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Improving discharge planning communication between

hospitals and patients
P. W. New,1,2,3 K. E. McDougall1 and C. P. R. Scroggie1
1
Rehabilitation and Aged Care, Kingston Centre, Monash Health, 2Epworth-Monash Rehabilitation Medicine Unit, Southern Medical School and
3
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Key words Abstract

discharge planning, communication,
patients, rehabilitation, stroke.
Correspondence
Peter New, Kingston Centre, Warrigal Road,
Cheltenham, Vic. 3192, Australia.
Email: peter.new@monashhealth.org
Received 14 July 2015; accepted 27
September 2015.
doi:10.1111/imj.12919
Background: A potential barrier to patient discharge from hospital is communication
problems between the treating team and the patient or family regarding discharge planning.
Aim: To determine if a bedside ‘Leaving Hospital Information Sheet’ increases patient and
family’s knowledge of discharge date and destination and the name of the key clinician
primarily responsible for team–patient communication.
Methods: This article is a ‘before-after’ study of patients, their families and the
interdisciplinary ward-based clinical team. Outcomes assessed pre-implementation and
post-implementation of a bedside ‘Leaving Hospital Information Sheet’ containing discharge
information for patients and families. Patients and families were asked if they knew the key
clinician for team–patient communication and the proposed discharge date and discharge
destination. Responses were compared with those set by the team. Staff were surveyed
regarding their perceptions of patient awareness of discharge plans and the benefit of the
‘Leaving Hospital Information Sheet’.
Results: Significant improvement occurred regarding patients’ knowledge of their key
clinician for team–patient communication (31% vs 75%; P = 0.0001), correctly identifying
who they were (47% vs 79%; P = 0.02), and correctly reporting their anticipated dis-
charge date (54% vs 86%; P = 0.004). There was significant improvement in the family’s
knowledge of the anticipated discharge date (78% vs 96%; P = 0.04). Staff reported the
‘Leaving Hospital Information Sheet’ assisted with communication regarding anticipated
discharge date and destination (very helpful n = 11, 39%; a little bit helpful n = 11, 39%).
Conclusions: A bedside ‘Leaving Hospital Information Sheet’ can potentially improve
communication between patients, families and their treating team.

Introduction on the patient or family’s knowledge of the discharge plan

Improving hospital patient flow is important in order to
optimise the use of limited healthcare resources efficiently,1
minimise iatrogenic adverse events,2 and it may ensure
patient-centred care.3,4 Numerous studies have identified
problems with patient flow in the emergency department,5–7
acute care8,9 and rehabilitation hospitals.10,11 Barriers to
discharge from hospital are common, with reports that these
occur in approximately 14–16% of acute hospital12,13 and
rehabilitation admissions.10
One of the barriers to discharge commonly identified is
communication problems between the treating team and
the patients or their families,10,14 particularly regarding
the discharge date or destination. This information is
typically relayed verbally. There has been little research
or strategies to improve this.15
The objective of this project was to determine
patient’s and family’s knowledge of important discharge
planning information and whether a bedside ‘Leaving
Hospital Information Sheet’ containing discharge
information could improve their knowledge. We also
planned to determine the treating team’s perception of
the patient or family’s awareness of key discharge infor-
mation and whether the ‘Leaving Hospital Information
Sheet’ improved this.
Methods
Setting

Conflict of interest: None. The stroke–neurological rehabilitation ward at Kingston

Funding: None. Centre, Monash Health, Victoria, Australia is a 32-bed ward

© 2016 Royal Australasian College of Physicians 57

New et al.
that primarily admits patients with a recent onset of stroke
or other neurological conditions requiring inpatient
rehabilitation.
Routine practice on the ward was for a key clinician
(medical, nursing or allied health) to be appointed for
each patient within 24 h of admission who would be
responsible for communication between the rehabilita-
tion team and the patient and/or their family. The key
clinician’s role included informing the patient/family of
the team’s recommendations regarding anticipated dis-
charge date and destination. On occasions, patients
and/or their families were not aware of this information
because of either not being informed or not remember-
ing. Communication breakdown was identified as a
potential barrier to discharge, increasing length of stay
(LOS) on occasions and adversely impacting on patient/
family satisfaction.
Study design
The ‘Leaving Hospital Information Sheet’ was developed
as a strategy to improve discharge communication. This
was a laminated A4 green sheet (symbolising go) placed
behind the patient’s bed for viewing by patients and
their family. The ‘Leaving Hospital Information Sheet’
had prompts for the name of the key clinician for
team–patient communication, the ‘estimated date ready
to leave hospital’, ‘likely discharge destination when
ready to leave hospital’ and the date the sheet was
updated.
Education was provided to the treating team regarding
the rationale for the project by email and verbal re-
minders from senior staff and at daily journey board
meetings.
The ‘Leaving Hospital Information Sheet’ was com-
pleted by the key clinician after the first team meeting
(held weekly) following the patient’s admission and
after discussion with the patient/family. It was recom-
mended that the ‘Leaving Hospital Information Sheet’
be updated by the key clinician following any change
in the discharge plans and after discussion with the
patient/family. If the discharge destination was not
known or unclear, the phrase ‘not certain’ was used,
and the potential discharge destination options were
listed until one was finalised.
A ‘before-after’ study design was used to evaluate the
impact of the ‘Leaving Hospital Information Sheet’.
Patients and/or their family were surveyed prior to imple-
mentation in July and August 2013 and following
implementation in November 2013 and May 2014. The
‘Leaving Hospital Information Sheet’ was implemented
in September 2013. Each of the surveys involved different
patient cohorts. Ward clinical staff were surveyed prior to
58
implementation in September 2013 and following imple-
mentation in October 2014. The delay between the two
post-implementation surveys was due to logistical issues.
Staff were blinded to the results of the patient/family
surveys.
Participants
All patients on the ward at the time of each survey were
eligible to participate if they had adequate cognition and
communication. Trained interpreters were used where
required, or family members assisted with interpreting.
Patients were excluded from the second pre-implementation
survey if they had participated in the previous survey. A
member of the patient’s family was surveyed if they were
nominated by the patient for involvement with discharge
planning or if the patient had inadequate cognition or
communication to participate in discharge planning
decisions. Medical, nursing and allied health professionals
working on the ward were also included as participants in
separate surveys.
Outcome measures and data sources
Patients (and their families where appropriate) were
verbally questioned regarding their knowledge of their
key clinician, proposed discharge date and destination.
Their responses were compared with those determined
by the treating team. No clinical or demographic
characteristics were collected about the patients or their
family.
A web-based survey was used to obtain information from
the ward clinical staff regarding their perceptions of
patients’ awareness of discharge plans, and additionally in
the post-implementation survey, their perception regarding
the benefit of the ‘Leaving Hospital Information Sheet’
along with comments regarding its use.
Sample size
No sample size calculations were performed as this was
an exploratory study with no baseline data available.
This was a convenient sample of the patients and the
staff. It was recognised, however, that conducting the
pre-implementation and post-implementation patient
surveys on two occasions would improve the power of
the study.
Statistical methods
Descriptive analysis was performed on available data.
Comparisons between responses were analysed using
the Chi-squared test, with the Fisher exact correction
used where appropriate. Statistical analysis was
© 2016 Royal Australasian College of Physicians
 Improving discharge communication

performed using Stata 12.1 (StataCorp, College Station, Staff survey

TX, USA). P-values of less than 0.05 were deemed clini-
cally significant.
Approval for the project was obtained from the Monash
Health Human Research and Ethics Committee. Partici-
pants gave verbal consent prior to their inclusion in the
study.
Results
Patient and family survey
Forty-nine patients and 40 family members partici-
pated in the pre-implementation surveys (an addi-
tional five patients were excluded because of the
severity of their cognitive or communication function-
ing and 14 patients excluded because they participated
in the previous survey). Fifty-two patients and 36
family members participated in the post-
implementation surveys (an additional 12 patients
were excluded because of cognitive or communication
functioning).
Statistically significant improvements were noted follow-
ing the implementation of the ‘Leaving Hospital Informa-
tion Sheet’ regarding the patients’ correct reporting of
their key clinician and the patient/family’s knowledge of
correct discharge date (Table 1).
The pre-implementation survey was completed by 35 staff
(allied health, n = 18, 51%; nursing, n = 14, 40%; medical,
n = 3, 9%; total response rate, 55%), and the post-
implementation survey was completed by 28 staff (allied
health, n = 15, 54%; nursing, n = 11, 39%; medical, n = 2,
7%; total response rate, 47%).
The staff did not perceive that patients’ knowledge of
their discharge date improved following the implementa-
tion of the ‘Leaving Hospital Information Sheet’,
however they thought that patients’ knowledge of their
discharge destination and key clinician improved, al-
though these results were not statistically significant
(Table 2). Because of limitations we had in the access to
the web-based survey software, not all questions were
asked of the staff at both pre-implementation and post-
implementation. Most staff responding to the post-
implementation survey believed the ‘Leaving Hospital
Information Sheet’ was helpful for optimising communi-
cation with the patient and family regarding the
discharge date and destination (very helpful n = 11,
39%; a little bit helpful n = 11, 39%; neither helpful or
unhelpful n = 4, 14%; unhelpful n = 2, 7%; due to
rounding total = 99%). However, 18% (n = 5) of the staff
reported that they did not use the ‘Leaving Hospital
Information Sheet’. The majority of staff (n = 25,
89%) indicated that discharge destination should be
included on the ‘Leaving Hospital Information Sheet’.

Table 1 Patient and family awareness and correctness of key discharge planning information before and after implementation of the ‘Leaving Hospital
Information Sheet’

Awareness of key discharge Pre-implementation Post-implementation P

planning information (n, %) (n, %)
Key clinician
Patients report they know the key clinician 15/49, 31 39/52, 75 0.0001
Patients correct in reporting the key clinician 7/15, 47 31/39, 79 0.02
Families report they know the key clinician 22/40, 55 23/36, 64 0.4
Families correct in reporting the key clinician 17/22, 77 22/23, 96 0.07
Discharge date
Patients report they know the discharge date 26/49, 53 37/52, 71 0.06
Patients correct in identifying the discharge date 14/26, 54 32/37, 86 0.004
Families report they know the discharge date 27/40, 68 27/36, 71 0.5
Families correct in identifying the discharge date 21/27, 78 26/27, 96 0.04
Discharge destination
Patients report they know the discharge destination 38/49, 78 41/52, 79 0.9
Patients correct in identifying the discharge destination 32/38, 84 36/41, 88 0.6
Families report they know the discharge destination 34/40, 85 28/36, 78 0.4
Families correct in identifying the discharge destination 30/34, 88 28/28, 100 0.06

© 2016 Royal Australasian College of Physicians 59

New et al.

Table 2 Staff perceptions of patient’s awareness of discharge plans and the benefit of the ‘Leaving Hospital Information Sheet’

Agreement with statements regarding Pre-implementation of ‘Leaving Post-implementation of ‘Leaving P‡

team–patient communication on the ward Hospital Information Sheet’, n = 35 (n, %†) Hospital Information Sheet’, n = 28 (n, %†)
Patients are aware of their discharge date
within 72 h of it being set by the treating
team in interdisciplinary team meeting:
Always 1, 3 1, 4 0.4
Most of the time 19, 54 14, 50
Sometimes 11, 31 13, 46
Rarely 3, 9 0
Never 1, 3 0
Patients are aware of their discharge date
within 72 h of it being altered:
Always 1, 3 0 0.9
Most of the time 15, 43 14, 50
Sometimes 17, 49 12, 43
Rarely 2, 6 2, 7
Never 0 0
Patients are aware of their discharge
destination within 72 h of it set by the
treating team in interdisciplinary
team meeting:
Always 2, 6 2, 7 0.9
Most of the time 14, 40 12, 43
Sometimes 17, 49 13, 46
Rarely 1, 3 1, 4
Never 1, 3 0
Patients are aware of their discharge
destination within 72 h of it being altered:
Always 4, 11 3, 11 0.5
Most of the time 12, 34 13, 46
Sometimes 16, 47 12, 43
Rarely 3, 9 0
Never 0 0
Patients know their key clinician for team–
patient communication:
Always 1, 3 1, 4 0.4
Most of the time 16, 46 17, 61
Sometimes 13, 37 9, 32
Rarely 5, 14 1, 4
Never 0 0
Staff satisfaction with the current process
of notifying patient/family of the discharge
date and destination:
Extremely satisfied 1, 3 Data not collected in post-implementation survey NA
Very satisfied 12, 34
Somewhat satisfied 18, 51
Slightly satisfied 4, 11
Not at all satisfied 0
†
Totals not always equal 100% because of rounding. ‡Fisher exact correction. NA, not applicable.

Discussion patients/family and their treating team, through improved

knowledge of their key clinician for team–patient commu-
A ‘Leaving Hospital Information Sheet’ has demonstrated nication and anticipated discharge date. Other aspects
improvements in aspects of the communication between of discharge planning information awareness among

60 © 2016 Royal Australasian College of Physicians


patients/family also improved, and the perception of ward
staff was that the ‘Leaving Hospital Information Sheet’
was helpful.
A significant proportion of patients/family knew their
discharge destination pre-implementation, creating a ceil-
ing effect and limiting the scope for the project to improve
significantly in this area. Improving the communication
between treating teams and patients/family has been a
focus of the health network and the ward team for some
time, with baseline findings reflecting these efforts.
It was interesting to note that staff perceived patient/family’s
knowledge of discharge information to be poor compared
with the actual patient/family awareness. The reason for the
discrepancy may have been due to suboptimal staff knowl-
edge of the ‘Leaving Hospital Information Sheet’ and its role
in facilitating discharge discussion or inadequate documenta-
tion by the key clinician of discussions regarding discharge
planning with the patient/family.
Implementation of the ‘Leaving Hospital Information
Sheet’ was suboptimal, with 18% of staff not utilising it. Some
staff commented they were not orientated to the rationale
and process of completing the ‘Leaving Hospital Information
Sheet’ when commencing work on the ward. In addition,
there were several other projects being implemented on the
ward concurrently, and the staff may have suffered from
‘change fatigue’. We believe that better implementation
would have improved our findings.
A previous report of a similar intervention in an elective
orthopaedic ward in Wales showed an average reduction in
LOS from 7.4 to 4.3 days.15 No details were given regarding
other interventions that may have occurred concurrently,
and we are surprised by such a remarkable reduction in
LOS from this intervention alone. Nevertheless, this finding
also supports the use of such communication interventions
to assist in reducing LOS.
The importance of interdisciplinary communication in
hospital teams in determining outcomes of care has been
well documented,16,17 including the influence on discharge
planning.18,19 Partnering with consumers is one of the 10
National Safety and Quality Health Service Standards.20
When miscommunication occurs between teams and
patients/families regarding discharge planning, this can
potentially cause frustration, stress and anxiety among all
and can contribute to unnecessarily prolonging the LOS.
We believe the strategy of using a ‘Leaving Hospital Infor-
mation Sheet’ can potentially reduce the risk of miscom-
munication between hospital teams and patients/families
regarding discharge planning.
The strength of this project is that the previous report of a
similar strategy did not describe in detail the methodology
or analysis of results.15 Although there are reports in the
literature on discharge planning that emphasise the impor-
tance of communication,21,22 there is none that we are
© 2016 Royal Australasian College of Physicians
Improving discharge communication
aware of focussing on communication with patients/family
about their discharge plans.
We believe that the ‘Leaving Hospital Information Sheet’
has the potential to be used across many other hospital
settings, especially rehabilitation and aged-care hospitals
where patients can have long admissions and uncertain dis-
charge destinations. There is also scope for using this strat-
egy to improve communication in acute hospital wards
where similar uncertainty in discharge planning can occur.
Limitations of this project are that it was set in a single
ward and the sample size was relatively small. In addition,
there was a notable delay between the pre-patient and
post-patient surveys, although we are uncertain as to how
this may have influenced the findings. Although there were
improvements in numerous aspects of patient/family
awareness of their key clinician and discharge date, deter-
mining whether this enhanced communication resulted in
reduced rehabilitation LOS or improved patient/family
satisfaction was beyond the scope of this study. Other
limitations of the project include possible responder bias
from clinicians in the post-implementation survey. Family
members acting as interpreters is another limitation and
possible bias; however, given that the survey questions
were not complex and given the pragmatic nature of the
project, we believed this was appropriate.
Further research is required to assess the potential for
bedside patient/family information to improve communi-
cation between clinical teams and patients. We believe that
there is enormous potential to reduce miscommunication
between clinical teams and patients/families by this ap-
proach and improve patient satisfaction. Future research
should include establishing what information patients and
families would like displayed at their bedside and through
what mode. One strategy worth considering is to incorpo-
rate the discharge information with general health and
patient-specific information into an information channel
on patients’ hospital television.
Conclusion
While this study has demonstrated that a ‘Leaving Hospital
Information Sheet’ can improve patient/family’s knowl-
edge regarding discharge date, extensive work is required
to engage staff in such a project for it to be successful.
Further studies are required to refine the implementation
of this strategy using knowledge translation principles,23,24
determine whether the ‘Leaving Hospital Information
Sheet’ can prevent unnecessary delays in discharge and
explore whether it can be utilised in alternative settings.
Ensuring efficient and accurate communication between
clinical teams and patients/families is patient centred and
can potentially improve the patient/family’s experience
and reduce LOS.
61
New et al.

Acknowledgements Trompf, Virginia Pilcher, Yurkdes Aran Sittampalam, Viran

Preliminary results from this project were presented at the
Monash Health Research week, 25–29 November 2013,
Melbourne, Victoria, Australia. The following Monash
University fifth-year medical students are thanked for
assisting with data collection: Heidi Zoumboulakis, Leisel
Chaminda Salgado, Anita Pither, Jonathan Chee Boon Lim,
Patricia Wei Ru Khoo and Felicia Su-Yen Tan. The staff of
Ward North-West 2, Kingston Centre, Monash Health,
Victoria, in particular Ms Katrina Hidalgo (Nurse Unit
Manager) and Dr Mohit Dhir, are thanked for their
assistance with implementing this project.

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