DDHA 9901 Week 9 Scope Boundary Example

Cutting the Discharge Summary Problem to a Size One Project Can Finish: Four Boundary Passes, Each Cut Recorded, and Where Every Removed Piece Went

Student Name

Walden University

DDHA 9901: Practice-Based Problem Identification

Instructor Name

Month Day, Year

Cutting the Discharge Summary Problem to a Size One Project Can Finish: Four Boundary Passes, Each Cut Recorded, and Where Every Removed Piece Went

The Problem at the Size the Evidence Supports

The evidence gathered this term supports a wide problem: across Larchmont Health, a composite two-hospital system, information about a patient's hospital stay often fails to reach the clinicians responsible for care after discharge. That statement covers medical and surgical patients, obstetric patients, patients going to skilled nursing facilities, emergency visits where the patient goes home from the department, the content of the summary as well as its delivery and every period for which records exist. No single project could close it. Four boundary passes follow, each cutting on a different axis.

Pass 1: Population

Kept: adults discharged home from the medical services. Excluded: surgical patients, obstetric patients and patients discharged to skilled nursing facilities.

Surgical summaries are written by surgeons through a different template and often supplemented by clinic notes; that is a later project, which could reuse this one's measure. Obstetric patients are followed by obstetric clinicians rather than primary care, and their discharge information belongs to the women's services leadership, so that portion is somebody else's problem. Patients going to skilled nursing facilities receive a transfer packet through a separate process that the post-acute coordination team owns; it is also somebody else's problem, and the evidence gathered here does not cover it.

Pass 2: Setting

Kept: both hospitals, and only patients whose primary care clinician practices outside the shared record. Excluded: patients of employed practices and emergency visits where nobody is admitted.

Employed practices see summaries immediately in the shared record, and the evidence shows no shortfall there, so including them would dilute the measure. Emergency department discharge notes follow a different workflow under emergency services leadership; that is a later project. Keeping both hospitals is a deliberate choice, because the smaller hospital refers more patients to independent practices and dropping it would hide part of the problem.

Pass 3: Mechanism

Kept: delivery, meaning whether the summary reaches the outside clinician within two business days. Excluded: the content of the summary and whether clinicians read it.

Content matters. Pending test results and the follow-up provider are often missing from summaries elsewhere (Were et al., 2009), and the same may be true here. But improving content is a different project with a different owner, the hospitalist group's documentation committee, and it should follow once delivery is reliable, since a better summary that does not arrive helps no one. Whether outside clinicians open and read what arrives cannot be reached from inside Larchmont, because it happens in other organizations' record systems. That piece is recorded as unreachable from here.

Pass 4: Period

Kept: discharges from June through August 2026 for the full transmission measure, with March through May included for secure messages only. Excluded: anything earlier.

The fax server purged its log after 90 days, so failures before June cannot be traced. Extending the period would mean counting only secure messages and treating every fax as unknown, which would overstate the problem. Earlier periods are unreachable rather than deferred.

What Remains

After the four passes, the project's problem is this: for adult medical patients sent home from either hospital to an outside primary care practice, discharge summaries reach that clinician within two business days only about half the time, against a contract term that promises delivery within that window. That problem has a measure, a baseline, an owner who could act and a period short enough to finish. Kripalani et al. (2007) describe information transfer at discharge as failing at many points, and this project chooses one of them deliberately.

Where the Removed Pieces Went

The pieces sent to other owners will be described in a short note to each, so that the boundary does not become a way of losing them. Hoyer et al. (2016) linked timeliness to readmissions across settings, which suggests that several of the removed pieces deserve projects of their own.

Table 1

Pieces Removed and Their Destination

Each removal names a destination so that the boundary records a decision rather than an omission.

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