Article Figures & Data
Figures
- Figure 1. A systems approach framed as an iterative series of questions.
Blue = people perspective. Green = systems perspective. Red = design perspective. Orange = risk perspective. Purple = systems approach ‘project questions’. Non colour-dependent versions of all figures are available in the supplementary materials, under the Figures & Data tab.
- Figure 2. A model of the local architecture of the current system of communication to GPs at hospital discharge, constructed as a hybrid of descriptions provided by the study participants and shown as four phases. Dotted lines represent optional elements to the communication system. Zoom-enabled and non colour-dependent versions of all figures are available in the supplementary materials, under the Figures & Data tab.
- Figure 3. The purpose model. Clinical Information elements were found to serve specific purposes in an emergent sequence, shown as left to right. ‘Constant purposes’ that are always required are shown in bold and with asterisk, with others dependent on the patient involved. The right-to-left arrows indicate how purposes should be used to determine the information and detail within each element, as proposed for future education of discharge summary authors
- Figure 4. Barriers to system performance: themes from “'what affects the system?'” organised by system phase.
Tables
Semi-structured interviews of clinicians (n = 10) Stakeholder type Number Notes FY1 doctors 2 Based in geriatrics Hospital registrars 1 Based in geriatrics Consultants 3 2 geriatricians, 1 consultant physician in senior management position GP registrars 2 1 in first year of training, 1 in final year of training GPs 2 1 in early career (<5 years post-qualification), 1 in later career (>20 years since qualification) Focus group of clinicians (n = 1)The group comprised: FY1 doctors 1 Based in geriatrics, not previously interviewed Consultants 2 2 geriatricians, one previously interviewed GP registrars 2 Both in final training year, one previously interviewed GPs 1 In later career, previously interviewed Semi-structured interviews of admin and supporting staff (n = 8) GP surgery admin staff (n = 5)Five GP surgeries were sampled purposively through interview with a single staff member. These surgeries were stratified by the following characteristics: Size of surgery 2 multisite, 3 single-site Location type 4 within city perimeter, 1 rural IT System 4 SystmOne, 1 EMIS Hospital staff (n = 3)Participants were identified as the project progressed and recruited by convenience sampling. Participating staff (1 per setting) were from: (i) the GP liaison office, (ii) the GP pharmacy queries office, and (iii) the IT development and support team FY1 = Foundation Year 1.
Stakeholder needs How well are their needs met? Patients To understand what has happened, what medications to take, and what is happening next
For care to be provided in a coordinated manner where necessary
'Probably the most common thing I find myself doing is helping them to understand what has been a very frightening period of time, with often quite poor communication about what’s going on .' (GP 2)
' I think as a patient, I'd be very disappointed that the hospital were looking at letters that are just being generated, no one’s really sure what’s on it, the person who wrote didn’t know, we’re not sure if the GP practice is going to get it .' (Consultant 2)
Hospital junior doctors(FY1 and SHO) Time to write the discharge summary before discharge
To know the relevant information to include in the discharge summary
Support or advice when unsure
Feedback on current performance and areas for improvement
' Junior doctors, who might not know the patient well, who are trying to do a million and one other things, getting bleeped by someone to go and do something. This is not setting up a system where somebody’s likely to produce a good output .' (Consultant 3)
' I don’t think I consistently know what a GP wants to know in a discharge summary . ' (FY1 doctor 2)
' Actually, I don't think we knew what we were doing [when we were hospital juniors].' (GP registrar 2)
' Of course, I think they should ask for help more .' (Geriatric registrar)
Hospital registrars Discharge summaries to be done proficiently
Discharge summaries to be done by junior doctors with support where required
' If I had to go off and do a clinic full of 30 patients , and do central lines, I know I wouldn't be looking at the d ischarge s ummaries because I wouldn't have time .' (Geriatric registrar)
'... there’s only been one time when the registrar was like " I'll look over this ” , there’s not much oversight .' (FY1 doctor 1)
Consultants Discharge summaries to be done proficiently
Other team members to author the discharge summaries with support if necessary
Patients to be discharged as promptly as possible
' It’s rare I see a d ischarge s ummary and think that’s exactly what I would like to be on it … it’s rarely going to go out as the quality you want it to be. ' (Consultant 2)
' You don't want to go up to the consultant and say " I'm really sorry … I'm trying to explain to the GP and it doesn't make sense " . ' (FY1 doctor 2)
GPsandGP registrars Relevant and complete information for the patient, as quickly as possible
Resolution of missing information in a timely manner with minimum additional workload
' I've been working since August, and I genuinely have no idea what the quality of my summaries are .' (FY1 doctor 3)
' I'd say things are improving, but I don't think we're consistently hitting that target of being good enough for a GP .' (Geriatric registrar)
' I'm not on the receiving end of d ischarge s ummaries. So I don't know how well it works .' (Consultant 1)
[Do you feel like the system works?] ' Often around here, no .' (GP 2)
' It works to a certain extent, I do get some information. There are definitely times when it’s lacking .' (GP 1)
[How easy is it to try and plug that information gap?] ' Usually pretty difficult .' (GP 2)
FY1 = Foundation Year 1. SHO = senior house officer.
Supplementary Data
- BJGPO.2021.0148_Supp.pdf -
Supplementary material is not copyedited or typeset, and is published as supplied by the author(s). The author(s) retain(s) responsibility for its accuracy.
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