Relationships Between Time-at-Bedside During Hospital Ward Rounds, Clinician-Patient Agreement, and Patient Experience

Using participatory research to identify actionable facilitators and barriers to effective inpatient interdisciplinary communication

BACKGROUND

Communication failures occur often in the inpatient setting. Efforts to understand and improve communication often exclude patients or are siloed by discipline.

OBJECTIVE

We aimed to identify barriers and facilitators to effective communication within interdisciplinary inpatient internal medicine (IM) teams using a participatory research approach.

DESIGN

We conducted a single-center participatory mixed methods study using group-level assessment (GLA) and concept mapping to iteratively engage stakeholders. Stakeholder groups included patients/families, IM faculty, IM residents, nurses and ancillary staff, and care managers. Stakeholder-specific GLA sessions were conducted. Participants responded to prompts addressing interdisciplinary communication then worked in small groups to synthesize the qualitative data into unique ideas. A subset of each stakeholder group then sorted ideas through a concept mapping exercise. Multidimensional scaling and hierarchical cluster analysis were used to generate a concept map of the data.

RESULTS

Participants generated 97 unique ideas that were then sorted. The research team chose an eight-cluster concept map representing patient inclusion and engagement, processes and resources, team morale and inclusive dynamics, attitudes and behaviors, effective communication, barriers to communication, the culture of healthcare, and clear expectations. Three larger domains of patient inclusion and engagement, organizational conditions and role clarity, and team dynamics and behaviors were noted.

CONCLUSION

Use of a participatory research approach made it feasible to engage diverse stakeholders including patients. Our results highlight the need to identify context-specific facilitators and barriers of interdisciplinary communication. The importance of clear expectations was identified as a prioritized area to target communication improvement efforts.

Dismissal disagreement and discharge delays: Associations of patient-clinician plan of care agreement with discharge outcomes

BACKGROUND

Many hospitalized patients do not understand or agree with their clinicians about their discharge plan. However, the effect of disagreement on discharge outcomes is unknown.

OBJECTIVE

To measure the correlation between patient-clinician care agreement and discharge outcomes.

DESIGN

A prospective cohort study was performed from September 2019 to March 2020 (Rochester, MN, USA).

SETTING AND PARTICIPANTS

Internal medicine patients and their primary clinician (resident, advanced practice clinician or attending) hospitalized from September 2019-March 2020 at Mayo Clinic Hospital. Participants were independently surveyed following hospital day #3 ward rounds regarding the goals of the hospitalization and discharge planning.

MAIN OUTCOME AND MEASURES

Patient-clinician agreement for main diagnosis, patient's main concern, and four domains of discharge planning was assessed. Readiness for hospital discharge, delayed discharge, and 30-day readmission was measured. Then, associations between patient-clinician agreement, delayed discharge, and 30-day readmissions were analyzed using multivariable logistic regression.

RESULTS

Of the 436 patients and clinicians, 17.7% completely agreed about what needs to be accomplished before dismissal, 40.8% agreed regarding discharge date, and 71.1% agreed regarding discharge location. In the multivariable model, patient-clinician agreement scores were not significantly correlated with discharge outcomes. Patient-clinician agreement on discharge location was higher for those discharged to home (81.5%) versus skilled nursing facility (48.5%) or assisted living (42.9%) (p < .0001). The agreement on the expected length of stay was highest for home-goers (45.9%) compared to skilled nursing (32.0%) or assisted living (21.4%) (p = .004).

CONCLUSIONS

Patients and their clinicians frequently disagree about when and where a patient will go after hospitalization, particularly for those discharged to a skilled nursing facility. While disagreement did not predict discharge outcomes, our findings suggest opportunities to improve effective communication and promote shared mental models regarding discharge earlier in the hospital stay.