Katy L. B. Araujo, MPH

Tool Design and Measures

The Handoff CEX (clinical evaluation exercise) is a structured assessment based on the format of the mini‐CEX, an instrument used to assess the quality of history and physical examination by trainees for which validation studies have previously been conducted.[14, 15, 16, 17] We developed the tool based on themes we identified from our own expertise,[1, 5, 6, 8, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29] the ACGME core competencies for trainees,[2] and the literature to maximize content validity. First, standardization has numerous demonstrable benefits for safety in general and handoffs in particular.[30, 31, 32] Consequently we created a domain for organization in which standardization was a characteristic of high performance.

Second, there is evidence that people engaged in conversation routinely overestimate peer comprehension,[27] and that explicit strategies to combat this overestimation, such as confirming understanding, explicitly assigning tasks rather than using open‐ended language, and using concrete language, are effective.[33] Accordingly we created a domain for communication skills, which is also an ACGME competency.

Third, although there were no formal guidelines for sign‐out content when we developed this tool, our own research had demonstrated that the content elements most often missing and felt to be important by stakeholders were related to clinical condition and explicating thinking processes,[5, 6] so we created a domain for content that highlighted these areas and met the ACGME competency of medical knowledge. In accordance with standards for evaluation of learners, we incorporated a domain for judgment to identify where trainees were in the RIME spectrum of reporter, interpreter, master, and educator.

Next, we added a section for professionalism in accordance with the ACGME core competencies of professionalism and patient care.[34] To avoid the disinclination of peers to label each other unprofessional, we labeled the professionalism domain as patient‐focused on the tool.

Finally, we included a domain for setting because of an extensive literature demonstrating increased handoff failures in noisy or interruptive settings.[35, 36, 37] We then revised the tool slightly based on our experiences among nurses and students.[13, 38] The final tool included the 6 domains described above and an assessment of overall competency. Each domain was scored on a 9‐point scale and included descriptive anchors at high and low ends of performance. We further divided the scale into 3 main sections: unsatisfactory (score 13), satisfactory (46), and superior (79). We designed 2 tools, 1 to assess the person providing the handoff and 1 to assess the handoff recipient, each with its own descriptive anchors. The recipient tool did not include a content domain (see Supporting Information, Appendix 1, in the online version of this article).

Setting and Subjects

We tested the tool in 2 different urban academic medical centers: the University of Chicago Medicine (UCM) and Yale‐New Haven Hospital (Yale). At UCM, we tested the tool among hospitalists, nurse practitioners, and physician assistants during the Monday and Tuesday morning and Friday evening sign‐out sessions. At Yale, we tested the tool among housestaff during the evening sign‐out session from the primary team to the on‐call covering team.

The UCM is a 550‐bed urban academic medical center in which the nonteaching hospitalist service cares for patients with liver disease, or end‐stage renal or lung disease awaiting transplant, and a small fraction of general medicine and oncology patients when the housestaff service exceeds its cap. No formal training on sign‐out is provided to attending or midlevel providers. The nonteaching hospitalist service operates as a separate service from the housestaff service and consists of 38 hospitalist clinicians (hospitalist attendings, nurse practitioners, and physicians assistants). There are 2 handoffs each day. In the morning the departing night hospitalist hands off to the incoming daytime hospitalist or midlevel provider. These handoffs occur at 7:30 _am in a dedicated room. In the evening the daytime hospitalist or midlevel provider hands off to an incoming night hospitalist. This handoff occurs at 5:30 _pm or 7:30 _pm in a dedicated location. The written sign‐out is maintained on a Microsoft Word (Microsoft Corp., Redmond, WA) document on a password‐protected server and updated daily.

Yale is a 946‐bed urban academic medical center with a large internal medicine training program. Formal sign‐out education that covers the main domains of the tool is provided to new interns during the first 3 months of the year,[19] and a templated electronic medical record‐based electronic written handoff report is produced by the housestaff for all patients.[22] Approximately half of inpatient medicine patients are cared for by housestaff teams, which are entirely separate from the hospitalist service. Housestaff sign‐out occurs between 4 _pm and 7 _pm every night. At a minimum, the departing intern signs out to the incoming intern; this handoff is typically supervised by at least 1 second‐ or third‐year resident. All patients are signed out verbally; in addition, the written handoff report is provided to the incoming team. Most handoffs occur in a quiet charting room.

Data Collection

Data collection at UCM occurred between March and December 2010 on 3 days of each week: Mondays, Tuesdays, and Fridays. On Mondays and Tuesdays the morning handoffs were observed; on Fridays the evening handoffs were observed. Data collection at Yale occurred between March and May 2011. Only evening handoffs from the primary team to the overnight coverage were observed. At both sites, participants provided verbal informed consent prior to data collection. At the time of an eligible sign‐out session, a research assistant (D.R. at Yale, P.S. at UCM) provided the evaluation tools to all members of the incoming and outgoing teams, and observed the sign‐out session himself. Each person providing a handoff was asked to evaluate the recipient of the handoff; each person receiving a handoff was asked to evaluate the provider of the handoff. In addition, the trained third‐party observer (D.R., P.S.) evaluated both the provider and recipient of the handoff. The external evaluators were trained in principles of effective communication and the use of the tool, with specific review of anchors at each end of each domain. One evaluator had a DO degree and was completing an MPH degree. The second evaluator was an experienced clinical research assistant whose training consisted of supervised observation of 10 handoffs by a physician investigator. At Yale, if a resident was present, she or he was also asked to evaluate both the provider and recipient of the handoff. Consequently, every sign‐out session included at least 2 evaluations of each participant, 1 by a peer evaluator and 1 by a consistent external evaluator who did not know the patients. At Yale, many sign‐outs also included a third evaluation by a resident supervisor.

The study was approved by the institutional review boards at both UCM and Yale.

Statistical Analysis

We obtained mean, median, and interquartile range of scores for each subdomain of the tool as well as the overall assessment of handoff quality. We assessed convergent construct validity by assessing performance of the tool in different contexts. To do so, we determined whether scores differed by type of participant (provider or recipient), by site, by training level of evaluatee, or by type of evaluator (external, resident supervisor, or peer) by using Wilcoxon rank sum tests and Kruskal‐Wallis tests. For the assessment of differences in ratings by training level, we used evaluations of sign‐out providers only, because the 2 sites differed in scores for recipients. We also assessed construct validity by using Spearman rank correlation coefficients to describe the internal consistency of the tool in terms of the correlation between domains of the tool, and we conducted an exploratory factor analysis to gain insight into whether the subdomains of the tool were measuring the same construct. In conducting this analysis, we restricted the dataset to evaluations of sign‐out providers only, and used a principal components estimation method, a promax rotation, and squared multiple correlation communality priors. Finally, we conducted some preliminary studies of reliability by testing whether different types of evaluators provided similar assessments. We calculated a weighted kappa using Fleiss‐Cohen weights for external versus peer scores and again for supervising resident versus peer scores (Yale only). We were not able to assess test‐retest reliability by nature of the sign‐out process. Statistical significance was defined by a P value 0.05, and analyses were performed using SAS 9.2 (SAS Institute, Cary, NC).

Handoff Providers

A total of 343 evaluations of handoff providers were completed regarding 67 unique individuals. For each domain, scores spanned the full range from unsatisfactory to superior. The highest rated domain on the handoff provider evaluation tool was professionalism (median: 8; interquartile range [IQR]: 79). The lowest rated domain was content (median: 7; IQR: 68) (Table 1).

Handoff Recipients

A total of 330 evaluations of handoff recipients were completed regarding 58 unique individuals. For each domain, scores spanned the full range from unsatisfactory to superior. The highest rated domain on the handoff provider evaluation tool was professionalism, with a median of 8 (IQR: 79). The lowest rated domain was setting, with a median score of 7 (IQR: 6‐9) (Table 1).

Validity Testing

Comparing provider scores to recipient scores, recipients received significantly higher scores for overall assessment (Table 1). Scores at UCM and Yale were similar in all domains for providers but were slightly lower at UCM in several domains for recipients (see Supporting Information, Appendix 2, in the online version of this article). Scores did not differ significantly by training level (Table 2). Third‐party external evaluators consistently gave lower marks for the same handoff than peer evaluators did (Table 3).

Spearman rank correlation coefficients among the CEX subdomains for provider scores ranged from 0.71 to 0.86, except for setting (Table 4). Setting was less well correlated with the other subdomains, with correlation coefficients ranging from 0.39 to 0.41. Correlations between individual domains and the overall rating ranged from 0.80 to 0.86, except setting, which had a correlation of 0.55. Every correlation was significant at P<0.001. Correlation coefficients for recipient scores were very similar to those for provider scores (see Supporting Information, Appendix 3, in the online version of this article).

We analyzed 343 provider evaluations in the factor analysis; there were 6 missing values. The scree plot of eigenvalues did not support more than 1 factor; however, the rotated factor pattern for standardized regression coefficients for the first factor and the final communality estimates showed the setting component yielding smaller values than did other scale components (see Supporting Information, Appendix 4, in the online version of this article).

Reliability Testing

Weighted kappa scores for provider evaluations ranged from 0.28 (95% confidence interval [CI]: 0.01, 0.56) for setting to 0.59 (95% CI: 0.38, 0.80) for organization, and were generally higher for resident versus peer comparisons than for external versus peer comparisons. Weighted kappa scores for recipient evaluation were slightly lower for external versus peer evaluations, but agreement was no better than chance for resident versus peer evaluations (Table 5).

Tool Design and Measures

The Handoff CEX (clinical evaluation exercise) is a structured assessment based on the format of the mini‐CEX, an instrument used to assess the quality of history and physical examination by trainees for which validation studies have previously been conducted.[14, 15, 16, 17] We developed the tool based on themes we identified from our own expertise,[1, 5, 6, 8, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29] the ACGME core competencies for trainees,[2] and the literature to maximize content validity. First, standardization has numerous demonstrable benefits for safety in general and handoffs in particular.[30, 31, 32] Consequently we created a domain for organization in which standardization was a characteristic of high performance.

Second, there is evidence that people engaged in conversation routinely overestimate peer comprehension,[27] and that explicit strategies to combat this overestimation, such as confirming understanding, explicitly assigning tasks rather than using open‐ended language, and using concrete language, are effective.[33] Accordingly we created a domain for communication skills, which is also an ACGME competency.

Third, although there were no formal guidelines for sign‐out content when we developed this tool, our own research had demonstrated that the content elements most often missing and felt to be important by stakeholders were related to clinical condition and explicating thinking processes,[5, 6] so we created a domain for content that highlighted these areas and met the ACGME competency of medical knowledge. In accordance with standards for evaluation of learners, we incorporated a domain for judgment to identify where trainees were in the RIME spectrum of reporter, interpreter, master, and educator.

Next, we added a section for professionalism in accordance with the ACGME core competencies of professionalism and patient care.[34] To avoid the disinclination of peers to label each other unprofessional, we labeled the professionalism domain as patient‐focused on the tool.

Finally, we included a domain for setting because of an extensive literature demonstrating increased handoff failures in noisy or interruptive settings.[35, 36, 37] We then revised the tool slightly based on our experiences among nurses and students.[13, 38] The final tool included the 6 domains described above and an assessment of overall competency. Each domain was scored on a 9‐point scale and included descriptive anchors at high and low ends of performance. We further divided the scale into 3 main sections: unsatisfactory (score 13), satisfactory (46), and superior (79). We designed 2 tools, 1 to assess the person providing the handoff and 1 to assess the handoff recipient, each with its own descriptive anchors. The recipient tool did not include a content domain (see Supporting Information, Appendix 1, in the online version of this article).

Setting and Subjects

We tested the tool in 2 different urban academic medical centers: the University of Chicago Medicine (UCM) and Yale‐New Haven Hospital (Yale). At UCM, we tested the tool among hospitalists, nurse practitioners, and physician assistants during the Monday and Tuesday morning and Friday evening sign‐out sessions. At Yale, we tested the tool among housestaff during the evening sign‐out session from the primary team to the on‐call covering team.

The UCM is a 550‐bed urban academic medical center in which the nonteaching hospitalist service cares for patients with liver disease, or end‐stage renal or lung disease awaiting transplant, and a small fraction of general medicine and oncology patients when the housestaff service exceeds its cap. No formal training on sign‐out is provided to attending or midlevel providers. The nonteaching hospitalist service operates as a separate service from the housestaff service and consists of 38 hospitalist clinicians (hospitalist attendings, nurse practitioners, and physicians assistants). There are 2 handoffs each day. In the morning the departing night hospitalist hands off to the incoming daytime hospitalist or midlevel provider. These handoffs occur at 7:30 _am in a dedicated room. In the evening the daytime hospitalist or midlevel provider hands off to an incoming night hospitalist. This handoff occurs at 5:30 _pm or 7:30 _pm in a dedicated location. The written sign‐out is maintained on a Microsoft Word (Microsoft Corp., Redmond, WA) document on a password‐protected server and updated daily.

Yale is a 946‐bed urban academic medical center with a large internal medicine training program. Formal sign‐out education that covers the main domains of the tool is provided to new interns during the first 3 months of the year,[19] and a templated electronic medical record‐based electronic written handoff report is produced by the housestaff for all patients.[22] Approximately half of inpatient medicine patients are cared for by housestaff teams, which are entirely separate from the hospitalist service. Housestaff sign‐out occurs between 4 _pm and 7 _pm every night. At a minimum, the departing intern signs out to the incoming intern; this handoff is typically supervised by at least 1 second‐ or third‐year resident. All patients are signed out verbally; in addition, the written handoff report is provided to the incoming team. Most handoffs occur in a quiet charting room.

Data Collection

Data collection at UCM occurred between March and December 2010 on 3 days of each week: Mondays, Tuesdays, and Fridays. On Mondays and Tuesdays the morning handoffs were observed; on Fridays the evening handoffs were observed. Data collection at Yale occurred between March and May 2011. Only evening handoffs from the primary team to the overnight coverage were observed. At both sites, participants provided verbal informed consent prior to data collection. At the time of an eligible sign‐out session, a research assistant (D.R. at Yale, P.S. at UCM) provided the evaluation tools to all members of the incoming and outgoing teams, and observed the sign‐out session himself. Each person providing a handoff was asked to evaluate the recipient of the handoff; each person receiving a handoff was asked to evaluate the provider of the handoff. In addition, the trained third‐party observer (D.R., P.S.) evaluated both the provider and recipient of the handoff. The external evaluators were trained in principles of effective communication and the use of the tool, with specific review of anchors at each end of each domain. One evaluator had a DO degree and was completing an MPH degree. The second evaluator was an experienced clinical research assistant whose training consisted of supervised observation of 10 handoffs by a physician investigator. At Yale, if a resident was present, she or he was also asked to evaluate both the provider and recipient of the handoff. Consequently, every sign‐out session included at least 2 evaluations of each participant, 1 by a peer evaluator and 1 by a consistent external evaluator who did not know the patients. At Yale, many sign‐outs also included a third evaluation by a resident supervisor.

The study was approved by the institutional review boards at both UCM and Yale.

Statistical Analysis

We obtained mean, median, and interquartile range of scores for each subdomain of the tool as well as the overall assessment of handoff quality. We assessed convergent construct validity by assessing performance of the tool in different contexts. To do so, we determined whether scores differed by type of participant (provider or recipient), by site, by training level of evaluatee, or by type of evaluator (external, resident supervisor, or peer) by using Wilcoxon rank sum tests and Kruskal‐Wallis tests. For the assessment of differences in ratings by training level, we used evaluations of sign‐out providers only, because the 2 sites differed in scores for recipients. We also assessed construct validity by using Spearman rank correlation coefficients to describe the internal consistency of the tool in terms of the correlation between domains of the tool, and we conducted an exploratory factor analysis to gain insight into whether the subdomains of the tool were measuring the same construct. In conducting this analysis, we restricted the dataset to evaluations of sign‐out providers only, and used a principal components estimation method, a promax rotation, and squared multiple correlation communality priors. Finally, we conducted some preliminary studies of reliability by testing whether different types of evaluators provided similar assessments. We calculated a weighted kappa using Fleiss‐Cohen weights for external versus peer scores and again for supervising resident versus peer scores (Yale only). We were not able to assess test‐retest reliability by nature of the sign‐out process. Statistical significance was defined by a P value 0.05, and analyses were performed using SAS 9.2 (SAS Institute, Cary, NC).

Handoff Providers

A total of 343 evaluations of handoff providers were completed regarding 67 unique individuals. For each domain, scores spanned the full range from unsatisfactory to superior. The highest rated domain on the handoff provider evaluation tool was professionalism (median: 8; interquartile range [IQR]: 79). The lowest rated domain was content (median: 7; IQR: 68) (Table 1).

Handoff Recipients

A total of 330 evaluations of handoff recipients were completed regarding 58 unique individuals. For each domain, scores spanned the full range from unsatisfactory to superior. The highest rated domain on the handoff provider evaluation tool was professionalism, with a median of 8 (IQR: 79). The lowest rated domain was setting, with a median score of 7 (IQR: 6‐9) (Table 1).

Validity Testing

Comparing provider scores to recipient scores, recipients received significantly higher scores for overall assessment (Table 1). Scores at UCM and Yale were similar in all domains for providers but were slightly lower at UCM in several domains for recipients (see Supporting Information, Appendix 2, in the online version of this article). Scores did not differ significantly by training level (Table 2). Third‐party external evaluators consistently gave lower marks for the same handoff than peer evaluators did (Table 3).

Spearman rank correlation coefficients among the CEX subdomains for provider scores ranged from 0.71 to 0.86, except for setting (Table 4). Setting was less well correlated with the other subdomains, with correlation coefficients ranging from 0.39 to 0.41. Correlations between individual domains and the overall rating ranged from 0.80 to 0.86, except setting, which had a correlation of 0.55. Every correlation was significant at P<0.001. Correlation coefficients for recipient scores were very similar to those for provider scores (see Supporting Information, Appendix 3, in the online version of this article).

We analyzed 343 provider evaluations in the factor analysis; there were 6 missing values. The scree plot of eigenvalues did not support more than 1 factor; however, the rotated factor pattern for standardized regression coefficients for the first factor and the final communality estimates showed the setting component yielding smaller values than did other scale components (see Supporting Information, Appendix 4, in the online version of this article).

Reliability Testing

Weighted kappa scores for provider evaluations ranged from 0.28 (95% confidence interval [CI]: 0.01, 0.56) for setting to 0.59 (95% CI: 0.38, 0.80) for organization, and were generally higher for resident versus peer comparisons than for external versus peer comparisons. Weighted kappa scores for recipient evaluation were slightly lower for external versus peer evaluations, but agreement was no better than chance for resident versus peer evaluations (Table 5).

Tool Design and Measures

The Handoff CEX (clinical evaluation exercise) is a structured assessment based on the format of the mini‐CEX, an instrument used to assess the quality of history and physical examination by trainees for which validation studies have previously been conducted.[14, 15, 16, 17] We developed the tool based on themes we identified from our own expertise,[1, 5, 6, 8, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29] the ACGME core competencies for trainees,[2] and the literature to maximize content validity. First, standardization has numerous demonstrable benefits for safety in general and handoffs in particular.[30, 31, 32] Consequently we created a domain for organization in which standardization was a characteristic of high performance.

Second, there is evidence that people engaged in conversation routinely overestimate peer comprehension,[27] and that explicit strategies to combat this overestimation, such as confirming understanding, explicitly assigning tasks rather than using open‐ended language, and using concrete language, are effective.[33] Accordingly we created a domain for communication skills, which is also an ACGME competency.

Third, although there were no formal guidelines for sign‐out content when we developed this tool, our own research had demonstrated that the content elements most often missing and felt to be important by stakeholders were related to clinical condition and explicating thinking processes,[5, 6] so we created a domain for content that highlighted these areas and met the ACGME competency of medical knowledge. In accordance with standards for evaluation of learners, we incorporated a domain for judgment to identify where trainees were in the RIME spectrum of reporter, interpreter, master, and educator.

Next, we added a section for professionalism in accordance with the ACGME core competencies of professionalism and patient care.[34] To avoid the disinclination of peers to label each other unprofessional, we labeled the professionalism domain as patient‐focused on the tool.

Finally, we included a domain for setting because of an extensive literature demonstrating increased handoff failures in noisy or interruptive settings.[35, 36, 37] We then revised the tool slightly based on our experiences among nurses and students.[13, 38] The final tool included the 6 domains described above and an assessment of overall competency. Each domain was scored on a 9‐point scale and included descriptive anchors at high and low ends of performance. We further divided the scale into 3 main sections: unsatisfactory (score 13), satisfactory (46), and superior (79). We designed 2 tools, 1 to assess the person providing the handoff and 1 to assess the handoff recipient, each with its own descriptive anchors. The recipient tool did not include a content domain (see Supporting Information, Appendix 1, in the online version of this article).

Setting and Subjects

We tested the tool in 2 different urban academic medical centers: the University of Chicago Medicine (UCM) and Yale‐New Haven Hospital (Yale). At UCM, we tested the tool among hospitalists, nurse practitioners, and physician assistants during the Monday and Tuesday morning and Friday evening sign‐out sessions. At Yale, we tested the tool among housestaff during the evening sign‐out session from the primary team to the on‐call covering team.

The UCM is a 550‐bed urban academic medical center in which the nonteaching hospitalist service cares for patients with liver disease, or end‐stage renal or lung disease awaiting transplant, and a small fraction of general medicine and oncology patients when the housestaff service exceeds its cap. No formal training on sign‐out is provided to attending or midlevel providers. The nonteaching hospitalist service operates as a separate service from the housestaff service and consists of 38 hospitalist clinicians (hospitalist attendings, nurse practitioners, and physicians assistants). There are 2 handoffs each day. In the morning the departing night hospitalist hands off to the incoming daytime hospitalist or midlevel provider. These handoffs occur at 7:30 _am in a dedicated room. In the evening the daytime hospitalist or midlevel provider hands off to an incoming night hospitalist. This handoff occurs at 5:30 _pm or 7:30 _pm in a dedicated location. The written sign‐out is maintained on a Microsoft Word (Microsoft Corp., Redmond, WA) document on a password‐protected server and updated daily.

Yale is a 946‐bed urban academic medical center with a large internal medicine training program. Formal sign‐out education that covers the main domains of the tool is provided to new interns during the first 3 months of the year,[19] and a templated electronic medical record‐based electronic written handoff report is produced by the housestaff for all patients.[22] Approximately half of inpatient medicine patients are cared for by housestaff teams, which are entirely separate from the hospitalist service. Housestaff sign‐out occurs between 4 _pm and 7 _pm every night. At a minimum, the departing intern signs out to the incoming intern; this handoff is typically supervised by at least 1 second‐ or third‐year resident. All patients are signed out verbally; in addition, the written handoff report is provided to the incoming team. Most handoffs occur in a quiet charting room.

Data Collection

Data collection at UCM occurred between March and December 2010 on 3 days of each week: Mondays, Tuesdays, and Fridays. On Mondays and Tuesdays the morning handoffs were observed; on Fridays the evening handoffs were observed. Data collection at Yale occurred between March and May 2011. Only evening handoffs from the primary team to the overnight coverage were observed. At both sites, participants provided verbal informed consent prior to data collection. At the time of an eligible sign‐out session, a research assistant (D.R. at Yale, P.S. at UCM) provided the evaluation tools to all members of the incoming and outgoing teams, and observed the sign‐out session himself. Each person providing a handoff was asked to evaluate the recipient of the handoff; each person receiving a handoff was asked to evaluate the provider of the handoff. In addition, the trained third‐party observer (D.R., P.S.) evaluated both the provider and recipient of the handoff. The external evaluators were trained in principles of effective communication and the use of the tool, with specific review of anchors at each end of each domain. One evaluator had a DO degree and was completing an MPH degree. The second evaluator was an experienced clinical research assistant whose training consisted of supervised observation of 10 handoffs by a physician investigator. At Yale, if a resident was present, she or he was also asked to evaluate both the provider and recipient of the handoff. Consequently, every sign‐out session included at least 2 evaluations of each participant, 1 by a peer evaluator and 1 by a consistent external evaluator who did not know the patients. At Yale, many sign‐outs also included a third evaluation by a resident supervisor.

The study was approved by the institutional review boards at both UCM and Yale.

Statistical Analysis

We obtained mean, median, and interquartile range of scores for each subdomain of the tool as well as the overall assessment of handoff quality. We assessed convergent construct validity by assessing performance of the tool in different contexts. To do so, we determined whether scores differed by type of participant (provider or recipient), by site, by training level of evaluatee, or by type of evaluator (external, resident supervisor, or peer) by using Wilcoxon rank sum tests and Kruskal‐Wallis tests. For the assessment of differences in ratings by training level, we used evaluations of sign‐out providers only, because the 2 sites differed in scores for recipients. We also assessed construct validity by using Spearman rank correlation coefficients to describe the internal consistency of the tool in terms of the correlation between domains of the tool, and we conducted an exploratory factor analysis to gain insight into whether the subdomains of the tool were measuring the same construct. In conducting this analysis, we restricted the dataset to evaluations of sign‐out providers only, and used a principal components estimation method, a promax rotation, and squared multiple correlation communality priors. Finally, we conducted some preliminary studies of reliability by testing whether different types of evaluators provided similar assessments. We calculated a weighted kappa using Fleiss‐Cohen weights for external versus peer scores and again for supervising resident versus peer scores (Yale only). We were not able to assess test‐retest reliability by nature of the sign‐out process. Statistical significance was defined by a P value 0.05, and analyses were performed using SAS 9.2 (SAS Institute, Cary, NC).

Handoff Providers

A total of 343 evaluations of handoff providers were completed regarding 67 unique individuals. For each domain, scores spanned the full range from unsatisfactory to superior. The highest rated domain on the handoff provider evaluation tool was professionalism (median: 8; interquartile range [IQR]: 79). The lowest rated domain was content (median: 7; IQR: 68) (Table 1).

Handoff Recipients

A total of 330 evaluations of handoff recipients were completed regarding 58 unique individuals. For each domain, scores spanned the full range from unsatisfactory to superior. The highest rated domain on the handoff provider evaluation tool was professionalism, with a median of 8 (IQR: 79). The lowest rated domain was setting, with a median score of 7 (IQR: 6‐9) (Table 1).

Validity Testing

Comparing provider scores to recipient scores, recipients received significantly higher scores for overall assessment (Table 1). Scores at UCM and Yale were similar in all domains for providers but were slightly lower at UCM in several domains for recipients (see Supporting Information, Appendix 2, in the online version of this article). Scores did not differ significantly by training level (Table 2). Third‐party external evaluators consistently gave lower marks for the same handoff than peer evaluators did (Table 3).

Spearman rank correlation coefficients among the CEX subdomains for provider scores ranged from 0.71 to 0.86, except for setting (Table 4). Setting was less well correlated with the other subdomains, with correlation coefficients ranging from 0.39 to 0.41. Correlations between individual domains and the overall rating ranged from 0.80 to 0.86, except setting, which had a correlation of 0.55. Every correlation was significant at P<0.001. Correlation coefficients for recipient scores were very similar to those for provider scores (see Supporting Information, Appendix 3, in the online version of this article).

We analyzed 343 provider evaluations in the factor analysis; there were 6 missing values. The scree plot of eigenvalues did not support more than 1 factor; however, the rotated factor pattern for standardized regression coefficients for the first factor and the final communality estimates showed the setting component yielding smaller values than did other scale components (see Supporting Information, Appendix 4, in the online version of this article).

Reliability Testing

Weighted kappa scores for provider evaluations ranged from 0.28 (95% confidence interval [CI]: 0.01, 0.56) for setting to 0.59 (95% CI: 0.38, 0.80) for organization, and were generally higher for resident versus peer comparisons than for external versus peer comparisons. Weighted kappa scores for recipient evaluation were slightly lower for external versus peer evaluations, but agreement was no better than chance for resident versus peer evaluations (Table 5).

Study Cohort

The DISCHARGE study was a prospective, observational cohort study of patients 65 years or older discharged to home from YaleNew Haven Hospital (YNHH) who were admitted with acute coronary syndrome (ACS), community‐acquired pneumonia, or heart failure (HF). Patients were screened by physicians for eligibility within 24 hours of admission using specialty society guidelines[17, 18, 19, 20] and were enrolled by telephone within 1 week of discharge. Additional inclusion criteria included speaking English or Spanish, and ability of the patient or caregiver to participate in a telephone interview. Patients enrolled in hospice were excluded, as were patients who failed the Mini‐Cog mental status screen (3‐item recall and a clock draw)[21] while in the hospital or appeared confused or delirious during the telephone interview. Caregivers of cognitively impaired patients were eligible for enrollment instead if the patient provided permission.

Study Setting

YNHH is a 966‐bed urban tertiary care hospital with statistically lower than the national average mortality for acute myocardial infarction, HF, and pneumonia but statistically higher than the national average for 30‐day readmission rates for HF and pneumonia at the time this study was conducted. Advanced practice registered nurses (APRNs) working under the supervision of private or university cardiologists provided care for cardiology service patients. Housestaff under the supervision of university or hospitalist attending physicians, or physician assistants or APRNs under the supervision of hospitalist attending physicians provided care for patients on medical services. Discharge summaries were typically dictated by APRNs for cardiology patients, by 2nd‐ or 3rd‐year residents for housestaff patients, and by hospitalists for hospitalist patients. A dictation guideline was provided to housestaff and hospitalists (see Supporting Information, Appendix 1, in the online version of this article); this guideline suggested including basic demographic information, disposition and diagnoses, the admission history and physical, hospital course, discharge medications, and follow‐up appointments. Additionally, housestaff received a lecture about discharge summaries at the start of their 2nd year. Discharge instructions including medications and follow‐up appointment information were automatically appended to the discharge summaries. Summaries were sent by the medical records department only to physicians in the system who were listed by the dictating physician as needing to receive a copy of the summary; no summary was automatically sent (ie, to the primary care physician) if not requested by the dictating physician.

Data Collection

Experienced registered nurses trained in chart abstraction conducted explicit reviews of medical charts using a standardized review tool. The tool included 24 questions about the discharge summary applicable to all 3 conditions, with 7 additional questions for patients with HF and 1 additional question for patients with ACS. These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, patient and family instructions, and attending physician's signature)[9] as well as the 7 elements (principal diagnosis and problem list, medication list, transferring physician name and contact information, cognitive status of the patient, test results, and pending test results) recommended by the Transitions of Care Consensus Conference (TOCCC), a recent consensus statement produced by 6 major medical societies.[13] Each content element is shown in (see Supporting Information, Appendix 2, in the online version of this article), which also indicates the elements included in the 2 guidelines.

Main Measures

We assessed quality in 3 main domains: timeliness, transmission, and content. We defined timeliness as days between discharge date and dictation date (not final signature date, which may occur later), and measured both median timeliness and proportion of discharge summaries completed on the day of discharge. We defined transmission as successful fax or mail of the discharge summary to an outside physician as reported by the medical records department, and measured the proportion of discharge summaries sent to any outside physician as well as the median number of physicians per discharge summary who were scheduled to follow‐up with the patient postdischarge but who did not receive a copy of the summary. We defined 21 individual content items and assessed the frequency of each individual content item. We also measured compliance with The Joint Commission mandates and TOCCC recommendations, which included several of the individual content items.

To measure compliance with The Joint Commission requirements, we created a composite score in which 1 point was provided for the presence of each of the 6 required elements (maximum score=6). Every discharge summary received 1 point for attending physician signature, because all discharge summaries were electronically signed. Discharge instructions to family/patients were automatically appended to every discharge summary; however, we gave credit for patient and family instructions only to those that included any information about signs and symptoms to monitor for at home. We defined discharge condition as any information about functional status, cognitive status, physical exam, or laboratory findings at discharge.

To measure compliance with specialty society recommendations for discharge summaries, we created a composite score in which 1 point was provided for the presence of each of the 7 recommended elements (maximum score=7). Every discharge summary received 1 point for discharge medications, because these are automatically appended.

We obtained data on age, race, gender, and length of stay from hospital administrative databases. The study was approved by the Yale Human Investigation Committee, and verbal informed consent was obtained from all study participants.

Statistical Analysis

Characteristics of the sample are described with counts and percentages or means and standard deviations. Medians and interquartile ranges (IQRs) or counts and percentages were calculated for summary measures of timeliness, transmission, and content. We assessed differences in quality measures between APRNs, housestaff, and hospitalists using ² tests. We conducted multivariable logistic regression analyses for timeliness and for transmission to any outside physician. All discharge summaries included at least 4 of The Joint Commission elements; consequently, we coded this content outcome as an ordinal variable with 3 levels indicating inclusion of 4, 5, or 6 of The Joint Commission elements. We coded the TOCCC content outcome as a 3‐level variable indicating <4, 4, or >4 elements satisfied. Accordingly, proportional odds models were used, in which the reported odds ratios (ORs) can be interpreted as the average effect of the explanatory variable on the odds of having more recommendations, for any dichotomization of the outcome. Residual analysis and goodness‐of‐fit statistics were used to assess model fit; the proportional odds assumption was tested. Statistical analyses were conducted with SAS 9.2 (SAS Institute, Cary, NC). P values <0.05 were interpreted as statistically significant for 2‐sided tests.

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Timeliness

Discharge summaries were completed for 376/377 patients, of which 174 (46.3%) were dictated on the day of discharge. However, 122 (32.4%) summaries were dictated more than 48 hours after discharge, including 93 (24.7%) that were dictated more than 1 week after discharge (see Supporting Information, Appendix 3, in the online version of this article).

Summaries dictated by hospitalists were most likely to be done on the day of discharge (35.3% APRNs, 38.2% housestaff, 68.4% hospitalists, P<0.001). After adjustment for diagnosis and length of stay, hospitalists were still significantly more likely to produce a timely discharge summary than APRNs (OR: 2.82; 95% confidence interval [CI]: 1.56‐5.09), whereas housestaff were no different than APRNs (OR: 0.84; 95% CI: 0.48‐1.46).

Transmission

A total of 144 (38.3%) discharge summaries were not sent to any physician besides the inpatient attending, and 209/374 (55.9%) were not sent to at least 1 physician listed as having a follow‐up appointment planned with the patient. Each discharge summary was sent to a median of 1 physician besides the dictating physician (IQR: 01). However, for each summary, a median of 1 physician (IQR: 01) who had a scheduled follow‐up with the patient did not receive the summary. Summaries dictated by hospitalists were most likely to be sent to at least 1 outside physician (54.7% APRNs, 58.5% housestaff, 73.7% hospitalists, P=0.006). Summaries dictated on the day of discharge were more likely than delayed summaries to be sent to at least 1 outside physician (75.9% vs 49.5%, P<0.001). After adjustment for diagnosis and length of stay, there was no longer a difference in likelihood of transmitting a discharge summary to any outpatient physician according to training level; however, dictations completed on the day of discharge remained significantly more likely to be transmitted to an outside physician (OR: 3.05; 95% CI: 1.88‐4.93) (Table 2).

Content

Rate of inclusion of each content element is shown in Table 3, overall and by training level. Nearly every discharge summary included information about admitting diagnosis, hospital course, and procedures or tests performed during the hospitalization. However, few summaries included information about the patient's condition at discharge. Less than half included discharge laboratory results; less than one‐third included functional capacity, cognitive capacity, or discharge physical exam. Only 4.1% overall of discharge summaries for patients with HF included the patient's weight at discharge; best were hospitalists who still included this information in only 7.7% of summaries. Information about postdischarge care, including home social support, pending tests, or recommended follow‐up tests/procedures was also rarely specified. Last, only 6.2% of discharge summaries included the name and contact number of the inpatient physician; this information was least likely to be provided by housestaff (1.6%) and most likely to be provided by hospitalists (15.2%) (P<0.001).

On average, summaries included 5.6 of the 6 Joint Commission elements and 4.0 of the 7 TOCCC elements. A total of 63.0% of discharge summaries included all 6 elements required by The Joint Commission, whereas no discharge summary included all 7 TOCCC elements.

APRNs, housestaff and hospitalists included the same average number of The Joint Commission elements (5.6 each), but hospitalists on average included slightly more TOCCC elements (4.3) than did housestaff (4.0) or APRNs (3.8) (P<0.001). Summaries dictated on the day of discharge included an average of 4.2 TOCCC elements, compared to 3.9 TOCCC elements in delayed discharge. In multivariable analyses adjusted for diagnosis and length of stay, there was still no difference by training level in presence of The Joint Commission elements, but hospitalists were significantly more likely to include more TOCCC elements than APRNs (OR: 2.70; 95% CI: 1.49‐4.90) (Table 4). Summaries dictated on the day of discharge were significantly more likely to include more TOCCC elements (OR: 1.92; 95% CI: 1.23‐2.99).

No discharge summary included all 7 TOCCC‐endorsed content elements, was dictated on the day of discharge, and was sent to an outside physician.

Study Cohort

The DISCHARGE study was a prospective, observational cohort study of patients 65 years or older discharged to home from YaleNew Haven Hospital (YNHH) who were admitted with acute coronary syndrome (ACS), community‐acquired pneumonia, or heart failure (HF). Patients were screened by physicians for eligibility within 24 hours of admission using specialty society guidelines[17, 18, 19, 20] and were enrolled by telephone within 1 week of discharge. Additional inclusion criteria included speaking English or Spanish, and ability of the patient or caregiver to participate in a telephone interview. Patients enrolled in hospice were excluded, as were patients who failed the Mini‐Cog mental status screen (3‐item recall and a clock draw)[21] while in the hospital or appeared confused or delirious during the telephone interview. Caregivers of cognitively impaired patients were eligible for enrollment instead if the patient provided permission.

Study Setting

YNHH is a 966‐bed urban tertiary care hospital with statistically lower than the national average mortality for acute myocardial infarction, HF, and pneumonia but statistically higher than the national average for 30‐day readmission rates for HF and pneumonia at the time this study was conducted. Advanced practice registered nurses (APRNs) working under the supervision of private or university cardiologists provided care for cardiology service patients. Housestaff under the supervision of university or hospitalist attending physicians, or physician assistants or APRNs under the supervision of hospitalist attending physicians provided care for patients on medical services. Discharge summaries were typically dictated by APRNs for cardiology patients, by 2nd‐ or 3rd‐year residents for housestaff patients, and by hospitalists for hospitalist patients. A dictation guideline was provided to housestaff and hospitalists (see Supporting Information, Appendix 1, in the online version of this article); this guideline suggested including basic demographic information, disposition and diagnoses, the admission history and physical, hospital course, discharge medications, and follow‐up appointments. Additionally, housestaff received a lecture about discharge summaries at the start of their 2nd year. Discharge instructions including medications and follow‐up appointment information were automatically appended to the discharge summaries. Summaries were sent by the medical records department only to physicians in the system who were listed by the dictating physician as needing to receive a copy of the summary; no summary was automatically sent (ie, to the primary care physician) if not requested by the dictating physician.

Data Collection

Experienced registered nurses trained in chart abstraction conducted explicit reviews of medical charts using a standardized review tool. The tool included 24 questions about the discharge summary applicable to all 3 conditions, with 7 additional questions for patients with HF and 1 additional question for patients with ACS. These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, patient and family instructions, and attending physician's signature)[9] as well as the 7 elements (principal diagnosis and problem list, medication list, transferring physician name and contact information, cognitive status of the patient, test results, and pending test results) recommended by the Transitions of Care Consensus Conference (TOCCC), a recent consensus statement produced by 6 major medical societies.[13] Each content element is shown in (see Supporting Information, Appendix 2, in the online version of this article), which also indicates the elements included in the 2 guidelines.

Main Measures

We assessed quality in 3 main domains: timeliness, transmission, and content. We defined timeliness as days between discharge date and dictation date (not final signature date, which may occur later), and measured both median timeliness and proportion of discharge summaries completed on the day of discharge. We defined transmission as successful fax or mail of the discharge summary to an outside physician as reported by the medical records department, and measured the proportion of discharge summaries sent to any outside physician as well as the median number of physicians per discharge summary who were scheduled to follow‐up with the patient postdischarge but who did not receive a copy of the summary. We defined 21 individual content items and assessed the frequency of each individual content item. We also measured compliance with The Joint Commission mandates and TOCCC recommendations, which included several of the individual content items.

To measure compliance with The Joint Commission requirements, we created a composite score in which 1 point was provided for the presence of each of the 6 required elements (maximum score=6). Every discharge summary received 1 point for attending physician signature, because all discharge summaries were electronically signed. Discharge instructions to family/patients were automatically appended to every discharge summary; however, we gave credit for patient and family instructions only to those that included any information about signs and symptoms to monitor for at home. We defined discharge condition as any information about functional status, cognitive status, physical exam, or laboratory findings at discharge.

To measure compliance with specialty society recommendations for discharge summaries, we created a composite score in which 1 point was provided for the presence of each of the 7 recommended elements (maximum score=7). Every discharge summary received 1 point for discharge medications, because these are automatically appended.

We obtained data on age, race, gender, and length of stay from hospital administrative databases. The study was approved by the Yale Human Investigation Committee, and verbal informed consent was obtained from all study participants.

Statistical Analysis

Characteristics of the sample are described with counts and percentages or means and standard deviations. Medians and interquartile ranges (IQRs) or counts and percentages were calculated for summary measures of timeliness, transmission, and content. We assessed differences in quality measures between APRNs, housestaff, and hospitalists using ² tests. We conducted multivariable logistic regression analyses for timeliness and for transmission to any outside physician. All discharge summaries included at least 4 of The Joint Commission elements; consequently, we coded this content outcome as an ordinal variable with 3 levels indicating inclusion of 4, 5, or 6 of The Joint Commission elements. We coded the TOCCC content outcome as a 3‐level variable indicating <4, 4, or >4 elements satisfied. Accordingly, proportional odds models were used, in which the reported odds ratios (ORs) can be interpreted as the average effect of the explanatory variable on the odds of having more recommendations, for any dichotomization of the outcome. Residual analysis and goodness‐of‐fit statistics were used to assess model fit; the proportional odds assumption was tested. Statistical analyses were conducted with SAS 9.2 (SAS Institute, Cary, NC). P values <0.05 were interpreted as statistically significant for 2‐sided tests.

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Timeliness

Discharge summaries were completed for 376/377 patients, of which 174 (46.3%) were dictated on the day of discharge. However, 122 (32.4%) summaries were dictated more than 48 hours after discharge, including 93 (24.7%) that were dictated more than 1 week after discharge (see Supporting Information, Appendix 3, in the online version of this article).

Summaries dictated by hospitalists were most likely to be done on the day of discharge (35.3% APRNs, 38.2% housestaff, 68.4% hospitalists, P<0.001). After adjustment for diagnosis and length of stay, hospitalists were still significantly more likely to produce a timely discharge summary than APRNs (OR: 2.82; 95% confidence interval [CI]: 1.56‐5.09), whereas housestaff were no different than APRNs (OR: 0.84; 95% CI: 0.48‐1.46).

Transmission

A total of 144 (38.3%) discharge summaries were not sent to any physician besides the inpatient attending, and 209/374 (55.9%) were not sent to at least 1 physician listed as having a follow‐up appointment planned with the patient. Each discharge summary was sent to a median of 1 physician besides the dictating physician (IQR: 01). However, for each summary, a median of 1 physician (IQR: 01) who had a scheduled follow‐up with the patient did not receive the summary. Summaries dictated by hospitalists were most likely to be sent to at least 1 outside physician (54.7% APRNs, 58.5% housestaff, 73.7% hospitalists, P=0.006). Summaries dictated on the day of discharge were more likely than delayed summaries to be sent to at least 1 outside physician (75.9% vs 49.5%, P<0.001). After adjustment for diagnosis and length of stay, there was no longer a difference in likelihood of transmitting a discharge summary to any outpatient physician according to training level; however, dictations completed on the day of discharge remained significantly more likely to be transmitted to an outside physician (OR: 3.05; 95% CI: 1.88‐4.93) (Table 2).

Content

Rate of inclusion of each content element is shown in Table 3, overall and by training level. Nearly every discharge summary included information about admitting diagnosis, hospital course, and procedures or tests performed during the hospitalization. However, few summaries included information about the patient's condition at discharge. Less than half included discharge laboratory results; less than one‐third included functional capacity, cognitive capacity, or discharge physical exam. Only 4.1% overall of discharge summaries for patients with HF included the patient's weight at discharge; best were hospitalists who still included this information in only 7.7% of summaries. Information about postdischarge care, including home social support, pending tests, or recommended follow‐up tests/procedures was also rarely specified. Last, only 6.2% of discharge summaries included the name and contact number of the inpatient physician; this information was least likely to be provided by housestaff (1.6%) and most likely to be provided by hospitalists (15.2%) (P<0.001).

On average, summaries included 5.6 of the 6 Joint Commission elements and 4.0 of the 7 TOCCC elements. A total of 63.0% of discharge summaries included all 6 elements required by The Joint Commission, whereas no discharge summary included all 7 TOCCC elements.

APRNs, housestaff and hospitalists included the same average number of The Joint Commission elements (5.6 each), but hospitalists on average included slightly more TOCCC elements (4.3) than did housestaff (4.0) or APRNs (3.8) (P<0.001). Summaries dictated on the day of discharge included an average of 4.2 TOCCC elements, compared to 3.9 TOCCC elements in delayed discharge. In multivariable analyses adjusted for diagnosis and length of stay, there was still no difference by training level in presence of The Joint Commission elements, but hospitalists were significantly more likely to include more TOCCC elements than APRNs (OR: 2.70; 95% CI: 1.49‐4.90) (Table 4). Summaries dictated on the day of discharge were significantly more likely to include more TOCCC elements (OR: 1.92; 95% CI: 1.23‐2.99).

No discharge summary included all 7 TOCCC‐endorsed content elements, was dictated on the day of discharge, and was sent to an outside physician.

Study Cohort

The DISCHARGE study was a prospective, observational cohort study of patients 65 years or older discharged to home from YaleNew Haven Hospital (YNHH) who were admitted with acute coronary syndrome (ACS), community‐acquired pneumonia, or heart failure (HF). Patients were screened by physicians for eligibility within 24 hours of admission using specialty society guidelines[17, 18, 19, 20] and were enrolled by telephone within 1 week of discharge. Additional inclusion criteria included speaking English or Spanish, and ability of the patient or caregiver to participate in a telephone interview. Patients enrolled in hospice were excluded, as were patients who failed the Mini‐Cog mental status screen (3‐item recall and a clock draw)[21] while in the hospital or appeared confused or delirious during the telephone interview. Caregivers of cognitively impaired patients were eligible for enrollment instead if the patient provided permission.

Study Setting

YNHH is a 966‐bed urban tertiary care hospital with statistically lower than the national average mortality for acute myocardial infarction, HF, and pneumonia but statistically higher than the national average for 30‐day readmission rates for HF and pneumonia at the time this study was conducted. Advanced practice registered nurses (APRNs) working under the supervision of private or university cardiologists provided care for cardiology service patients. Housestaff under the supervision of university or hospitalist attending physicians, or physician assistants or APRNs under the supervision of hospitalist attending physicians provided care for patients on medical services. Discharge summaries were typically dictated by APRNs for cardiology patients, by 2nd‐ or 3rd‐year residents for housestaff patients, and by hospitalists for hospitalist patients. A dictation guideline was provided to housestaff and hospitalists (see Supporting Information, Appendix 1, in the online version of this article); this guideline suggested including basic demographic information, disposition and diagnoses, the admission history and physical, hospital course, discharge medications, and follow‐up appointments. Additionally, housestaff received a lecture about discharge summaries at the start of their 2nd year. Discharge instructions including medications and follow‐up appointment information were automatically appended to the discharge summaries. Summaries were sent by the medical records department only to physicians in the system who were listed by the dictating physician as needing to receive a copy of the summary; no summary was automatically sent (ie, to the primary care physician) if not requested by the dictating physician.

Data Collection

Experienced registered nurses trained in chart abstraction conducted explicit reviews of medical charts using a standardized review tool. The tool included 24 questions about the discharge summary applicable to all 3 conditions, with 7 additional questions for patients with HF and 1 additional question for patients with ACS. These questions included the 6 elements required by The Joint Commission for all discharge summaries (reason for hospitalization, significant findings, procedures and treatment provided, patient's discharge condition, patient and family instructions, and attending physician's signature)[9] as well as the 7 elements (principal diagnosis and problem list, medication list, transferring physician name and contact information, cognitive status of the patient, test results, and pending test results) recommended by the Transitions of Care Consensus Conference (TOCCC), a recent consensus statement produced by 6 major medical societies.[13] Each content element is shown in (see Supporting Information, Appendix 2, in the online version of this article), which also indicates the elements included in the 2 guidelines.

Main Measures

We assessed quality in 3 main domains: timeliness, transmission, and content. We defined timeliness as days between discharge date and dictation date (not final signature date, which may occur later), and measured both median timeliness and proportion of discharge summaries completed on the day of discharge. We defined transmission as successful fax or mail of the discharge summary to an outside physician as reported by the medical records department, and measured the proportion of discharge summaries sent to any outside physician as well as the median number of physicians per discharge summary who were scheduled to follow‐up with the patient postdischarge but who did not receive a copy of the summary. We defined 21 individual content items and assessed the frequency of each individual content item. We also measured compliance with The Joint Commission mandates and TOCCC recommendations, which included several of the individual content items.

To measure compliance with The Joint Commission requirements, we created a composite score in which 1 point was provided for the presence of each of the 6 required elements (maximum score=6). Every discharge summary received 1 point for attending physician signature, because all discharge summaries were electronically signed. Discharge instructions to family/patients were automatically appended to every discharge summary; however, we gave credit for patient and family instructions only to those that included any information about signs and symptoms to monitor for at home. We defined discharge condition as any information about functional status, cognitive status, physical exam, or laboratory findings at discharge.

To measure compliance with specialty society recommendations for discharge summaries, we created a composite score in which 1 point was provided for the presence of each of the 7 recommended elements (maximum score=7). Every discharge summary received 1 point for discharge medications, because these are automatically appended.

We obtained data on age, race, gender, and length of stay from hospital administrative databases. The study was approved by the Yale Human Investigation Committee, and verbal informed consent was obtained from all study participants.

Statistical Analysis

Characteristics of the sample are described with counts and percentages or means and standard deviations. Medians and interquartile ranges (IQRs) or counts and percentages were calculated for summary measures of timeliness, transmission, and content. We assessed differences in quality measures between APRNs, housestaff, and hospitalists using ² tests. We conducted multivariable logistic regression analyses for timeliness and for transmission to any outside physician. All discharge summaries included at least 4 of The Joint Commission elements; consequently, we coded this content outcome as an ordinal variable with 3 levels indicating inclusion of 4, 5, or 6 of The Joint Commission elements. We coded the TOCCC content outcome as a 3‐level variable indicating <4, 4, or >4 elements satisfied. Accordingly, proportional odds models were used, in which the reported odds ratios (ORs) can be interpreted as the average effect of the explanatory variable on the odds of having more recommendations, for any dichotomization of the outcome. Residual analysis and goodness‐of‐fit statistics were used to assess model fit; the proportional odds assumption was tested. Statistical analyses were conducted with SAS 9.2 (SAS Institute, Cary, NC). P values <0.05 were interpreted as statistically significant for 2‐sided tests.

Enrollment and Study Sample

A total of 3743 patients over 64 years old were discharged home from the medical service at YNHH during the study period; 3028 patients were screened for eligibility within 24 hours of admission. We identified 635 eligible admissions and enrolled 395 patients (62.2%) in the study. Of these, 377 granted permission for chart review and were included in this analysis (Figure 1).

Figure 1

The study sample had a mean age of 77.1 years (standard deviation: 7.8); 205 (54.4%) were male and 310 (82.5%) were non‐Hispanic white. A total of 195 (51.7%) had ACS, 91 (24.1%) had pneumonia, and 146 (38.7%) had HF; 54 (14.3%) patients had more than 1 qualifying condition. There were similar numbers of patients on the cardiology, medicine housestaff, and medicine hospitalist teams (Table 1).

Timeliness

Discharge summaries were completed for 376/377 patients, of which 174 (46.3%) were dictated on the day of discharge. However, 122 (32.4%) summaries were dictated more than 48 hours after discharge, including 93 (24.7%) that were dictated more than 1 week after discharge (see Supporting Information, Appendix 3, in the online version of this article).

Summaries dictated by hospitalists were most likely to be done on the day of discharge (35.3% APRNs, 38.2% housestaff, 68.4% hospitalists, P<0.001). After adjustment for diagnosis and length of stay, hospitalists were still significantly more likely to produce a timely discharge summary than APRNs (OR: 2.82; 95% confidence interval [CI]: 1.56‐5.09), whereas housestaff were no different than APRNs (OR: 0.84; 95% CI: 0.48‐1.46).

Transmission

A total of 144 (38.3%) discharge summaries were not sent to any physician besides the inpatient attending, and 209/374 (55.9%) were not sent to at least 1 physician listed as having a follow‐up appointment planned with the patient. Each discharge summary was sent to a median of 1 physician besides the dictating physician (IQR: 01). However, for each summary, a median of 1 physician (IQR: 01) who had a scheduled follow‐up with the patient did not receive the summary. Summaries dictated by hospitalists were most likely to be sent to at least 1 outside physician (54.7% APRNs, 58.5% housestaff, 73.7% hospitalists, P=0.006). Summaries dictated on the day of discharge were more likely than delayed summaries to be sent to at least 1 outside physician (75.9% vs 49.5%, P<0.001). After adjustment for diagnosis and length of stay, there was no longer a difference in likelihood of transmitting a discharge summary to any outpatient physician according to training level; however, dictations completed on the day of discharge remained significantly more likely to be transmitted to an outside physician (OR: 3.05; 95% CI: 1.88‐4.93) (Table 2).

Content

Rate of inclusion of each content element is shown in Table 3, overall and by training level. Nearly every discharge summary included information about admitting diagnosis, hospital course, and procedures or tests performed during the hospitalization. However, few summaries included information about the patient's condition at discharge. Less than half included discharge laboratory results; less than one‐third included functional capacity, cognitive capacity, or discharge physical exam. Only 4.1% overall of discharge summaries for patients with HF included the patient's weight at discharge; best were hospitalists who still included this information in only 7.7% of summaries. Information about postdischarge care, including home social support, pending tests, or recommended follow‐up tests/procedures was also rarely specified. Last, only 6.2% of discharge summaries included the name and contact number of the inpatient physician; this information was least likely to be provided by housestaff (1.6%) and most likely to be provided by hospitalists (15.2%) (P<0.001).

On average, summaries included 5.6 of the 6 Joint Commission elements and 4.0 of the 7 TOCCC elements. A total of 63.0% of discharge summaries included all 6 elements required by The Joint Commission, whereas no discharge summary included all 7 TOCCC elements.

APRNs, housestaff and hospitalists included the same average number of The Joint Commission elements (5.6 each), but hospitalists on average included slightly more TOCCC elements (4.3) than did housestaff (4.0) or APRNs (3.8) (P<0.001). Summaries dictated on the day of discharge included an average of 4.2 TOCCC elements, compared to 3.9 TOCCC elements in delayed discharge. In multivariable analyses adjusted for diagnosis and length of stay, there was still no difference by training level in presence of The Joint Commission elements, but hospitalists were significantly more likely to include more TOCCC elements than APRNs (OR: 2.70; 95% CI: 1.49‐4.90) (Table 4). Summaries dictated on the day of discharge were significantly more likely to include more TOCCC elements (OR: 1.92; 95% CI: 1.23‐2.99).

No discharge summary included all 7 TOCCC‐endorsed content elements, was dictated on the day of discharge, and was sent to an outside physician.