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

Abstract

Background: 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.

Objective: 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.

Design: 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.

Participants: 61 internal medicine residents.

Main results: 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.

Conclusions: Reducing resident workload can significantly improve discharge summary quality, a measure of resident performance.