BACKGROUND

Patients are at risk for adverse events during inpatient-to-outpatient transitions of care. Previous improvement work has been targeted at this care transition, but gaps in discharge communication still exist. We aimed to increase documentation of 2-way communication between hospitalists and primary care providers (PCPs) for high-risk discharges from pediatric hospital medicine (PHM) services from 7% to 60% within 30 months.

METHODS

A3 improvement methodology was used. A list of high-risk discharge communication criteria was developed through engagement of PCPs and hospitalists. A driver diagram guided interventions. The outcome measure was documentation of successful 2-way communication with the PCP. Any documented 2-way discharge communication attempt was the process measure. Via a survey, hospitalist satisfaction with the discharge communication expectation served as the balancing measure. All patients discharged from PHM services meeting ≥1 high-risk criterion were included. Statistical process control charts were used to assess changes over time.

RESULTS

There were 3241 high-risk discharges (442 baseline: November 2017 to January 2018; 2799 intervention and sustain: February 2018 to June 2020). The outcome measure displayed iterative special cause variation from a mean baseline of 7% to peak of 39% but regressed and was sustained at 27%. The process measure displayed iterative special cause variation from a 13% baseline mean to a 64% peak, with regression to 41%. The balancing measure worsened from baseline of 5% dissatisfaction to 13%. Interventions temporally related to special cause improvements were education, division-level performance feedback, standardization of documentation, and offloading the task of communication coordination from hospitalists to support staff.

CONCLUSIONS

Improvement methodology resulted in modestly sustained improvements in PCP communication for high-risk discharges from the PHM services.

Poor communication during transitions of care can result in patient harm. Adverse events after hospital discharge have been found to occur in nearly 20% of discharges, with 66% of those being medication related, and, of all adverse events, 6% resulted in a nonpermanent disability, whereas 3% caused permanent disability.1  In pediatrics, discharge-related care failures (eg, unplanned return visits to seek care, not receiving discharge education or necessary medical equipment, not having a plan to follow-up on pending tests, etc) may occur in as many as 34% of hospital discharges.2  Pediatric hospital-to-home quality measures have been reported, with some targeting timely communication between inpatient and outpatient providers (within 24 to 48 hours of discharge) through either 1-way communication (eg, faxed discharge summary) or 2-way communication (eg, in-person conversation, phone call, or e-mail).35  Both the American Academy of Pediatrics’ Section on Hospital Medicine and Council on Children with Disabilities recommend adequate and timely communication between hospitalists and primary care providers (PCPs).68  Specifically, hospitalists should work with PCPs to develop preferences for communication,6  and PCPs should be involved in discharge coordination of patients with special health care needs.8 

In previous literature, researchers identified verbal handoff as a preferred mode of communication, particularly for high-risk discharges, defined as those with medical and social complexity and those with uncertain diagnoses or care plans.911  Direct communication between hospitalists and PCPs occurs in only 3% to 20% of discharges.1214  Unfortunately, the literature is scant regarding improvements in 2-way communication for high-risk discharges. Improvement efforts have been focused on pediatric hospital-to-home transitions,2,1518  with few addressing verbal discharge communication.2,17,18  Recent literature, however, reflects a shift in 2-way communication preferences by PCPs and hospitalists, moving away from real-time, verbal modalities (eg, in-person or phone call) and toward electronic, asynchronous modalities (eg, e-mail, electronic medical record [EMR] messaging, secure text messaging, etc).11,19  PCPs have also expressed that electronic 2-way communication modalities can benefit inpatient-to-outpatient care coordination.10 

At our institution, 2-way discharge communication between hospitalists and PCPs was encouraged but was not an expectation. We sought to improve the frequency of this discharge communication for high-risk discharges using both verbal and/or electronic communication. The A3 performance improvement framework was used and is an improvement methodology adapted from the Toyota Production System. This framework is similar to the traditional Plan-Do-Study-Act cycle, and a majority of A3 components are focused on understanding a system or process in detail (background, current condition, goal, root-cause analysis: plan) before conducting improvement efforts (countermeasures, effect confirmation, and follow-up actions: do, study, and act).20  Our global aim was to improve inpatient-to-outpatient transitions of care. The primary aim was to increase documentation of 2-way communication between hospitalists and PCPs for high-risk discharges from the pediatric hospital medicine (PHM) services from 7% to 60% within 30 months.

Our institution is a freestanding, 367-bed, tertiary-care, academic children’s hospital and serves as the primary regional referral center for pediatric care. Inpatient beds are split between 2 locations. The primary pediatric campus has comprehensive pediatric surgical and subspecialty services. A satellite, community-based hospital has emergency services, an inpatient unit, and limited subspecialty and surgical services. Patients at the primary campus have higher degrees of medical complexity, with longer lengths of stay, whereas admissions to the community-based hospital are less complex, with shorter lengths of stay, resulting in higher daily turnover.

Hospital Medicine-Only Services

The division of PHM was composed of 42 hospitalists performing a mix of direct patient care, supervising attending, and academic and administrative duties. PHM-only services make up 2 of the 6 general pediatric inpatient services, have an average combined daily census of 31 patients, and account for >4500 discharges annually. A PHM service is based at each hospital location, and each hospitalist’s PHM shifts are evenly distributed across locations. Medical students, residents, and fellows rotate on the PHM service, but hospitalists are primarily responsible for providing direct patient care. Each PHM service has dedicated support staff, including a pharmacist, team coordinator, nurse care manager, nutritionist, and social worker. Given implementation complexities on the resident teams at our institution, efforts were purposefully focused on PHM-only services initially.

PCP Communication

Before this project, there was no expectation for PCP communication during a patient’s hospitalization other than through daily documentation within the EMR (PowerChart; Cerner, Kansas City, MO). PCP communication occurred at the hospitalist’s discretion. Previous improvement work led to standardization of discharge summary content, but no standardized location existed to document PCP communication. Institutional guidelines call for discharge summaries to be completed within 72 hours of discharge. Once a discharge summary is signed, it is either, on the basis of PCP preference, faxed to the PCP office or becomes immediately available within the online provider portal. Hospital admission representatives, team coordinators, and nurse care managers share responsibility for identifying, verifying, and documenting PCP contact information within the EMR before patient discharge.

A total of 3 hospitalists were the project’s core team, whereas ad hoc team members included a hospitalist serving within clinical informatics, both PHM team coordinators, and members from our institution’s community provider outreach and clinical informatics departments. Key stakeholders of hospitalists, PCPs, and team coordinators were engaged throughout the project.

Development of High-Risk Criteria

Although the literature has been supportive of verbal handoffs,911,17,18  verbal communication may not be value added for every discharge because of inefficiencies in coordination and time requirements, resulting in negative impacts to workflows.11  PCPs and hospitalists were engaged to determine local communication preferences. Voluntary hospitalist involvement was solicited, as were PCPs from 11 hospital-affiliated community practices. During discussions, PCPs and hospitalists agreed that 2-way communication would be of benefit in some clinical scenarios, but not all discharges warranted 2-way communication. On the basis of these conversations and previous literature,10,11  the team created a list of 7 high-risk criteria that may warrant 2-way discharge communication: an unplanned operating room visit, unplanned ICU stay, new prescription for durable medical equipment, “patient at risk” form completed by social work, new subspecialty clinic referral unrelated to discharge diagnosis, transfer to another facility, and medical complexity.

Hospitalists and PCPs were anonymously surveyed to determine the consensus regarding criteria (Research Electronic Data Capture; Vanderbilt University, Nashville, TN). Response rates were high (PCPs: 93% [n = 13 of 14]; hospitalists: 100% [n = 42 of 42]). Criteria were included if ≥50% of both groups approved of inclusion (n = 5 of 7). Of the remaining 2, at least 1 party displayed a strong preference for inclusion. The 2 criteria with disagreement were as follows: new subspecialty clinic referral made unrelated to a discharge diagnosis (PCPs: 77% [n = 10 of 13]; hospitalists: 29% [n = 12 of 42]) and prescription of new durable medical equipment (PCPs: 46% [n = 6 of 13]; hospitalists: 81% [n = 34 of 42]). With 1 or both parties finding value in each of the 7 proposed criteria, all were included in the final list. Both parties were resurveyed 6 months later (response rate [PCPs: 57% (n = 8 of 13); hospitalists: 47% (n = 20 of 42)]), and similar preferences were found. Therefore, high-risk criteria were not altered for the duration of the project. High-risk criteria definitions, examples, and EMR data tracking methods can be found in Supplemental Table 3. Discharges with ≥1 criterion from a PHM service at either hospital location were included.

Breaking Down the Problem and Identifying Root Causes

Barriers to communication were solicited from hospitalists via voluntary, anonymous surveys with 100% (n = 42) of hospitalists responding. Responses were categorized into themes by using an affinity diagram. A Pareto diagram was constructed from those themes (Supplemental Fig 4), mirroring previously identified inpatient-to-outpatient communication barriers.11  Two themes comprised 65% of barriers: inability to reach the PCP (34%) and time required to complete the task (31%). An Ishikawa diagram was used to identify root causes (Supplemental Fig 5). Also, through voluntary, anonymous survey and discussions, PCPs preferred the noon hour for communication because of smaller impacts on clinic workflow and also preferred direct communication over communicating through others (ie, on-call provider, receptionist, nurse, etc).

Baseline Data Collection

During the baseline period (November 2017 to January 2018; 13 weeks), hospitalists were instructed to document discharge communication within the discharge summary. Data were collected weekly. A retrospective chart review was conducted on the basis of automated reports generated from predefined EMR flags (Supplemental Table 3). Discharges meeting ≥1 high-risk criterion on a PHM service from either hospital campus were included in the denominator for both outcome and process measures and data were presented in aggregate across sites.

Outcome Measure

Documentation of successful 2-way discharge communication with the PCP was the outcome measure, and the goal was 60%. Documentation of communication has been used as a suitable marker of communication frequency.17  During the intervention/sustain periods, EMR documentation was to occur in either the discharge paperwork or discharge summary (Supplemental Fig 6). Two-way communication was defined as any mode of communication that afforded both senders and receivers the ability to communicate bidirectionally (eg, phone call, in-person conversation, secure e-mail, EMR messaging, and/or secure text messaging). Two-way communication modalities beyond verbal were included (eg, secure e-mail, EMR messaging, and secure text messaging) because these additional asynchronous modes contrast with 1-way communication (eg, faxed discharge summary or leaving a voicemail). Furthermore, they are an interface in which bidirectional closed loop communication can occur, inclusion aligns with previous literature and recommendations, and use of asynchronous modalities is supported by local PCP and hospitalist preferences.3,7,911,14,17,19 

“Successful” 2-way communication was defined as any mode of 2-way communication that was initiated by the hospitalist and directly reached the PCP. Two-way communications with office staff and non-PCP providers (eg, on-call provider) were excluded from the definition of “successful” because local PCP preferences were for direct communication, and communication errors could occur during information relay from hospitalist to non-PCP individual to PCP. For real-time, 2-way communication modalities (eg, in-person or phone call), if direct communication with the PCP was not achieved initially (eg, voicemail left on nurse line or message left with nurse or on-call provider), the PCP subsequently contacted the hospitalist, and the hospitalist documented this communication, credit would be given for “success.” The underlying premise of 2-way, asynchronous communication modalities is that information directly reaches the PCP (eg, PCP’s text messaging application on cellphone, e-mail inbox, or EMR inbox) and the PCP may respond at his or her convenience, and a response may occur well after completion of the discharge summary. Therefore, any documented use of an asynchronous modality was counted as “successful.”

Process Measure

Any documented discharge communication attempt was the process measure, and the goal was 90%. This was defined as documentation outlining any attempt at 2-way PCP communication. Both successful PCP communication (outcome measure numerator) and unsuccessful communication attempts (eg, communicating with other clinic personnel, a non-PCP provider, and unanswered phone calls) were included within the measure numerator.

Balancing Measure

Evaluation for hospitalist dissatisfaction with the new communication expectation served as the balancing measure, assessed by a standard 5-point Likert scale (the number of respondents marking “Dissatisfied” or “Extremely Dissatisfied” over the total number of respondents). The anonymous, voluntary survey was distributed every 6 to 12 months (August 2018, July 2019, and May 2020). PCP satisfaction was not evaluated.

On the basis of investigation of our system, a driver diagram was developed (Fig 1). The primary drivers consisted of streamlining communication processes, increasing provider buy-in, improving awareness of patients meeting high-risk criteria, and standardization of documentation. A prioritization matrix guided interventions (Supplemental Fig 7). Major interventions included hospitalist education, performance feedback, creating systems to document PCP communication, automated reports identifying patients meeting high-risk criteria, and engaging support staff to facilitate PCP communication. A detailed list of all interventions, dates of implementation, descriptions of activities, and associated drivers can be found in Table 1.

Statistical process control charts assessed changes over time (QI Macros version 2016.10; KnowWare International, Denver, CO). Common and special cause variation were determined by using previously established improvement rules.21,22 

The project was deemed exempt as quality improvement by our institution’s office of research integrity.

A total of 3241 high-risk discharges were included (442 baseline [November 2017 to January 2018]; 2799 intervention [February 2018 to August 2019] and sustain periods [September 2019 to June 2020]), averaging 23.2 discharges per week. The average weekly percent of high-risk discharges per all PHM discharges was 27.2% (Supplemental Fig 9). A total of 3977 separate high-risk criteria were met (565 baseline; 3412 intervention or sustain), averaging 1.2 criteria per discharge (Table 2). PCP contact information was documented in 91% of high-risk discharges. During the baseline period, 96.5% of discharge summaries were signed within 48-hours of discharge, compared with 94.9% during the intervention period.

The mean baseline performance was 7.2%. At project kickoff, consisting of standardization of documentation, education, and division-level performance feedback (Table 1), special cause improvement to 29% occurred (February 2018). After a short period of reduced performance to 17% (June 2018 to July 2018), further special cause improvements to 32% (August 2018) and a peak of 39% (October 2018) were temporally related to automated weekday e-mail and team coordinators facilitating PCP communication interventions, respectively. Peak performance was sustained for 11 months (October 2018 to September 2019). Regression to 27.4% (September 2019) occurred and was sustained until project completion (June 2020; Fig 2).

The mean baseline performance was 13%. Special cause improvements to 38.5% (February 2018), 53.1% (October 2018), and peak of 64.1% (February 2019) were seen. The first 2 improvements coincided with outcome measure special cause improvements. Short-lived peak performance (11 weeks) occurred after implementation of individual performance feedback (Table 1). Regression to 50% (May 2019) and again to 41.2% (September 2019) occurred, with final performance being sustained until project completion (June 2020; Fig 3).

Hospitalist response rates to 3 anonymous, voluntary surveys were 47.6% (n = 20 of 42; August 2018), 42.9% (n = 18 of 42; July 2019), and 35.7% (n = 15 of 42; May 2020). When first surveyed, 5% (n=1) of respondents were dissatisfied with the new communication expectation, which increased to 11.1% (n = 2) with the second and 13.3% (n = 2) by the third. From the 5 dissatisfied responses, 9 causes were shared. Disagreement with inclusion of ≥1 high-risk criterion was the most common cause of dissatisfaction (n = 4 of 5 dissatisfied responses). “Patient at risk” and “unplanned operating room visit” were the only high-risk criteria not specifically identified as a cause of dissatisfaction.

Using the A3 improvement framework,20  we increased the proportion of documented 2-way communication between hospitalists and PCPs for high-risk discharges from the PHM service. Although short of our aim, a modestly sustained increase in performance was achieved, and feedback from local PCPs and hospitalists helped narrow efforts to a select group of high-risk discharges. Removal of non–value-added steps from clinical workflows is of particular importance because of ever growing regulatory burdens and task demands associated with health care delivery during the complex inpatient-to-outpatient transition.

Historically, pediatric discharge communication improvement literature has encompassed a wide patient scope,1618  yet literature and local preferences investigated during our project suggest verbal handoff may not be value added in all clinical scenarios.11  Patient populations with underlying medical and social complexity and uncertain diagnoses and plans of care may have greater need for 2-way discharge communication over healthy children with uncomplicated hospitalizations.911  Our work expands on the existing literature not only by engaging local PCPs and hospitalists in understanding communication preferences and developing high-risk discharge criteria but also by focusing improvement efforts on patients meeting said criteria.

In our project, several interventions were linked to special cause improvements in our outcome measure: provider feedback, automation and EMR integration, standardization of documentation, and shifting of communication coordination tasks to support staff. A pediatric collaborative previously identified local factors leading to improvements in discharge communication: individualized provider feedback, financial incentives, a multidisciplinary team, process automation and EMR integration, and a standard location for communication documentation.17  Additionally, Mussman et al18  successfully combined EMR integration, automation, and offloading of tasks from hospitalists workflows to achieve >90% verbal discharge handoff performance. Interventions tied to special cause improvements in our project were similar to and further support successful interventions conducted in these publications.17,18  Interventions unrelated to those factors did not result in special cause improvement, except project education, but this intervention was bundled with both standardization of documentation as well as division-level performance feedback. Therefore, it is hard to substantiate the true impact of education. We also cannot discount the potential impact lesser interventions had on project outcomes. However, improvements seen in our work were minor, compared with previous studies. Reasons for this discrepancy may be because of differences in baseline performance (7% vs >70%), barriers to implementation of highly reliable interventions,23  implementation of processes reliant on human capabilities, which are subject to internal and external influences,2426  and other unmeasured local contextual and cultural factors.27,28 

Performance feedback and financial incentives have been linked to discharge communication success,1618  but, again, our experience was different. Although division-level feedback was tied to special cause improvement, incorporation of provider-level performance feedback did not translate to further outcome measure gains (Fig 2). Individual deidentified feedback was only temporally related to short-lived special cause improvement in the process measure, and transparent individual performance feedback did not result in changes of either measure (Fig 3). This may be that division-level feedback was viewed positively, thereby facilitating intrinsic motivation, whereas individual performance feedback, despite leadership support, may have been viewed negatively, thus undermining intrinsic motivation.26 

Performance feedback is essential to financial incentive effectiveness. Our project was not tied to a financial incentive, and, therefore, did not benefit from synergy that likely occurs between these 2. Maintenance of certification (MOC) Part IV credit was provided during our project, but it did not drive improvement. Although MOC participation spanned the 6 months after implementation, outcome measure improvement was not temporally related to implementation of MOC credit for hospitalists. However, the week after implementation of MOC credit for PCPs, there was special cause improvement in the outcome measure. We do not believe that PCP MOC was a driver of this change because only 14 PCPs participated in MOC out of the entire PCP referral base. The limited effectiveness of MOC Part IV credit may also be because receipt of credit is not contingent on project success (whereas financial incentives often are). MOC credit is frequently included as part of our divisional improvement projects (thereby decreasing intervention efficacy), physicians’ perceived value of MOC and improvement work may be lacking,29,30  and any gains in intrinsic and extrinsic motivation by offering credit may be overshadowed by gains already experienced through the act of participation in efforts to improve patient care.31,32  Although inclusion of MOC Part IV credit has been shown to provide some benefit33  and may be viewed favorably in local settings,34  our work builds on the literature that offering credit may not translate to improvement in project measures or exhibit strong behavioral influences on physicians.31,32,35  Before implementation of performance feedback or incentives, improvement teams would benefit from exploring local preferences and contextual and cultural factors that may influence their effectiveness, such as team potency, collective efficacy, and intrinsic and extrinsic drivers of motivation.2436 

Several unintended benefits occurred. First, although not formally tracked, increases in PHM service discharge communication have been appreciated for patients not meeting high-risk criteria. Second, a resident-led discharge communication spinoff project was conducted on 2 additional general pediatric services, resulting in local improvement awards. Third, several subspecialty services have begun improving PCP communication processes, and, as a result of a rising tide of services addressing PCP communication, referring provider communication has become a hospital priority.

Limitations to our work exist. First, the project was conducted on 2 PHM services at a freestanding, academic children’s hospital. The work was conducted at both a primary academic hospital as well as a satellite hospital, which more closely resembles a traditional community hospital. Results were presented in aggregate across sites, in which outcomes between sites may be different given their heterogeneous patient populations. Although the lessons learned may be applied to other health care settings and care teams, generalizability may be limited. Second, the project was focused on specific high-risk criteria, rather than including all discharges, and we did not track impacts related to patient characteristics (eg, age, sex, insurance status, race and/or ethnicity, etc). Third, the project was focused on process improvement and did not have a specific patient-centered outcome such as communication failures, readmission rates, or medical errors. These were not focused on because of the rarity of events and difficulties with reliability of reporting. Fourth, our team did not directly engage patients and families in the improvement process, and PCP involvement was small, compared with the referral base. Additionally, we did not monitor patient, family, or PCP satisfaction. As a result, patient, family, and PCP preferences may be different from those we identified. Local communication preferences matched the literature, however.10,11  Lastly, we tracked documentation of PCP communication and did not verify if documentation matched actual performance. In previous pediatric discharge communication literature, similar methodology was used to measure discharge communication,17  and local PCPs, and hospitalists agreed low baseline documentation matched perceptions of actual communication frequency. Moreover, documentation may not have been updated if PCP communication occurred after discharge summary completion, and, given the ethical and legal ramifications of purposeful falsification of the medical record, we believe, if anything, underdocumentation of true performance occurred.

Future directions could address each limitation, standardization of communication practices across the institution, and modernization of communication modalities to include those growing in popularity, such as secure text messaging and video conferencing.

Improvement methodology resulted in modestly sustained improvements in documented PCP communication of high-risk discharges from PHM services. Exploring communication barriers, needs, and preferences of frontline providers may help focus discharge communication efforts on value-added tasks. Given the ubiquitous nature of inpatient-to-outpatient transitions, which are hampered by competing tasks, asynchronous PCP and hospitalist workflows, and inefficiencies in the discharge process, institutions may be able to add value by adopting a similar targeted approach. Further study is needed, however, to determine if narrowing the communication expectation will improve workflows, reduce workloads, and have beneficial impacts to patient care.

We acknowledge the following ad hoc team members for their contributions to our project (alphabetical order by last name): Linda Anderson (Inpatient Care Services Team Coordinator); Douglas Blowey, MD (Medical Director, Chief Clinical Integration Officer, Children’s Mercy Integrated Care Solutions); Nebjosa Copic, MBA IS (Clinical Informatics); Lisa Crump (Inpatient Care Services Team Coordinator); Isaac Jonas, MS (Clinical Decision Support); Brandan Kennedy, MD (Pediatric Hospital Medicine, Clinical Informatics); Lauren Twist (Office Manager, Pediatric Hospital Medicine); and the physician services team.

FUNDING: No external funding.

Dr Clark conceptualized and designed the project, led interventions, participated in interpretation of data, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Simmons, Etzenhouser, and Pallotto assisted with conceptualization and design of the project, assisted with interventions and interpretation of data, and reviewed and revised the manuscript; and all authors provided critical revisions of the manuscript and approved the final manuscript as submitted.

1
Forster
AJ
,
Murff
HJ
,
Peterson
JF
,
Gandhi
TK
,
Bates
DW
.
The incidence and severity of adverse events affecting patients after discharge from the hospital
.
Ann Intern Med
.
2003
;
138
(
3
):
161
167
2
Wu
S
,
Tyler
A
,
Logsdon
T
et al
.
A quality improvement collaborative to improve the discharge process for hospitalized children
.
Pediatrics
.
2016
;
138
(
2
):
e20143604
3
Leyenaar
JK
,
Desai
AD
,
Burkhart
Q
et al
.
Quality measures to assess care transitions for hospitalized children
.
Pediatrics
.
2016
;
138
(
2
):
e20160906
4
Auger
KA
,
Simon
TD
,
Cooperberg
D
et al
.
Summary of STARNet: Seamless Transitions and (Re)admissions Network
.
Pediatrics
.
2015
;
135
(
1
):
164
175
5
DeLucia
M
,
Martens
A
,
Leyenaar
J
,
Mallory
LA
.
Improving hospital-to-home transitions for children entering foster care
.
Hosp Pediatr
.
2018
;
8
(
8
):
465
470
6
SECTION ON HOSPITAL MEDICINE
.
Guiding principles for pediatric hospital medicine programs
.
Pediatrics
.
2013
;
132
(
4
):
782
786
7
Rauch
DA
;
COMMITTEE ON HOSPITAL CARE; SECTION ON HOSPITAL MEDICINE
.
Physician’s role in coordinating care of hospitalized children
.
Pediatrics
.
2018
;
142
(
2
):
e20181503
8
Elias
ER
,
Murphy
NA
;
Council on Children with Disabilities
.
Home care of children and youth with complex health care needs and technology dependencies
.
Pediatrics
.
2012
;
129
(
5
):
996
1005
9
Pantilat
SZ
,
Lindenauer
PK
,
Katz
PP
,
Wachter
RM
.
Primary care physician attitudes regarding communication with hospitalists
.
Am J Med
.
2001
;
111
(
9B
):
15S
20S
10
Leyenaar
JK
,
Bergert
L
,
Mallory
LA
et al
.
Pediatric primary care providers’ perspectives regarding hospital discharge communication: a mixed methods analysis
.
Acad Pediatr
.
2015
;
15
(
1
):
61
68
11
Jones
CD
,
Vu
MB
,
O’Donnell
CM
et al
.
A failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations
.
J Gen Intern Med
.
2015
;
30
(
4
):
417
424
12
Kripalani
S
,
LeFevre
F
,
Phillips
CO
,
Williams
MV
,
Basaviah
P
,
Baker
DW
.
Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care
.
JAMA
.
2007
;
297
(
8
):
831
841
13
Coller
RJ
,
Klitzner
TS
,
Saenz
AA
et al
.
Discharge handoff communication and pediatric readmissions
.
J Hosp Med
.
2017
;
12
(
1
):
29
35
14
Rush
M
,
Herrera
N
,
Melwani
A
.
Discharge communication practices for children with medical complexity: a retrospective chart review
.
Hosp Pediatr
.
2020
;
10
(
8
):
651
656
15
Hamline
MY
,
Speier
RL
,
Vu
PD
et al
.
Hospital-to-home interventions, use, and satisfaction: a meta-analysis
.
Pediatrics
.
2018
;
142
(
5
):
e20180442
16
Mallory
LA
,
Osorio
SN
,
Prato
BS
et al
;
IMPACT Pilot Study Group
.
Project IMPACT pilot report: feasibility of implementing a hospital-to-home transition bundle
.
Pediatrics
.
2017
;
139
(
3
):
e20154626
17
Shen
MW
,
Hershey
D
,
Bergert
L
,
Mallory
L
,
Fisher
ES
,
Cooperberg
D
.
Pediatric hospitalists collaborate to improve timeliness of discharge communication
.
Hosp Pediatr
.
2013
;
3
(
3
):
258
265
18
Mussman
GM
,
Vossmeyer
MT
,
Brady
PW
,
Warrick
DM
,
Simmons
JM
,
White
CM
.
Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge
.
J Hosp Med
.
2015
;
10
(
9
):
574
580
19
Ruth
JL
,
Geskey
JM
,
Shaffer
ML
,
Bramley
HP
,
Paul
IM
.
Evaluating communication between pediatric primary care physicians and hospitalists
.
Clin Pediatr (Phila)
.
2011
;
50
(
10
):
923
928
20
Sobek
DK
,
Smalley
A
.
Understanding A3 Thinking: a Critical Component of Toyota’s PDCA Management System
.
Abingdon, UK
:
Taylor & Francis Group
;
2008
21
Benneyan
JC
,
Lloyd
RC
,
Plsek
PE
.
Statistical process control as a tool for research and healthcare improvement
.
Qual Saf Health Care
.
2003
;
12
(
6
):
458
464
22
Brady
PW
,
Tchou
MJ
,
Ambroggio
L
,
Schondelmeyer
AC
,
Shaughnessy
EE
.
Displaying and analyzing quality improvement data
.
J Pediatric Infect Dis Soc
.
2018
;
7
(
2
):
100
103
23
Nolan
T
,
Resar
R
,
Haraden
C
,
Griffin
F
.
Improving the Reliability of Health Care
.
Cambridge, MA
:
Institute for Healthcare Improvement
;
2004
.
24
Hilton
K
,
Anderson
A
.
IHI Psychology of Change Framework to Advance and Sustain Improvement
.
Cambridge, MA
:
Institute for Healthcare Improvement
;
2018
25
Kotter
JP
.
Leading Change
.
Boston, MA
:
Harvard Business School Press
;
1996
26
Ryan
RM
,
Deci
EL
.
Intrinsic and extrinsic motivations: classic definitions and new directions
.
Contemp Educ Psychol
.
2000
;
25
(
1
):
54
67
27
Kaplan
HC
,
Provost
LP
,
Froehle
CM
,
Margolis
PA
.
The Model for Understanding Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement
.
BMJ Qual Saf
.
2012
;
21
(
1
):
13
20
28
Kaplan
HC
,
Froehle
CM
,
Cassedy
A
,
Provost
LP
,
Margolis
PA
.
An exploratory analysis of the model for understanding success in quality
.
Health Care Manage Rev
.
2013
;
38
(
4
):
325
338
29
Cook
DA
,
Holmboe
ES
,
Sorensen
KJ
,
Berger
RA
,
Wilkinson
JM
.
Getting maintenance of certification to work: a grounded theory study of physicians’ perceptions
.
JAMA Intern Med
.
2015
;
175
(
1
):
35
42
30
Kelley
S
.
Is there purpose behind MOC Part 4, or is it just ‘busy work’?
AAP News
.
2010
;
31
(
12
):
7
31
Freed
GL
,
deJong
N
,
Macy
ML
,
Van
KD
,
Leslie
LK
.
Pediatricians’ participation in quality improvement at the time of enrollment in MOC
.
Pediatrics
.
2018
;
142
(
5
):
e20180712
32
Marshall
TL
,
Jerardi
KE
,
Shah
SS
.
Making MOC quality improvement participation meaningful
.
Pediatrics
.
2018
;
142
(
5
):
e20182559
33
Gorzkowski
JA
,
Klein
JD
,
Harris
DL
et al
.
Maintenance of Certification Part 4 credit and recruitment for practice-based research
.
Pediatrics
.
2014
;
134
(
4
):
747
753
34
Tieder
JS
,
Prall
SP
,
Beck
J
et al
.
A Survey of perceived effectiveness of Part 4 Maintenance of Certification
.
Hosp Pediatr
.
2017
;
7
(
11
):
642
648
35
Klein
JD
,
Gorzkowski
J
,
Resnick
EA
et al
.
Delivery and impact of a motivational intervention for smoking cessation: a PROS study
.
Pediatrics
.
2020
;
146
(
4
):
e20200644
36
Stajkovic
AD
,
Lee
D
,
Nyberg
AJ
.
Collective efficacy, group potency, and group performance: meta-analyses of their relationships, and test of a mediation model
.
J Appl Psychol
.
2009
;
94
(
3
):
814
828
37
Agency for Healthcare Research and Quality
.
Confidential physician feedback reports: designing for optimal impact on performance
.
Available at: https://www.ahrq.gov/ncepcr/tools/confid- report/index.html. Accessed September 1, 2020

Competing Interests

POTENTIAL CONFLICTS OF INTEREST: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

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