Improve medication reconciliation and post-acute referral with a two-part discharge checklist


An effective hospital discharge process created by the Cleveland Clinic is essential in the transfer of patients to post-acute care providers.

Discharge from hospital is a complex process involving the primary care team, which may include residents, interns, fellows, nurse practitioners, medical assistants and other staff in addition to the attending physician.

Without a complete and completed discharge summary Drug reconciliation, post-acute care teams may be confused and patients may be at risk for costly readmissions. Research linked readmissions to poor communication and coordination of care between hospitals and primary care providers.

Amy O’Linn, DO, hospitalist and company doctor readmission reduction at the Cleveland Clinic, says an effective discharge process is about patient safety.

“There can be medication errors, side effects and confusion after a dump if we don’t do it right, ”says O’Linn.

To strengthen the process of transferring patients from acute to post-acute care, the Cleveland Clinic has created a new discharge checklist to improve discharge summaries and medication reconciliation. According to the Ohio Hospital Association, the goal of the new process was “to achieve a 100% completion rate on all medication reconciliation and discharge summaries before a patient leaves the hospital.”

Since the new discharge checklist was established, the medication reconciliation completion rate at the main Cleveland Clinic campus has increased from approximately 88.0% to 98.7%, and the rate of medication reconciliation has increased from approximately 88.0% to 98.7%. The completion of discharge summaries at the main Cleveland Clinic campus increased from 58% to 80%.

In March, the Ohio Patient Safety Institute awarded the Cleveland Clinic with the Acute Care Best Practice Award for the health system’s development of the new exit checklist.

The Cleveland Health System Discharge Checklist, which was implemented in November 2018, has two components: a medication reconciliation document and an exit summary.

1. Medication reconciliation

“The discharge medication list was reconciled with the medications the patient was previously taking at home and the medications the patient was taking in the hospital. The discharge medication list is the final list that the patient receives, [and it] is very valuable. Without a complete, signed list, the patient doesn’t know what to take, ”says O’Linn.

The medication reconciliation document is a mandatory step in the Cleveland Clinic’s new discharge process, she says. “It’s a tough stop. The patient cannot leave campus until the medication list is signed by the primary care team.”

2. Discharge summary

While completing a discharge summary isn’t absolutely necessary to discharge a patient, it is a policy of the Cleveland Clinic and almost as essential as medication reconciliation, O’Linn says.

Under the healthcare system’s discharge summary policy, the document contains 18 items, including date of admission, date of discharge, main main complaint when patient came to hospital, disposition to discharge and medication list. Clinicians are also encouraged to include “history” of hospital admission, she said.

“What we encourage providers to do is answer the key questions: What brought the patient to the hospital? What happened during the hospital stay? And what is the plan for the future? The 18 items that are part of our policy are not as useful for detailing the history of a hospital stay. The story is where the money is, it’s what happened and what will happen now, ”says O’Linn.

Developing the discharge checklist

A multidisciplinary team from the Cleveland Clinic developed the discharge checklist, she says.

“We had the IT people; we had Epic, which had to make the difficult technical shutdown [in our EHR]. We had a lot of help from pharmacists because there is nothing more painful for a provider than having a bandage or a piece of gauze on a medication reconciliation – we brought out medications and others things that don’t need to be reconciled like insulin syringes. We had nurse managers and care managers. We worked with documentation specialists, who helped get the word out to vendors. “

One of the main obstacles to the new dump checklist effort was fear, O’Linn says.

“People were concerned that if we suddenly stopped for medication reconciliation, patients would never leave the hospital. After working on the process for a few months, we came out knowing we could do it. It did not affect the length of stay. On the day we launched, we were biting our nails, but never got a call. We had all the lines open to help people who were having problems, but everything was fine. “

Advise other adopters

Incorporating a new discharge list into a healthcare system’s electronic health record is a key step, says O’Linn. The EHR reports discharges that do not have a medication reconciliation.

“You can use your electronic medical record to make that happen. Some of our hospitals have tried to use nursing as people who stop the queue for unstable discharge or incomplete medication reconciliation, but it takes a lot of nursing strength and can create uncomfortable encounters, ”he says. she.

The support of the C-suite is also of crucial importance.

“Culture change has to come from above. The administration must say, ‘We will protect the patient.’ The only reason we were able to do this is because our CEO, Dr Tomislav Mihaljevic, said we had to do it. He said we couldn’t let patients go without a list of medications. Without his support at the highest level, we could not have done it at the grassroots, ”said O’Linn.

Christopher Cheney is the editor of clinical care at HealthLeaders.


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