• Jon D Lurie, Edward J Merrens, Joshua Lee, and Mark E Splaine.
• Department of Medicine, Dartmouth Medical School, Hanover, NH, USA. jon.d.lurie@dartmouth.edu
• Med. Clin. North Am. 2002 Jul 1;86(4):825-45.

AbstractThis study demonstrates many of the important features and challenges of improving hospital care. The unique confluence of software technology advances and increasingly complex clinical needs have made possible a redesign of the process by which discharge documentation is generated and disseminated. Using knowledge of the patients' experience of hospital care, a multidisciplinary team identified communication at the time of discharge as a key interaction point in the system of care. With this need in mind, the team identified an aim of improving the accuracy and timeliness of discharge data and their dissemination. The project leveraged existing information technology to help satisfy the general aims of recording only useful information only once and reducing wait times for information [14]. The ability to manage structured medication data and translate this information and specialized care instructions into patient-directed language facilitated the creation of a document that would ensure that patients knew what was expected of them after discharge. Implementation of a discharge form requires understanding all of the constituencies within a medical center. It was therefore necessary to put together a team that included representation from all the groups who interact with this discharge information. The authors proceeded with a small-scale test of change during which they identified training and education needs that would be useful as the new process expands to other areas of the hospital. The case illustrates how in one project a team needs to address all of the challenges to improving hospital quality. The discharge form clearly required understanding the patient's perspective. The approach taken by the team to change the discharge form also showed detailed understanding of the process of discharging a patient from the hospital. Many microsystems are involved in this process and the change that was implemented took into account the needs of each of those subsystems and drew on resources from the macroorganization (computer information system). Measurement was embedded into the system for monitoring. Organizational culture was addressed in that the organization itself was moving in the direction of greater use of electronic information for better patient care. Finally, multiple staff members needed to come together to accomplish this task, all working together as a team. They created an implementation plan that allowed them to do the work in staged, planned efforts, and to learn from each endeavor. Was the change an improvement? The team was able to implement successively a change in the discharge process as measured by utilization of the new form. Will the quality of care improve? Probably, although that remains to be seen. Improvements in care do not need to be sophisticated, they do not need to be elaborate, and they do not need to involve new devices or new technologies. Improvements start with thinking about the way work is done and reflecting on how the work might be done differently to meet and exceed patients' needs and expectations.

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