Improving communication to GPs at discharge: the value of a systems approach

Problem

Poor communication at transitions of care continues to be a threat to patient safety. At hospital discharge, communication to GPs relies on discharge summaries that are usually written by the most junior doctors, who are inexperienced, can be error prone and lack insight into community care. To raise quality, national improvement efforts have focused on guidance and standardisation through idealised templates. These were adopted and abandoned in the author's local trust, due to poor feedback from both primary and secondary care. National concerns persist over information at discharge, which is essential for patient safety and for GPs to optimally coordinate patient care following discharge. This study aims to explore how to improve this transfer of information.

Approach

A ‘systems approach’, recently co-developed by the Royal Academy of Engineering and Royal College of Physicians, enables understanding of the system, its processes and inherent risks, and is valuable when addressing persistent and complex healthcare service issues such as discharge communication to GPs. Aiming for an holistic understanding of the wider system, we are interviewing key stakeholders (administrative staff and clinicians across the primary-secondary care interface), focusing on their information needs, the barriers to their performance and perceived safety risks. In keeping with a systems approach, a design mindset is permeating interviews, asking what ‘good’ might look like for these stakeholders. Detailed clinical vignettes of unmet needs will elicit nuances unavailable from generalisations of such a complex environment. Following initial thematic data analysis, focus group discussions of key stakeholders will explore proposed improvements alongside the acceptability of risks.

Findings

This exploratory study started with the question “What is the system of discharge communication?”. Emergent data is highlighting that the techno-social environment is not always understood by its stakeholders, and that it must constantly adapt to accommodate the spectrum of patients and NHS services involved. The more complex a patient’s care, the more complex the information for inexperienced doctors to convey becomes, and the more complex the system within which the information needs to be shared. Embracing complexity and explicitly designing for it, could better facilitate the patient’s care in the community.

Consequences

Using the results of this study, a systems approach will then add rigour by reiteration of solution design before any implementation. By providing methodological support to balance stakeholder needs and to ensure continuous refinement of understanding throughout the process of change, sustainable and dynamic improvements that such complex and varied service problems require can be achieved. A systems approach is well placed to target many such issues in an increasingly multidisciplinary NHS.