Running head: QUALITY IMPROVEMENT

Quality Improvement: Post-discharge Call Backs

Elizabeth Degelbeck, Misty Donley, Kristen Kubik, Lisa Porter
Ferris State University

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Quality Improvement Post-discharge Call Backs

To err is human, to forgive, divine. Although this quote by Alexander Pope seems like
a great concept, it does not uphold to its full potential in the healthcare field. Patients trust and
depend on healthcare professionals and industries for their own wellness and safety. When that
confidence is broken through poor healthcare quality and errors, not only is the patient and
family harmed, but also anyone that was involved in the error. As the Institute of Medicine
(IOM) stated in their 1999 report brief that health care in the United States could and should be
safer that it is (p. 1). Since this report, healthcare has been focusing on improving quality
outcomes and decreasing the cost of healthcare. Healthcare mistakes alone cost 17 to 29 billion
per year and result in 98,000 deaths in hospitals (IOM, 1999).
Nurses are in the forefront of examining the work environment to identify where quality
and safety are issues and how it is influenced by human factors, the interrelationship between
people, technology, and the environment in which they work (Sherwood & Barnsteiner, 2012, p.
9). Improving quality and safety begins at the bedside and it is imperative that nurses are
prepared to continuously scan for any areas that affect that quality and safety of the healthcare
environment and need to be addressed. Nurses that are actively involved in the quality
improvement process with an interdisciplinary team, not only improve patient outcomes but
ensure job satisfaction and a healthy working environment (Yoder-Wise, 2015).
Analysis of Clinical Activity
The quality improvement (QI) process is structured in nature and involves a continual
analysis of the clinical activities being addressed. There are six steps involved with the QI
process according to Yoder-Wise (2015, p. 367) and they include:
1.) Identify needs most important to the consumer of healthcare services.

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2.) Assemble an interprofessional team to review the identified consumer needs and
3.)
4.)
5.)
6.)

services.
Collect data to measure the current status of these services.
Establish measurable outcomes and quality indicators.
Select and implement a plan to meet the outcomes.
Collect data to evaluate the implementation of the plan and the achievement of
outcomes.

The transition from hospital to home can at times be quite difficult for patients due to a
new diagnosis, change in medications, wound care, or significant diet and lifestyle changes.
With multiple changes in their care plan, a patient easily becomes perplexed by the discharge
papers, the hurried discharge instructions given by the nurse, and the abundance of information
given. These factors as well as many others lead to preventable adverse events for the patient
such as medication errors, discontinuity of care, or re-hospitalization within 30 days (Soong,
Kurabi, Wells, Caines, Morgan, Ramsden, & Bell, 2014). In fact, multiples studies have stated
that adverse events have occurred in as much as one in five patients when recently discharged
(Harrison, Aeurbach, Quinn, Kynoch, & Mourad, 2014).
A clinical activity that has recently been implemented in the hospitals, to assist with the
transition of care from hospital to home, is discharge follow-up phone calls. Post-discharge calls
are used to identify and resolve potential issues in care that may occur once the patient is home.
This also gives the healthcare provider an opportunity to reinforce teaching conducted on
medication changes, follow-up plans, and other specific elements in their discharge instructions
(Harrison, Aeurbach, Quinn, Kynoch, & Mourad, 2014, p. 1519). According to various studies,
call backs have proven to be beneficial in patient outcomes, health care provider outcomes, and
health system outcomes. It is important to make the discharge phone call within 24-72 hours of
discharge to improve the outcomes, however that time period is somewhat unfeasible for some

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floor nurses and it is important to consider other staff to complete this intervention. Other
constraints for this intervention could include being unable to make contact with patient and the
cost involved (Bahr, Solverson, Schlidt, Hack, Smith, & Ryan, 2014). To improve the discharge
follow-up phone call process, it is important to address the intervention, collect data, and
establish outcomes that could potentially enhance the safety of patients that have recently been
discharged.
Interdisciplinary Team
Determining whether post-discharge phone calls are effective or not will take an
interdisciplinary team analyzing the data. This team will include nurses, doctors, lawyers, and
hospital management. Anytime policies and procedures are being changed, thorough and
intensive data collection and research must be conducted in order to determine the benefits or
detriments prior to implementation. These members will be looking at what the task entails, its
feasibility and cost effectiveness, any advantages or disadvantages, and liability.
The physicians and nurses will be assessing the medical impact of the action and looking
for improved patient satisfaction and safety. With their knowledge, they will be able to look into
the medical responsibilities of the action. Examples of issues decided by the medically trained
team members are: questions the caller will ask, how long after discharge will the phone call be
made, who is medically able to make the phone call, and to what extent are they allowed to
advise the patient.
Hospital management determines whether the task is worth the time and effort, whether it
will improve patient satisfaction, and how it will meet requirements set up by state regulating
agencies. It is the managements legal and moral commitment to ensure high quality care and
strive to improve care (Parand, Dopson, Renze, & Vincent, 2014). They are in the prime

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position to mandate policy, systems and procedures. If management does not foresee these
callbacks as being cost-effective and increasing patient safety and satisfaction, they will not
implement the initiative.
The legal team will be looking into the legal responsibilities this action places on the
caller and hospital. A very important question to consider is, Does the advice given during the
follow-up calls put your staff or facility at risk? In 1998, Christine Flanagan received a bilateral
tubal ligation by the Bay Shore, N.Y. hospital. She had no complications and had an excellent
recovery during her hospital time. Ms. Flanagan received discharge instructions to notify the
hospital if she had any abdominal pain or discomfort. Once home, she did experience abdominal
pain but did not notify anyone. The next day, a nurse conducted a follow-up call where she was
told about the abdominal pain. The patient and nurse decided Ms. Flanagan would call her
surgeon immediately and get the issue checked out. However, Ms. Flanagan did not place the
phone call and was seen days later in the emergency department for a bowel perforation, which
ended in a colostomy for the patient. Ms. Flanagan sued for negligence. Even though the jury
found her 85% responsible because she failed to call the surgeon as she agreed to, they also
thought the nurse conducting the phone call should have informed the surgeon herself (Lyddane,
2013). Because of stories like this, it is important that the hospital have well trained staff
conducting the phone calls, as well as, legal representation for the hospital and its staff.
The final part of the interdisciplinary team is those actually involved in making the phone
calls. First, a patient will have a discharge educator (DE). This person sees the patient during
their hospital stay and is responsible for all discharge planning and education conducted during
that time (Tool 5, 2015). To maintain continuity of care it is important that whoever is making
the post discharge phone call (if it is not the DE) is in communication with the DE. The DE has

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already spent time getting to know the patient, family and circumstance and will lend useful
insight into the situation. However, it is important that the designated team member conducting
the phone call does not hold to any preconceived notions or personal bias based on certain
information gained during the hospital stay. The patient is now in a different setting with
different needs (2015).
The second member of the phone call team is the person making the call. As stated, it is
important they communicate with the DE, promising a smooth transition of care. Key tasks the
caller should accomplish are reviewing the patients health history and familiarizing themselves
with the discharge plan. It is important to look for:

Diagnosis and condition at discharge

Personal information including daily routine, relevant cultural practice, family

involvement, support staff, and relevant stressors

Follow-up appointments
Home services and equipment (2015).
Data Collection
Once the activity and team have been determined, it is time to establish a data collection

method. Data collection refers to the process of gathering and measuring information (Data
collection, 2015). For this study, our team will be retrieving the phone call progress notes from
an electronic medical record (EMR) database. This will let us know which calls have been
attempted, whether the patient or caregiver answered the call and what resulted from the phone
call intervention (Harrison et al, 2014). Then inpatient admissions and readmissions during a
specific time-period can be determined by reviewing billing data. Reasons why patients would
be excluded from the study include: they were readmitted within 72 hours of discharge so they
may not have received a phone call or they were readmitted for a different medical issue than
what was addressed during the original visit. Also, for patients who were readmitted more that

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two times during a 30-day period, we collected data from only the initial and second admittance.
Patients with so many remittances might suggest a unique issue putting them in a different
population group than those our study was looking at.
Outcomes
The expected outcomes from post-discharge callbacks is to achieve 95 99 percent
Press Ganey satisfaction scores, reduce the risk of negative outcomes following discharge, and
collect timely and statistically significant patient data (Robert Wood Johnson Foundation,
2013). Nursing would also be able to identity patient concerns related to new medications,
effectiveness of antibiotics, changes to diet and exercise plans and the patients ability to get
follow up care. If the patient or caregiver is unable to get prescriptions filled, needed services or
follow-up care, nursing can make referrals to social work or other available resources.
Ideally, nursing call-backs will allow for early intervention and correction for patient
issues post-discharge. The hospital will benefit financially from decreased readmission rates and
repeat emergency department visits with higher reimbursement. The patient data collected can
benefit future discharge education and identification of needed services.
Implementation Strategies
Implementation strategies for patient call backs post-discharge will be done by using the
five Ws and how: Who is going to do it? Whats going to be done? Where are we going to do
it? When are we going to do it? Why are we going to do it? And how are we going to do it?
(FastCompany, INC., 2015). With any change process, there comes resistance. However,
change is important in any leadership process. Through transformational theories, a leader can
implement strategies that are responsive to a patients needs through optimism, empowerment,
motivation, and scholarship of practice (Yoder-Wise, 2015). After discussing the process with

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the interdisciplinary team through open communication, education will be given to staff
members involved and tasks will be appointed. It is important to note, that with any part of the
implementation process, there needs to be continual feedback and education that will assist in
improved positive outcomes.
The assigned registered nurse from the interdisciplinary team will make the postdischarge call-backs. A scripted questionnaire will be asked of the patients or caregivers via
telephone. Questions that will be included in the call-backs will be more open-ended to ensure
the patients understanding of their discharge instructions, medications, and plan of care which
utilizes the teach-back method in patient education (Rush, 2012). Questions that will be included
will assess the health status, medication compliance, clarification of appointments, diagnostic
and laboratory studies, home services, and if the patient knows what to do if a health problem
occurs.
1.) How is the patient feeling?
2.) Were they able to schedule all follow up appointments? If they were not able to, why
not?
3.) Did they get their prescriptions filled? If not, why not? Are they taking any
medications that were not on the list that we provided them? If so, which ones?
4.) Have the home services been in contact with you?
5.) And most importantly do they have any questions or concerns?
Call-backs will be done by the RN from the individual units on post-discharge day one
through three. According to Harrison, Aeurbach, Quinn, Kynoch, & Mourad, a discharge phone
call placed within 72 hours will decrease the 30-day readmission rate (2014). The information
gathered from the call will be entered into their electronic medical record and concerns will be
addressed and documented in the moment. For example, the RN will also touch base with
primary care providers as needed if the patient is struggling to get a follow-up appointment that

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is needed. These call-backs will be tracked and evaluated in order to further aid with how the
process can be improved upon to better patient outcomes, increase patient satisfaction and
compliance, decrease 30-day re-hospitalization rates, and decrease healthcare costs.
Evaluation
The nurse manager will monitor Press Ganey satisfaction scores and re-admission rates
on a monthly basis to determine the effect that call-backs have. The EMR will be reviewed to
ensure that the call-backs are being performed effectively and on a timely basis. Hospital
management will review the patient satisfaction scores, patient outcomes, and re-admission rates
as well as financial amount spent on performing call-backs to determine the process and whether
it is cost effective to continue. This data will be discussed at staff meetings and leadership
councils on a monthly basis so any needed changes can be discussed and implemented.
Current research shows the successfulness evaluated from implementing these postdischarge calls. The Annals of Internal Medicine (2009) determined that there is a lower rate of
hospitalizations within 30 days of discharge in patients who received post-discharge follow-up.
This could include any form of discharge service that reached out to the patient once they
returned home. Another study in the Annals of Internal Medicine (2011) conducted a systematic
review of the current research regarding any intervention, enacted post-discharge. They pulled
from databases that included MEDLINE, Web of Science, Cochrane Library, and EMBASE.
Physicians split into two teams and reviewed the literature and assessed studies quality. The
interventions analyzed were post-discharge phone calls, patient-activated hotlines, patient
education, post-discharge home visits, and timely provider follow-up. They concluded that no
specific intervention was regularly linked to a decrease in hospitalizations within 30 days of
discharge. However, periodic benefits were seen when post-discharge interventions were

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implemented. Finally, a study in the American Journal of Managed Care (2012) looked at the
benefits of post-discharge calls and stated that telephonic communication is shown to encourage
self-enhancement skills. The patients interest in obtaining a healthier lifestyle and the
encouragement from the medical staff conducting the calls can lead to a 10% reduction in
hospital readmissions (2012).
Conclusion
Nurses are an important aspect of patient safety and quality assurance. Recognizing
potential errors and safety issues and implementing a strategy to ensure safe and quality care is
essential to healthcare. By creating an interdisciplinary team of providers to implement a process
for patient call-backs and follow ups, steps can be taken towards increasing patient satisfaction,
improving the discharge process and patient education, decreasing re-admission rates, and
improving patient health and healing. The healthcare environment must be updated with
evidence-based practice, and the data collected by this strategy will provide the evidence needed
to support patient call-backs and follow-up after discharge.

References
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http://ori.hhs.gov/education/products/n_illinois_u/datamanagement/dctopic.html.

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Melton, L.D., Foreman, C., Scott, E., McGinnis, M., Cousins, M. (2012). Prioritized postdischarge telephonic outreach reduces hospital readmissions for select high-risk patients.

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