Centre Projects

The discharge summary timeliness project is a high priority corporate project designed to optimize patient transitions and decrease readmission rates. Sponsored by the London Health Sciences Centre (LHSC) Medical Advisory Board, the project is driven by the CPSO mandate to make inpatient discharge summaries available within 48 hours of discharge. After multiple improvement cycles using audit and feedback score cards and education, LHSC had only 50% of summaries distributed within 48 hours in September 2020, with an average distribution time of 89 hours.

The Centre for Quality, Innovation, and Safety (CQUINS), Schulich Medicine, Western University is engaged with multiple stakeholders and implemented a series of Plan-Do-Study-Act cycles to test interventions:

• 1. Resident authentication of the discharge summary
• 2. Dictation code to auto distribute the summary, prior to physician review
• 3. 24 h email notification of deficient summaries
• 4. Monthly data to Department Chairs

As of April 2021 we are tracking to reach the target of 65% by June 30th 2021 with a reduction of mean time to distribution of 51 hours. The use of a multi- intervention approach, with multi-sectorial collaboration resulted in significant improvement in a short time period. Ongoing improvement strategies will be implemented to further improve this outcome to meet the CPSO standards.

This overall improvement wouldn’t have been possible without work going on locally within the Departments and Divisions. One example has been in Hematology where they started a project to understand the root causes of their poor performance with completing discharge summaries. Discharge summary sign off was 36% during the baseline collection period from September to December 2020. Root cause analysis highlighted some key areas for improvement and after 2 PDSA improvement cycles discharge summary signoff has increased to 52% by the end of April 2021. This work is ongoing and there continues to be new PDSA cycles completed during the implementation of their planned improvements.

Discharge Planning & D/C Note (PDF, 585KB)

In 2020, an interdisciplinary team consisting of medical faculty, nurses, administrators, research staff and hospital leaders developed a new model of care for an accessible virtual clinic, intended to support those in the community who had a COVID-19 diagnosis – the LHSC Urgent COVID-19 Care Clinic (LUC3). The clinic also aimed to support those discharged home, following a COVID-19 related inpatient admission. Patients were referred from the Middlesex London Health Unit, local family physicians, discharging LHSC hospital physicians or emergency department physicians and many were at risk of deterioration and needing rapid medical attention.  

LUC3 was founded with support from the Centre for Quality, Innovation and Safety (CQuInS) and a provincial grant. It became a central component of the local COVID-19 care pathway, providing a powerful example of rapidly initiated and effective quality improvement implementation; conceived and delivered in the face of an escalating and unknown threat with the potential to cause widespread collapse of the healthcare system.  

The program provided daily weekday virtual clinics, with follow up over the weekend. Patients had their first virtual appointment within two days of a referral being received, and were assessed to see if they required at home blood oxygen monitoring. If determined to be required, a pulse-oximeter and an easy-to-use algorithm were delivered to their home. Given the rapidly progressive nature of the disease in some patients, care was augmented with access to a dedicated on-call physician if needed, and further supported by a novel direct admission pathway to a COVID-19 in-patient bed.  

The clinic provided a comprehensive package of care for both escalation and de-escalation of therapy. This integrated pathway increased patient safety, reduced patient anxiety and mitigated the risk of exposure for other patients and care providers within the hospital setting.  This accrued additional benefits such as minimizing the number of in-person encounters, even if requiring direct admission, and significantly reducing personal protective equipment consumption. 

As LUC3 referrals surged, the LUC3 team partnered with CQuInS to study and improve the impact of the clinic. The clinical and fiscal benefits of LUC3 along with the patients’ experience of the clinic, were studied.  Data were collected and analyzed at regular intervals, with improvement cycles implemented based on these data. Ongoing iterative patient-centred changes provided a direct organic response to real time data collection and analysis. Initial findings suggested that LUC3 supported a diverse and often isolated population who have limited access to other forms of healthcare; this led to direct outreach by our physician members to support vulnerable populations including individuals who identified as Indigenous and unhoused individuals residing in group settings. During its two years of operation, LUC3 cared for 2558 patients; the work now continues to review the wealth of collected data to understand the clinic’s impact and how these lessons can be applied to future planning and other patient populations and clinical settings. 

Initial qualitative assessment has shown that the virtual care provided by LUC3 was particularly well received by patients and their care givers. Patient feedback was extremely positive, with patients feeling well supported, less anxious and grateful not to feel alone in the course of their illness. 

Data analysis has shown that LUC3 provided key support to other parts of the healthcare system by facilitating earlier discharge from hospital – even patients still requiring oxygen or close monitoring at home – thus creating inpatient capacity. In the 13 months between 1st January 2021 to the end of February 2022, 371 were followed up by the clinic after discharge from hospital, with 56% of these patients still on oxygen at discharge and remotely monitored by the clinics’ doctors and nurses. The clinic also played a key role in preventing admissions and readmissions by managing patients’ care virtually. This prevented many unnecessary emergency department visits, while many others who did attend the ED were discharged and followed by LUC3. Patients sent home on oxygen showed no differences in readmission or mortality, when compared to those sent home that did not require home oxygen. These patients also reported that the clinic significantly reduced their levels of anxiety after being discharged, knowing that they would be followed up with by LUC3. 

As well as improving the safety, quality of care, and experience for these patients, a significant cost savings was achieved. During the first four months of LUC3 $25,495 was saved by preventing 25 unnecessary ED visits (all adjudicated by none LUC3 physicians) and replacing 228 in-person appointments with telephone assessments. The net savings after accounting for LUC3 operational costs, intentional ED visits and admissions was $11,756. These numbers are likely an underestimate and the cost savings impact of the clinic was likely amplified during the surge of patients and increase in disease severity during later waves.  

LUC3 provided equitable and accessible care to those who needed it, across the whole of the London Middlesex region and beyond. With the support of CQuInS, LUC3 was able to be responsive and implement change rapidly to provide safe and efficient care in the ever-evolving pandemic environment. With data analysis currently in progress, it is expected that lessons learned from LUC3’s operation will contribute to innovative models of care in other populations that may benefit from remote monitoring. 

Based on the data collected with the support of CQuInS, there have been 5 conference abstracts and 1 clinical peer reviewed paper accepted for publication, with 3 manuscripts in process. 

The hospital discharge process can be a stressful experience for patients with lifelong disease who often have complex health care needs. This study is led by principal investigator Dr. Saira Zafar and research coordinator/transitional coach Claudia Jarosz (MKin). Funding has been acquired through the  Academic  Medical  Organization  of  Southwestern  Ontario  (AMOSO)  and  supplemented  by CQuIns.  The study is also supported by steering committee members Dr. Natasha McIntyre, Dr. Alan Gob and Krista Delmage from CQuInS. It aims to improve patient education, discharge planning, and outpatient follow up with the goal of reducing hospital readmissions on a medical clinical teaching unit. It evaluates a patient-centered intervention that uses a “Transitional Coach” and a standard checklist to  enhance  patients’ capacity  to  self-care  for  a  safer  transition  to  home.  This  project  is designed  to  employ  Quality  Improvement  methods  to  test  the  intervention  in  rapid,  small  cycles while collecting and analyzing data on various quality indicators to make changes to the intervention and adapt it for sustainability. 

Patients’ post-hospital  self-care  preparedness  is  obtained  using  a  CTM-3 scoring  tool  following patients' discharge from hospital. Patients also scored as high risk for readmission (using a validated screening tool) are followed up by telephone following discharge by the Transitional Coach.  Patients are  also  provided  with  a  pager  number  to  contact the Transitional  Coach  with  questions  and concerns.  This  study  is  important to  educate  and  guide  patients, improve  patient  outcomes,  and achieve significant savings to the health care system by reducing readmissions.

A two-week pilot study was completed in July 2021 to better delineate the role of the Transitional Coach  and identify  barriers  to  the  intervention  implementation.  After  recruiting  the  Transitional Coach, data collection began in October 2021 and is ongoing. As of the end of June 2022, 300 patients have been recruited into the study. Data shows a reduction in 30-day readmission rates to 17% in comparison  to  29%  from  October  2020  to  December  2020.  Patients’ post-hospital  self-care preparedness (CTM-3 score) is 82% with a response rate of 55%. Patient satisfaction, obtained during the follow-up telephone calls through direct patient feedback, highlights key areas of improvement around staff communication and the discharge process. In addition, the transitional coach role has been  acknowledged  through  an  LHSC  “Celebrating  Our  Values”  e-mail  as  a  patient submitted the following: “I understand you have introduced a new role known as the Transition Coach. Cheers to that! Patients are certainly nervous and perhaps frightened; so knowledge is king. My Coach (Claudia) really provided insight and info that anyone would like to have. Nurses and doctors are busy and I am sure struggle to communicate updates to worried patients and families. This role seems to broker this. Claudia was very helpful, detailed and prompt – it was truly an unexpected positive surprise (imagine that when you are ill).”