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\begin{document}

\title{Improving Resident Satisfaction with Post-Hospitalization Follow-up at
Mayo Clinic Florida}



\author[1]{Megan Melody}%
\author[1]{Samantha  Espinosa}%
\author[1]{Karl Mareth}%
\author[1]{Lindsay Gardner}%
\author[1]{Alexander Heckman}%
\author[1]{Annamaria Mechtler}%
\author[1]{SeQuoya Killebrew}%
\author[1]{Matthew Dudgeon}%
\author[1]{Richard White}%
\author[1]{Leigh Speicher}%
\affil[1]{Mayo Clinic Florida}%


\vspace{-1em}



  
  \date{June 14, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Rationale, aims, and objectives: Post-hospitalization follow-up within
30 days following discharge has been shown to positively impact time to
readmission, healthcare costs, and patient self-reported adherence and
satisfaction. We aimed to improve resident satisfaction with the process
of establishing post-hospitalization, primary care provider (PCP)
follow-up. Methods: In this quality improvement study we surveyed all
internal medicine residents at our institution regarding their
satisfaction with the process of establishing PCP follow-up at the time
of hospital discharge. A streamlined process was developed and two
subsequent interventions were enacted; a dedicated teaching session and
distribution of pocket cards outlining the process. Residents were then
surveyed following each intervention to assess for impact on overall
satisfaction and burden of work. Results: Initially, 77.3\% of residents
were not satisfied with the process of establishing post-hospitalization
PCP follow-up. Following the first intervention there was a trend
towards increasing satisfaction rates by 16.7\% (p= 0.20), and after the
second intervention there was a statistically significant increase in
satisfaction rates from baseline by 44\% (p= 0.007). There was also a
reduction in the feeling of workload burden associated with establishing
PCP follow-up from 32\% to 25\%, and over 67\% of participants either
agreed or strongly agreed that the workload was not too burdensome.
Conclusion: This quality improvement initiative established that
resident physicians at our institution previously found the process of
establishing PCP follow-up at the time of patient discharge both
confusing and burdensome. Through the implementation of our
interventions we were able to achieve our aims of improving resident
satisfaction.%
\end{abstract}%



\sloppy


\textbf{Improving Resident Satisfaction with Post-Hospitalization
Follow-up at Mayo Clinic Florida}

\emph{Introduction:}

The transition from inpatient medical care to the outpatient setting is
a high risk time for patients and relies heavily on communication and
coordination of medical care across multiple
settings\textsuperscript{1-4}. Studies have shown that patients who
receive follow-up medical care within the first 30-days following
hospital discharge have decreased readmission rates, decreased health
care costs, and improved medical adherence and satisfaction
\textsuperscript{4-6}. However, literature shows that communication
between hospital physicians and primary care providers (PCP) occurs
infrequently (only 3\%-20\%) and only 56\% of PCPs were satisfied with
communication with hospitalists\textsuperscript{2,3,7-12}. Improvements
in provider satisfaction have been seen with the utilization of
pre-formatted electronic communication, computer generated discharge
summaries, and standardized processes to improve the coordination of
care\textsuperscript{1-3,11,13-16}. Our quality improvement project was
undertaken after it was observed that there was no standardized process
for scheduling a patient's PCP follow-up appointment at the time of
hospital discharge, causing increase burden of workload for the resident
and leading to dissatisfaction. Our aim was to improve resident
satisfaction rating of the post-hospitalization PCP follow-up process by
10\% over the course of nine months, without increasing resident
perception of workload or burden.

\emph{Methods:}

Our team conducted a prospective quality improvement project with the
specific intention to evaluate and improve a specific practice or
program, which per institutional guidance was exempt from Institutional
Review Board review. Utilizing an online survey generator, Survey
Monkey\selectlanguage{ngerman}®, we sent a link via email for an anonymous survey to 49 internal
medicine residents. The survey consisted of one question identifying the
resident's year of training, two Likert-scale questions, and four
open-answer questions (Figure 1) to assess baseline resident
satisfaction and workload burden associated with establishing PCP
follow-up at the time of patient discharge from the hospital. Following
the results of the first survey, our team identified factors leading to
dissatisfaction among residents in the discharge planning process
(Figure 2) and created a flow diagram outlining the current process for
establishing PCP follow-up at the time of discharge (Figure 3). Our team
then worked within the confines of our current electronic medical record
(EMR) system to create a standardized, streamlined process for
establishing patient follow-up at the time of discharge. This process
included step-by-step instructions to locate PCP information in the
chart; provide patient with discharge instructions; order follow-up
appointments, labs, and tests; and communicate with PCPs both inside and
outside of our institution's healthcare network. Our first intervention,
an instructional conference held at resident noon conference, outlined
this new streamlined process. Six weeks after the educational session, a
second, four-question survey was sent to 49 residents, using the same
method as previously outlined. This survey again contained one question
identifying the resident's year of training, the same two Likert-scale
questions, and one multiple choice question to assess whether the
resident had attended the teaching session. For our second quality
improvement intervention, pocket cards (Figure 4) were distributed to
residents via email and hung on the wall of all inpatient resident work
stations. Following the second intervention, a third, five-question,
anonymous survey was sent to all internal medicine residents. This
survey again contained one question identifying the resident's year of
training, the same two Likert-scale questions, one multiple choice
question to assess whether the resident had attended the initial
teaching session, and an additional multiple choice question to assess
whether the resident had referenced the instructional pocket cards. Data
from all surveys were compiled using Survey Monkey® software and
exported to excel for statistical analysis. Data analysis was completed
using the Mann Whitney U test.

\emph{Results:}

The initial survey had a 45\% resident response rate (22 of 49). Of
these residents, five (22.7\%) were satisfied with the
post-hospitalization primary care follow-up process, 11 (50\%) were
neither satisfied nor dissatisfied, and six (27.3\%) were dissatisfied
(Figure 5).

There was a large variation in responses to the free text question
asking residents to identify their role in establishing
post-hospitalization PCP follow-up. Some residents identified their
primary role as communicating with the patients' PCP, with responses
such as ``letter to PCP'', ``call outside PCP'', ``route discharge
summary to their (patient's) PCP's fax'', or ``messaging the PCP to let
them know that their patient was hospitalized''. Other residents
identified their primary role as ordering, or placing a request for,
follow-up appointments with the following responses: ``placing an order
on discharge'', ``usually request follow-up but not involved in
scheduling'', ``putting in the order'', and ``placing an order and
hoping it happens''. Lastly, some residents stated that their role in
post-hospitalization follow-up was to advise the patient to contact
their PCP office to independently make follow-up appointments with
responses including: ``collect the PCP information and put it in the
patient discharge instructions'', ``making sure the patient knows to ask
outside PCP for appointment'', ``advise the patient to see their own PCP
within the week'', and ``let the patient schedule their own follow-up''.
In response to the question ``What aspects of the post-hospitalization
primary care follow up process work well?'' residents primarily
identified one component, with nine out of the 21 free text responses
stating that establishing patient follow-up was much easier within the
Mayo Clinic Health Care Network. Another six out of the 21 residents
responded with variations of ``I don't know'' or ``I am not sure''.

Twenty residents provided free text responses to the question ``What
aspects of the post-hospitalization primary care follow-up process don't
work well''? Residents identified difficulty in communicating with PCPs
(especially when outside the Mayo network), incomplete documentation or
difficulty finding documentation of patients' PCP information in the
EMR, and uncertainty about whether follow-up appointments actually
occur. Of the 17 residents who answered the question ``What do you think
would improve how arrangements are made for PCP follow-up?'', six
residents suggested increased administrative support, five residents
described standardized order sets and protocols, four residents
recommended improved means for communication with PCP, one resident
asked for clearer documentation of patient's PCP contact information,
and one resident was unsure.

Following our first intervention, 34 out of 49 residents (69.4\%)
responded to the survey and, although not statistically significant,
there was an improvement when compared to the initial survey by 16.7\%
(p=0.20). Two residents (6.1\%) reported being very satisfied with the
process, 11 (33.3\%) satisfied, 14 (42.4\%) neither satisfied nor
dissatisfied, and 6 (18.2\%) dissatisfied (Figure 5). Following our
second intervention, 12 of the 49 residents (24\%) responded to the
third survey. There was a statistically significant increase in
satisfaction rates from baseline by 44\% (p= 0.007). Two out of twelve
(16.7\%) responding residents reported being very satisfied with the
post-hospitalization primary care follow-up process, six (50\%)
satisfied, four (33.3\%) neither satisfied nor dissatisfied, and zero
residents reported being dissatisfied or very dissatisfied (Figure 5).

Prior to any intervention, the baseline survey showed only one out of 22
(4.5\%) responding residents strongly agreed that the time and workload
associated with establishing primary care follow-up post hospitalization
was not too burdensome. Seven out of 22 (31.8\%) agreed, seven (31.8\%)
neither disagreed or agreed, and seven (31.8\%) disagreed (Figure 6).
Following the first intervention there was no increase in perceived
workload burden (p= 0.58). Three of 34 (8.8\%) residents strongly agreed
that the workload was not too burdensome, 14 (41.2\%) agreed, six
(17.6\%) neither agreed nor disagreed, 10 (29.4\%) disagreed, and one
(2.9\%) strongly disagreed (Figure 6). After the second intervention,
there again was no increase in perceived workload burden from baseline
(p= 0.19). Two out of 12 residents (16.7\%) strongly agreed, six (50\%)
agreed, one (8.3\%) neither agreed nor disagreed, three (25\%)
disagreed, and zero residents strongly disagreed (Figure 6).

\emph{Discussion:}

Timely post-hospitalization follow-up has been shown to significantly
reduce hospital readmission rates \textsuperscript{1,4-6}. Transition of
patient care from the inpatient to the outpatient setting can lead to
missed test results, medical errors, and both patient and provider
dissatisfaction in the discharge process \textsuperscript{7-9,17-19}.
Our initial baseline resident survey identified areas of resident
dissatisfaction with the discharge planning process to include:
confusion about the residents' role, difficulty in communication, and
lack of a standardized process for establishing PCP follow-up. We
conducted a prospective quality improvement initiative to improve
resident physician satisfaction with establishing post-hospitalization
PCP follow-up.

In an effort to elicit unbiased responses all survey responses were
anonymous without the ability to retrospectively link resident responses
with identifying information. For the first two surveys, our team was
able to achieve acceptable resident response rates, with 45\% and 65\%
of all internal medicine residents responding, respectively. Although
there was a statistically significant increase in resident satisfaction
rates from the initial survey to the last survey, the response rate to
the last survey was significantly lower than the prior two surveys with
only 24\% of residents responding. Response rates to the final survey
may be attributed to alert or email fatigue, as this was a longitudinal
process requiring resident participation throughout the length of nearly
an entire academic year \textsuperscript{20-22}.

Our team was able to utilize our current hospital and clinic
infrastructure and work within the technological confines of our current
EMR to develop a standardized and streamlined process for establishing
post hospitalization PCP follow-up. This process also included pathways
to augment follow-up with both PCPs within our clinic system and PCPs at
outside institutions. Through the use of two simple interventions
focused on provider education, we were able to implement this new method
at no additional cost to our institution. However, the ongoing use of
this standardized process will require continued efforts from our
quality improvement team or additional support from our institution. As
current trainees graduate and new trainees enter into the residency
program each year, there will need to be annual educational sessions to
inform new residents of this process. Additionally, each resident will
need to be provided the instructional pockets cards, whether via e-mail
or in print, each year and the pocket cards at resident work-stations
will need to be maintained.

Although this initiative was able to show an improvement in resident
physician satisfaction, the intervention and analysis were limited to a
small subset of resident physicians within one department and at only
one academic medical center. This project did not evaluate if senior
physicians and faculty or providers in other specialties encounter the
same baseline dissatisfaction with establishing post-hospitalization
follow-up. In addition, the trainees involved in this quality
improvement project have time each day designated for education, making
our interventions of provider education easier to implement. It is
unclear whether this initiative, if expanded hospital wide, would have
as high a yield of participation and therefore, as significant an impact
on overall provider satisfaction. However, the consolidated process that
we identified relied highly on tools already built into the EMR, so it
is likely that this process could be more easily generalized to other
services and departments at our institution or others hospitals.

\emph{Conclusion:} This quality improvement initiative identified
factors contributing to resident dissatisfaction with the process of
establishing post-hospitalization PCP follow-up. The implementation of a
standard and streamlined process resulted in a statistically significant
increase in resident satisfaction with establishing PCP follow-up at the
time of hospital discharge without an increase in perceived workload
burden. Further efforts are required to continue the utilization of this
process and to assess if this same process can increase provider
satisfaction across all levels of training and specialties. \emph{}

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\emph{Acknowledgements} : The authors thank the Internal Medicine
Residency Program at Mayo Clinic Florida, the Office of Quality
Improvement Scholarship at Mayo Clinic, Dr. Colt Cowdell, and Dr. John
Matulis for the support of this quality improvement initiative.

\emph{Conflict of Interest Statement} : Each of the authors confirms
that this manuscript has not been previously published and is not
currently under consideration by any other journal. Each named author
has substantially contributed to conducting the underlying research and
drafting this manuscript. Additionally, all of the named authors have no
conflict of interest, financial or otherwise.\emph{}

\emph{Figures:}

Figure 1. Initial resident survey.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\emph{} Figure 2. Fishbone diagram identifying factors leading to
dissatisfaction amongst residents in the discharge planning process.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 3. Flow diagram outlining initial process of establishing PCP
follow-up at the time of discharge.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\emph{}

Figure 4. Pocket card outlining the streamlined process, using the
current electronic medical record system, to effectively communicate
with the patient's PCP and establish follow-up appointments and tests at
the time of hospital discharge\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\emph{}

Figure 5. Resident satisfaction with the post-hospitalization primary
care follow-up process across all three survey time points.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

Figure 6. Resident perception of workload burden in establishing primary
care follow-up across all three survey time points.\selectlanguage{english}
\begin{figure}[H]
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\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

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