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de Pins AM, Adu-Amankwah D, Shadman KA, Hess SM, Elaiho CR, Butler LR, Ranade SC, Shah BJ, Fields R, Lin EP. A Quality Improvement Project to Improve After-visit Summary Patient Instructions in a Pediatric Multidisciplinary Neuromuscular Program. Pediatr Qual Saf 2024; 9:e743. [PMID: 38993270 PMCID: PMC11236396 DOI: 10.1097/pq9.0000000000000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 05/25/2024] [Indexed: 07/13/2024] Open
Abstract
Introduction Multidisciplinary clinics aim to coordinate care between multiple specialties for children with medical complexity yet may result in information overload for caregivers. The after-visit summary (AVS) patient instruction section offers a solution by summarizing visit details and recommendations. No known studies address patient instruction optimization and integration within a multidisciplinary clinic setting. This project aimed to improve the quality of patient instructions to support better postvisit communication between caregivers and providers in a multidisciplinary pediatric neuromuscular program. Methods A multidisciplinary stakeholder team created a key driver diagram to improve postvisit communication between caregivers and providers in the clinic. The first specific aim was to achieve an 80% completion rate of AVS patient instructions within 6 months. To do so, a standardized electronic medical record "text shortcut" was created for consistent information in each patient's instructions. Feedback on AVS from caregivers was obtained using the Family Experiences with Coordination of Care survey and open-ended interviews. This feedback informed the next specific aim: to reduce medical jargon within patient instructions by 25% over 3 months. Completion rates and jargon use were reviewed using control charts. Results AVS patient instruction completion rates increased from a mean of 39.4%-85.0%. Provider education reduced mean jargon usage in patient instructions, from 8.2 to 3.9 jargon terms. Conclusions Provider education and caregiver feedback helped improve patient communication by enhancing AVS compliance and diminishing medical jargon. Interventions to improve AVS patient instructions may enhance patient communication strategies for complex medical visits.
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Affiliation(s)
- Agathe M de Pins
- From the Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, N.Y
| | - Dorothy Adu-Amankwah
- From the Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, N.Y
| | - Kristin A Shadman
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Skylar M Hess
- From the Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, N.Y
| | | | - Liam R Butler
- From the Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, N.Y
| | - Sheena C Ranade
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, N.Y
| | - Brijen J Shah
- Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, N.Y
| | | | - Elaine P Lin
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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Joseph D, Hu R, Min R, Jolly M, Hassan S. Use and Utility of Patient After-Visit Instructions at a University Rheumatology Outpatient Clinic: Status and Randomized Prospective Pilot Intervention Study. ACR Open Rheumatol 2024; 6:321-329. [PMID: 38387613 PMCID: PMC11089441 DOI: 10.1002/acr2.11659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the use of after-visit instructions (AVIs) in an academic rheumatology clinic and assess the impact of standardized AVIs (sAVIs) and teach-back (TB) on comprehension of health information. METHODS A retrospective review of adult patients seen between October 1 and 8, 2021, at the rheumatology clinic collected data on patient demographics, clinical features, and the presence, content, and readability of AVIs. During a subsequent prospective proof-of-concept study, routinely scheduled patients seen at the rheumatology clinic were randomized into three groups: control (received standard of care), received sAVIs only, and received sAVIs plus TB. Patients completed a health literacy questionnaire, satisfaction survey, and a one- to two-week postvisit telephone survey to assess AVI comprehension. RESULTS Out of 316 retrospective patient visits, 82 (25.9%) received AVIs. Among 210 of 316 patients (66.5%) with management changes, 76 (36.1%) received AVI, with 74.2% of the instructions considered concordant with the provider's note. Use of AVIs was higher with management changes, new patient visits, and medical trainee/teaching clinics. AVIs were written at a median 6.8 grade level. A total of 75 patients completed the prospective study: 31 (41.3%) were in the control group, 19 (25.3%) were in the group that received sAVIs only, and 25 (33.3%) were in the group that received AVIs with TB. There were no differences in overall postvisit survey comprehension/retention scores among the three patient groups evaluated. CONCLUSION Although a lack of AVI use was identified, implementation of sAVIs did not appear to impact patient retention or comprehension of discharge health information.
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Affiliation(s)
- Dijo Joseph
- Rush University Medical CenterChicagoIllinois
| | - Rong Hu
- Rush University Medical CenterChicagoIllinois
| | - Robert Min
- Rush University Medical CenterChicagoIllinois
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Friedman DI. Approach to the Patient With Headache. Continuum (Minneap Minn) 2024; 30:296-324. [PMID: 38568485 DOI: 10.1212/con.0000000000001413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The evaluation of patients with headache relies heavily on the history. This article reviews key questions for diagnosing primary and secondary headache disorders with a rationale for each and phrasing to optimize the information obtained and the patient's experience. LATEST DEVELOPMENTS The availability of online resources for clinicians and patients continues to increase, including sites that use artificial intelligence to generate a diagnosis and report based on patient responses online. Patient-friendly headache apps include calendars that help track treatment response, identify triggers, and provide educational information. ESSENTIAL POINTS A structured approach to taking the history, incorporating online resources and other technologies when needed, facilitates making an accurate diagnosis and often eliminates the need for unnecessary testing. A detailed yet empathetic approach incorporating interpersonal skills enhances relationship building and trust, both of which are integral to successful treatment.
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Schwartz NH, Teed DN, Glover CM, Basapur S, Blodgett C, Giesing C, Lawm G, Podzimek G, Reeter R, Schorfheide L, Swiderski S, Greenberg JA. Clinician-initiated written communication for families of patients at a long-term acute care hospital. PEC INNOVATION 2023; 3:100179. [PMID: 38213760 PMCID: PMC10782111 DOI: 10.1016/j.pecinn.2023.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 01/13/2024]
Abstract
Objective To assess the experience of families and clinicians at a long term acute care hospital (LTACH) after implementing a written communication intervention. Methods Written communication templates were developed for six clinical disciplines. LTACH clinicians used templates to describe the condition of 30 mechanically ventilated patients at up to three time points. Completed templates were the basis for written summaries that were sent to families. Impressions of the intervention among families (n = 21) and clinicians (n = 17) were assessed using a descriptive correlational design. Interviews were analyzed using thematic content analysis. Results We identified four themes during interviews with families: Written summaries 1) facilitated communication with LTACH staff, 2) reduced stress related to COVID-19 visitor restrictions, 3) facilitated understanding of the patient condition, prognosis, and goals and 4) facilitated communication among family members. Although clinicians understood why families would appreciate written material, they did not feel that the intervention addressed their main challenge - overly optimistic expectations for patient recovery among families. Conclusion Written communication positively affected the experience of families of LTACH patients, but was less useful for clinicians. Innovation Use of written patient care updates helps LTACH clinicians initiate communication with families.
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Affiliation(s)
| | - Don N. Teed
- West Suburban Medical Center, Oak Park, United States
| | - Crystal M. Glover
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, United States
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, United States
- Department of Neurological Sciences, Rush University Medical Center, Chicago, United States
| | - Santosh Basapur
- Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, United States
| | | | | | - Gerald Lawm
- RML Specialty Hospital, Chicago, United States
| | | | | | | | | | - Jared A. Greenberg
- Department of Internal Medicine, Rush University Medical Center, Chicago, United States
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Meyers N, Kaminski M, Master S, Catallozzi M, Friedman S. A qualitative assessment of adolescent perspectives on patient education in the outpatient setting. PEC INNOVATION 2023; 2:100117. [PMID: 37214505 PMCID: PMC10194254 DOI: 10.1016/j.pecinn.2022.100117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 10/13/2022] [Accepted: 12/07/2022] [Indexed: 05/24/2023]
Abstract
Objective To explore adolescent perspectives on the content and delivery of anticipatory guidance (AG), both during and after outpatient visits, in order to develop targeted resources and educational material for adolescent patients. Methods Semi-structured phone interviews among patients ages 12 to 21 seen between May-July 2021 at four outpatient sites of NewYork Presbyterian Hospital were recorded, transcribed and analyzed using thematic analysis. Content domains included attitudes toward and preferences around AG, discharge instructions and patient education resources. Results Twenty-eight of 156 recruited patients completed interviews; 52% received an After Visit Summary (AVS); of the 48% who did not receive it, half of them expressed interest in receiving one. Themes included positive perceptions of the AVS, patient-physician communication, multimodal delivery of educational materials, and critical discussion topics such as mental health and nutrition. Conclusion Adolescents value the AVS and prefer multimodal materials and topics that are specifically geared towards them, rather than their caregivers. Innovation This study is the first to explore adolescent perspectives on AG and after-visit informational materials. These findings may help more effectively reach, educate and engage adolescent patients in the primary care setting by guiding the focused development of patient-centered instructions and resources.
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Affiliation(s)
- Nicole Meyers
- Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children’s Hospital, 630 W 168th Street, PH 5, East Room 520, New York, NY 10032, USA
| | - Michelle Kaminski
- Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY 10032, USA
| | - Samuel Master
- Department of Pediatrics, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY 10032, USA
| | - Marina Catallozzi
- Columbia University Mailman School of Public Health, 722 W 168th Street, New York, NY 10032, USA
- Department of Pediatrics, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY 10032, USA
| | - Suzanne Friedman
- Department of Pediatrics, Columbia University Irving Medical Center, 630 W 168th Street, New York, NY 10032, USA
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Kumar B, Zahn C, Seeman L, Levins L, Davis B, Swee M. What Do Rheumatology Patients Want in an After-Visit Summary? A Kano Analysis of Patient Preferences. J Clin Rheumatol 2023; 29:52-57. [PMID: 35067509 DOI: 10.1097/rhu.0000000000001817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND After-visit summaries (AVS) are patient-specific documents curated by providers to summarize the content of medical encounters. Despite widespread use, little is known about rheumatology patient preferences for AVS content and style. The aims of this quality improvement project are to identify patient preferences and to design a rheumatology-specific AVS, using the Kano method. METHODS This quality improvement project consists of 4 parts. First, investigators interviewed veterans and clinic staff to derive a list of potential features. Second, a Kano questionnaire assessing satisfaction with the presence or absence of each feature was distributed to veterans. Third, qualitative and quantitative Kano analyses were performed to categorize features as mandatory, performance, attractive, or indifferent. Fourthly, based on these findings, an AVS was drafted and distributed to Veterans with an associated survey to assess satisfaction with content, visual appeal, and readability. RESULTS Nine physicians, 5 veterans, 5 schedulers, 3 nurses, and 3 medical assistants identified 15 features for inclusion in a Kano-style questionnaire. The questionnaire was distributed to 50 Veterans using consecutive sampling. Quantitative Kano analysis demonstrated 4 mandatory, 2 performance, and 3 attractive features that were ultimately included in the AVS; 6 indifferent features were excluded. A postintervention survey of 50 Veterans showed high satisfaction scores in AVS content (4.3/5), visual appeal (4.6/5), and readability (4.4/5). CONCLUSIONS We developed an AVS that included 9 mandatory, attractive, and performance features, as identified by the Kano method. Veterans were highly satisfied by the content, visual appeal, and readability of the AVS.
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Affiliation(s)
- Bharat Kumar
- From the Division of Immunology, University of Iowa
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A Quality Improvement Initiative to Improve After-visit Summary Distribution in Orthopedic Outpatient Clinics. Pediatr Qual Saf 2022; 7:e620. [PMID: 36518154 PMCID: PMC9742082 DOI: 10.1097/pq9.0000000000000620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/10/2022] [Indexed: 01/25/2023] Open
Abstract
UNLABELLED Communication and patient education are key to effective healthcare encounters and improved health outcomes. The after-visit summary (AVS) is an integral communication and education tool for patients and families. Without effective communication, gaps in comprehension may result in decreased satisfaction with medical encounters, lack of adherence to recommended treatment plans, missed appointments, and increased malpractice claims. METHODS We initiated a quality improvement (QI) initiative implementing concepts derived from the Institute for Healthcare Improvement (IHI) model, including plan-do-study-act cycles, to increase AVS distribution rates in a high-volume, fast-paced ambulatory pediatric orthopedic clinic. Interventions included staff education and training, trainee instruction, enlistment of electronic medical record superusers to enhance the distribution process, and provision of regular, transparent communication of individual and team performance. The impact of interventions was measured using a p-chart. RESULTS There was a consistent improvement in the rate of AVS distribution with each intervention implemented. The distribution rate on project initiation was 81.9%, with a final rate of 95.7%. The most statistically significant shift occurred following the final intervention, which included sharing unblinded individual performance data. CONCLUSION Our data demonstrate that a dedicated QI program using IHI methodology improved AVS distribution rates in a pediatric orthopedic clinic. Consistently distributing the AVS affords our patients and families a better opportunity to review pertinent visit information, education, medication changes, and upcoming appointments.
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Daily Written Care Summaries for Families of Critically Ill Patients: A Randomized Controlled Trial. Crit Care Med 2022; 50:1296-1305. [PMID: 35607975 DOI: 10.1097/ccm.0000000000005583] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the effect of daily written updates on the satisfaction and psychologic symptoms of families of ICU patients. DESIGN Randomized controlled trial. SETTING Single, urban academic medical center. SUBJECTS Surrogates of nondecisional, critically ill adults with high risk of mortality (n = 252) enrolled from June 2019 to January 2021. INTERVENTIONS Usual communication with the medical team with or without written communication detailing the suspected cause and management approach of each ICU problem, updated each day. MEASUREMENTS AND MAIN RESULTS Participants completed surveys at three time points during the ICU stay: enrollment (n = 252), 1 week (n = 229), and 2 weeks (n = 109) after enrollment. Satisfaction with care was measured using the Critical Care Family Needs Inventory (CCFNI). The presence of anxiety, depression, and acute stress were assessed using the Hospital Anxiety and Depression Scale (HADS) and Impact of Events Scale Revised (IES-R). CCFNI, HADS, and IES-R scores were similar among participants assigned to the intervention group and control group upon enrollment and during the first week after enrollment (p > 0.05). From enrollment to the second week after enrollment, there was an improvement in CCFNI and HADS scores among participants assigned to the intervention group versus the control group. At week 2, CCFNI scores were significantly lower among participants in the intervention group versus the control group, indicating greater satisfaction with care: 15.1 (95% CI, 14.2-16.0) versus 16.4, (95% CI, 15.5-17.3); p = 0.04. In addition, 2 weeks after enrollment, the odds of symptoms of anxiety, depression, and acute stress among participants assigned to the intervention versus control group were 0.16 (95% CI, 0.03-0.82; p = 0.03); 0.15 (95% CI, 0.01-1.87; p = 0.14); and 0.27 (95% CI, 0.06-1.27; p = 0.10), respectively. CONCLUSIONS Written communication improved satisfaction and the emotional well-being of families of critically ill patients, supporting its use as a supplement to traditional communication approaches.
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Written Care Summaries Facilitate Communication Between Families and Providers of ICU Patients: A Pilot Study. Crit Care Explor 2021; 3:e0473. [PMID: 34278309 PMCID: PMC8280084 DOI: 10.1097/cce.0000000000000473] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: ICU providers may invite families to participate in daily rounds to inform them of the patient’s condition and to support their emotional well-being. Daily written summaries of care may provide complementary benefits. DESIGN: Qualitative interviews with surrogates of ICU patients who received daily written summaries of care. SETTING: Single, urban academic medical center. PATIENTS/SUBJECTS: A convenience sample of 30 surrogates of nondecisional, medical ICU patients. INTERVENTIONS: Daily written summaries detailed each of the patient’s main ICU problems, the presumed causes of each of the problems, and the medical team’s plan to address each of the problems for each ICU day. MEASUREMENTS AND MAIN RESULTS: There were four ways that written summaries affected the participant’s experience: 1) providing clarity to participants regarding the patient’s condition, 2) facilitating participant understanding of the patient’s clinical course, 3) facilitating communication between participants and medical providers, and 4) facilitating communication between participants and other family members. Overarching themes were that summaries were understandable, had appropriate level of detail, and added value to the ICU experience. CONCLUSIONS: In this pilot study, family members had positive impressions of receiving daily written summaries of care. Further study is needed to determine the extent to which written communication may affect family and patient outcomes.
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