Next day discharge rate has little use as a quality measure for individual physician performance.

INTRODUCTION: Emergency Department (ED) physicians' next day discharge rate (NDDR), the percentage of patients who were admitted from the ED and subsequently discharged within the next calendar day was hypothesized as a potential measure for unnecessary admissions. The objective was to determine if NDDR has validity as a measure for quality of individual ED physician performance. METHODS: Hospital admission data was obtained for thirty-six ED physicians for calendar year 2015. Funnel plots were used to identify NDDR outliers beyond 95% control limits. A mixed model logistic regression was built to investigate factors contributing to NDDR. To determine yearly variation, data from calendar years 2014 and 2016 were analyzed, again by funnel plots and logistic regression. Intraclass correlation coefficient was used to estimate the percent of total variation in NDDR attributable to individual ED physicians. RESULTS: NDDR varied significantly among ED physicians. Individual ED physician outliers in NDDR varied year to year. Individual ED physician contribution to NDDR variation was minimal, accounting for 1%. Years of experience in Emergency Medicine practice was not correlated with NDDR. CONCLUSION: NDDR does not appear to be a reliable independent quality measure for individual ED physician performance. The percent of variance attributable to the ED physician was 1%.

Improving medication reconciliation at hospital admission, discharge and ambulatory care through a transition of care team.

Medication reconciliation is an important component to the care of hospitalised patients and their safe transition to the ambulatory setting. In our Family Medicine Hospitalist Service, patient care is frequently transferred between the various physicians, residents, nurses and eventually to a separate group of providers who provide ambulatory management. Due to frequent transitions of care, there was no clear ownership of the medication reconciliation process. To improve the medication reconciliation process, a Transition of Care Team composed of registered nurses was created to oversee the entire reconciliation process. The team engaged the patient and their family, when needed, contacted patients' pharmacies and their providers, reconciled the patients' hospital medication list with the ambulatory list at hospital admission and within 24 hours of discharge, and attended the hospital follow-up visit to verify medications and provide continuity of care. Implementation of the team allowed for additional investigative resources, redundancy in preventing errors and early recovery should an error occur. The percent of medications with error after implementation of the Transition of Care Team was reduced from 131/386 (33.9%) to 147/787 (18.7%) at hospital admission, 81/354 (22.9%) to 42/834 (5.0%) at discharge and 43/337 (12.8%) to 6/809 (0.7%) at follow-up visit (two proportion tests, p<0.001). In addition, the percent of charts without any errors improved at hospital discharge from 8/31 (25.8%) to 46/70 (65.7%) and at hospital follow-up visit from 16/31 (51.6%) to 64/70 (91.4%) (two-proportion test, p<0.001). Previously viewed as three separate reconciliations occurring at admission, discharge and hospital follow-up, the approach to medication reconciliation was reframed as a continuous process occurring throughout the hospitalisation and hospital follow-up resulting in improved reconciliation accuracy and safer transitions to the ambulatory setting.

The costs and value of modelling-based design in healthcare delivery: five case studies from the US.

In the nineties and noughties, Hollocks surveyed the use of Discrete Event Simulation (DES) in industry and listed (although he could not quantify the value of) benefits. This paper explores how DES is now used to design healthcare facilities and services, developing a value-for-money case with a protocol on collecting information. We present a set of five DES case studies from the US care system and, following Hollocks, focus on modelling as part of a rigorous design process, capturing as many of the benefits as possible. Healthcare offers the possibility of ascribing value to health improvement, but in these cases it is primarily the operational benefits of a better service that are reported and monetarised. By estimated the cost of modelling and the value of the operation gains, this paper contributes significantly to the literature. We conclude with a protocol for collecting information and a discussion of methods by which different types of benefit may be captured.