DDHA 9901 Week 11 Reflection Post Example

Week 11 Discussion: Reflecting on the Case You Built

What Would Retire My Problem: The Finding That Would Prove Late Discharge Summaries Are Not a Shortfall, and the Conclusion I Now Hold Most Loosely

My problem would be retired by one finding: a matched record showing that most summaries the logs count as late actually reached the practices in time by a route I did not measure. The most likely route is the regional health information exchange. If independent practices routinely pulled summaries from the exchange before follow-up visits, my 52% figure would undercount delivery, and the shortfall against the two-day contract term might disappear. I did not measure exchange queries, because Larchmont, the composite system in my case, does not log them in a way I could obtain this term. A query log from the exchange, matched to discharges, would settle it either way. A second finding would weaken the case without retiring it: an audit showing that many discharges with no primary care clinician recorded belonged to patients who genuinely had none, which would shrink the group of summaries that should have gone somewhere.

The conclusion I hold most loosely is the cost estimate. Its range spans roughly a fourfold difference between low and high, and almost all of that spread comes from two assumptions I could not measure: how many minutes practice staff spend chasing a summary and how many minutes a clinician spends reconstructing a hospital stay at the visit. Writing the estimate taught me how easily an assumed number becomes a fact once it sits in a table. The Maryland work on completion delays and readmissions (Hoyer et al., 2016) tempted me to add a large readmission cost. I left it out because their measure was completion, not delivery, and that restraint is the decision I am most confident about.

What changed most was my sense of where the problem lives. I began the term expecting to show that hospitalists were slow. The signature data showed the opposite, and the problem turned out to sit in registration data and in the gap between groups that each do their own part correctly. Kripalani et al. (2007) describe information failures at discharge as occurring at many points; I now think the most important one here is the point where nobody is responsible.

Reply to Wen

Wen, your falsifying condition, that the overtime increase you documented came from a single unit's leave cluster, is well chosen, because it is checkable in the payroll register you already have. I would add one more. You compared this year's overtime with last year's, and last year included a hiring freeze that ended in March. If overtime fell during the freeze for reasons unrelated to staffing need, your comparison year may be the anomaly rather than this one. Were et al. (2009) remind me, in my own area, that missing fields can shape a finding as much as present ones; in yours, a missing explanation for last year could.

Reply to Ama

Ama, I agree that your benchmark comparison is the conclusion you should hold most loosely, since the peer distribution came from hospitals with different patient mixes. But I would hold your cost estimate even more loosely. You valued each missed medication reconciliation at the cost of an adverse drug event, which assumes every miss produces harm. The share that does is the key unknown. Stating your estimate as a range across a few plausible shares would make it far easier to defend.

References

Hoyer, E. H., Odonkor, C. A., Bhatia, S. N., Leung, C., Deutschendorf, A., & Brotman, D. J. (2016). Association between days to complete inpatient discharge summaries with all-payer hospital readmissions in Maryland. Journal of Hospital Medicine, 11(6), 393-400. https://doi.org/10.1002/jhm.2556

Kripalani, S., LeFevre, F., Phillips, C. O., Williams, M. V., Basaviah, P., & Baker, D. W. (2007). Deficits in communication and information transfer between hospital-based and primary care physicians: Implications for patient safety and continuity of care. JAMA, 297(8), 831-841. https://doi.org/10.1001/jama.297.8.831

Were, M. C., Li, X., Kesterson, J., Cadwallader, J., Asirwa, C., Khan, B., & Rosenman, M. B. (2009). Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers. Journal of General Internal Medicine, 24(9), 1002-1006. https://doi.org/10.1007/s11606-009-1057-y