Pattie Boast
Cathy Potts

Providing easy-to-understand discharge instructions has helped one hospital lower the number of readmissions and cut the number of patient questions in the call center.

At a Glance

By using 140 sets of automated discharge instructions, Department of Veterans Affairs Medical Center at Portland, Ore., cut its 14-day readmission rate to 1.5 for every 1,000 outpatient procedures. Providers are prompted to document:

  • Dosage directions for any medications to be taken upon discharge  
  • The date when it is safe to resume any medications taken routinely  
  • Pain medications received during the procedure  
  • Dates of follow-up appointments  

Linking a hospital's payments to its readmission rates has become a top target of current healthcare reform efforts. A 2009 study in The New England Journal of Medicine shows 20 percent of Medicare patients are readmitted to hospitals within 30 days-at an annual cost of $17.4 billion. Beginning in 2012, Medicare will start cutting reimbursement on all inpatient discharges to hospitals that experience "excessive" readmissions for certain diagnoses.

It is just one initiative among many designed to link payment to improvements in patient care quality. One hospital, however, has found that providing personalized discharge instructions is a fairly simple, patient-centric, effective way to combat costly readmissions.

The Department of Veterans Affairs Medical Center (PVAMC) at Portland, Ore., routinely fielded 100 phone calls daily from recently discharged patients with questions about post-procedure care. Because call center nurses typically were unsure of the specific discharge instructions provided by surgeons, they often were forced to refer patients to the emergency department (ED) for further care. Lack of easily understood instructions also occasionally led to otherwise preventable readmissions.

A few years ago, PVAMC was experiencing about 4.1 readmissions for every 1,000 outpatient procedures. By using 140 unique sets of automated discharge instructions, PVAMC has reduced its 14-day readmission rate to about 1.5 for every 1,000 outpatient procedures.

Streamlining the Discharge Process

In the past, PVAMC providers gave discharge instructions by offering handwritten notes, typically in conjunction with fairly generic paper forms, or by using software within the Department of Veterans Affairs (VA) electronic health record (EHR) system.

The paper-based process required a surgeon to discuss instructions with a nurse, who would locate the appropriate paper documents, review them with the patient, and write any patient-specific or procedure-specific details. Understandably, handwriting legibility sometimes became an issue, as well as the print quality of forms that were photocopied repeatedly.

Although the EHR software was a step in the right direction, the EHR lacked important formatting functionality to allow instructions to be typed directly into it. The EHR could not accommodate boldface type or bulleted lists, for instance, and font sizes were not adjustable. Although seemingly minor, these limitations proved quite significant to PVAMC patients. Many elderly veterans, for example, expressed difficulty reading small font sizes.

The readmission rate-and the numerous queries to the call center for routine postoperative issues-made it clear that neither discharge process served patient needs as desired. Consequently, PVAMC decided to develop a new instruction method focusing on improving care quality and reducing costs associated with preventable readmissions, workflow inefficiency, and litigation risk.

A team was formed to create a system in which automated patient- and procedure-specific discharge materials could be compiled. This end was accomplished by a four-step process.

First, a nurse was appointed for each clinical specialty to spearhead the project. Duties included identifying the outpatient procedures most frequently performed within the specialty, and then creating draft instructions for each of those procedures.

Second, each section chief was asked to review and approve the draft instruction sets.

Next, the instruction sets were submitted for formal review by the PVAMC Forms Committee. At this point in the process, the instructions were presented in a standard format, identified by procedure.
Last, all approved instruction sets were imported into PVAMC's automated informed-consent application (AICA). Once imported, prompts were added to the documents to help obtain desired information, as well as patient signatures. (Patients sign the electronic forms using a digital signature pad to indicate that they have discussed and received their discharge instructions).

As might be expected with any major change to long-entrenched practice habits, PVAMC faced some initial provider pushback. Acceptance of the new process quickly grew, however, as providers experienced the benefits to patient care, documentation, workflow, and risk management.

The Economy of Patient-Centric Care

To many providers, "standardized" and "patient-specific" seem somewhat inconsistent. Yet the provision of discharge materials at PVAMC now promotes more personalized care while also gaining workflow efficiencies.

PVAMC surgeons now choose an appropriate postoperative care plan for their patients from the order entry module in the medical center's EHR. Nursing staff retrieve the order and create the discharge instructions within the AICA. Through a combination of check-boxes and free-form fields, providers are prompted to document:

  • Dosage directions for any medications to be taken upon discharge
  • The date when it is safe to resume any medications taken routinely, such as aspirin, therapy, or anticoagulant drugs
  • Pain medications received during the procedure
  • Information about the proper use of any medical equipment required after discharge dates of follow-up appointments
  • Other relevant details

Completed instructions are printed and handed to the patient and also posted to the EHR through its integration with the AICA. A note indicating that the patient has received a copy of the discharge instructions is automatically saved within the patient's electronic chart. A digital image of the signed form also is saved in the document management system. In addition, imported provider lists allow the name of the physician responsible for care to be clearly identified on the discharge instruction sheets.

Integration of the two systems ensures that all providers-including regional call center staff-can easily access and clearly understand the exact set of personalized instructions for each patient. The precise information enables any provider to quickly clarify and reinforce crucial details with the patient over the phone. Higher quality and more patient-centric responses to patient concerns have diminished the need for costly readmissions back to the ED or hospital.

A Full-Circle Approach

Providing easily understood post-procedure discharge instructions has helped PVAMC dramatically lower the number of questions in the call center and the number of readmissions into the hospital. It is important to realize, however, that these goals have not been achieved simply by handing patients better educational material on the back end. Incorporating the documents into preprocedure processes has been an essential component of PVAMC's success.

Facilities should keep in mind the physical limitations many patients experience immediately following surgery. Factors such as stress, anesthesia aftereffects, and pain medications can make it difficult for patients to comprehend and remember detailed information after a procedure.

Patients who feel invested in their own healthcare decisions from the beginning of the process are more likely to understand and adhere to their follow-up care plans. As part of preprocedure education planning, nurses at PVAMC question patients about preferred ways to receive information-for example, whether they favor written or verbal communication. Information is disseminated accordingly. For example, a nurse might enlarge the font size on documents printed for a patient who communicates a concern about poor eyesight.

Days before a scheduled procedure, patients are provided a preliminary copy of the discharge instructions. This allows ample time for patients to read and understand education materials, ask questions, and become truly involved in care decisions.

Advantages Gained

Prior to automating the discharge process, post-procedure patient calls consumed an enormous amount of nursing staff time. After implementation, PVAMC quickly saw a dramatic decline in the number of incoming discharge-related calls. More cost-effective care is provided for the remaining calls.

With fewer calls and real-time access to information through the EHR, it is possible for a small pool of nurses to handle call-backs, freeing all of them for more daily care duties. The former "scavenger hunt" for paper documents is gone. In fact, paper forms are no longer used in the outpatient surgery department, where compliance with electronic documentation is 100 percent.

There are also legal advantages from documenting all discharge material in the patient chart. Patients must sign to acknowledge receipt and understanding of their instructions, leaving patients with a deeper commitment to follow the directives and providing proof that all information was provided, helping to reduce the potential for malpractice litigation. Fewer than 40 discharge instructions were saved in PVAMC's EHR in the year before the automated process was implemented. In 2010, more than 8,500 documents were saved.

Moving Forward: The Essence of "Meaningful Use"

PVAMC now employs its discharge instruction process in the outpatient surgery department and emergency department observation unit. The inpatient surgery/medicine department soon will implement the process too. It has shown itself to be a straightforward, efficient, and cost-effective way to provide higher quality and more patient-centric care.

The concept of tying hospital payment to patient-oriented processes that improve care quality now predominates in national healthcare policy. It is the backbone of reform legislation initiatives, such as those outlining the "meaningful use" of health IT.



As a VA facility, PVAMC admittedly follows different rules and regulations than most hospitals and health systems. It cannot, for instance, qualify for "meaningful use" incentive dollars. Yet PVAMC's automated discharge process certainly exemplifies the kind of procedure envisioned by the Stage 1 "meaningful use" core objective that requires hospitals to provide patients with electronic copies of their discharge instructions.

It is not surprising that a "meaningful use" objective targets discharge information. Academic research shows a distinct correlation between discharge instructions and hospital readmissions. The conclusion: Better discharge processes seem to contribute to fewer costly returns to acute care settings, which ultimately can lead to better patient outcomes.

The discharge process at PVAMC appears to support the conclusion. Through tools that offer legible instructions in plain, easy-to-read language, patients gain a greater understanding and commitment to their health care. The investment in up-front education has paid back-end dividends. Patients are more compliant with their instructions and less likely to require increasingly costly readmission.

Pattie Boast is a program specialist, operative care division, Veterans Affairs Medical Center, Portland, Ore. (

Cathy Potts is a clinical applications coordinator, Veterans Affairs Medical Center, Portland, Ore. (


Checklist for a Well-Designed Discharge Instruction Process   

  • Develop a library of procedure-specific discharge instructions. Creating consistency in what is delivered to each patient minimizes repetitive nursing input
  • Allow for some patient-specific customization. Patient-specific variables including medication instructions and follow-up visit information should be noted on the form.
  • Store discharge instructions in an electronic database. A database ensures that only the most current versions of discharge instructions are used and that fresh, printed materials are always legible.
  • List the surgeon or responsible physician on the discharge instructions. If questions arise, providers who reference the discharge instruction document should readily see where to address questions.
  • Capture a patient signature. Requiring a signature helps solidify the patient's ownership in his or her post-procedure care plan.
  • Place a note documenting the provision of discharge instructions in the patient's medical record. A note allows providers to quickly verify that the patient has been supplied with post-procedure instructions.
  • Retain an electronic copy of the discharge instruction in the patient's medical record. If lost or misplaced, the discharge instructions may be quickly reprinted; all providers have ready access to the exact instructions provided to the patient.

Publication Date: Monday, August 01, 2011

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