized patients represent critical points in patient care. Poor quality handoffs carry the risk of poor outcomes for patients and physicians. The Joint Commission and Society of Hospital Medicine (SHM) have published best practices for handoffs. Purpose: The goal of this quality improvement project is to standardize the elements of the handoff [...]