A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service

Hospital discharge describes the point where patient care and recovery within an in-patient acute facility is transferred and continued within a community, social care or domestic setting. Policies repeatedly suggest hospital discharge is not an end-point in patient care, but rather one of multiple transitions within the patient’s journey [1, 2]. The organisation and provision of this transitional care typically involves multiple health and social care actors, who need to coordinate their specialist activities so patients receive integrated and, importantly, safe care. The problems of coordinating these various actors have resulted in hospital discharge being identified as a vulnerable or ‘at risk’ transitional stage. This vulnerability has been associated with system pressures, such as ‘delayed discharge’ or ‘bed blocking’ because of the failure to coordinate care [2‐5]. According to Victor et al. [6], nearly 30 % of older people experience some delay in their hospital discharge, which exposes patients to additional hospital-related risks, creates emotional and physical dependency, incurs additional hospital costs and restricts the availability of hospital beds.

Studies show that care quality can be suboptimal during, or as a consequence of, hospital discharge [5]. Data provided by the former English National Patient Safety Agency (NPSA) [7] indicates that ‘transfer/discharge of patient and infrastructure’ accounted for 7–8 % of reported safety incidents in 2009. This figure is likely to be a significant underestimate given most incident reporting systems are not well utilised across health and social care boundaries. A major telephone survey of 400 patients following discharge found that nearly 20 % reported some form of adverse event, of which 6 % were preventable and 6 % ameliorable [8]. Research highlights a number of common discharge-related risks including the management of medicines, the provision of appropriate health and social care, incomplete tests and scans, the fitting and use of home adaptation, and the risks of falls, infections or sores [4, 5, 8‐11]. The underlying sources of these risks can range from factors related to the patient condition or co-morbidities, to the assessment of patient need, the availability of specialist resources in the community and wider organisational factors. However, there is limited evidence of the common contributing factors that influence the safety of transitional care.

Of the factors often identified as contributing to unsafe discharge, communication is often seen as integral to the quality and safety of hospital discharge. Returning to NPSA data [7], ‘notifying and organising external services’ was identified as the most common category of reported incident. A systematic review conducted by Kripalani et al. [4] found that communications between hospitals and family doctors were often partial or missing, relying primarily upon frequently incomplete, ambiguous and delayed discharge summaries. A recent large-scale European study found consistent problems in communication and information exchange during discharge processes as contributed to common problems of medicines reconciliation, loss of information, and absence of care plans [12‐14]. Furthermore, complications and risks are exacerbated by a failure to involve patients and families in the discharge process [12].

Significantly, problems with communication and coordination can be interpreted as stemming from the inherent complexity of the health and social care system, where there are multiple inter-dependent organisations and specialists involved in the discharge planning and care transition. Glasby [2] highlights three dimensions as influencing the interaction of different agencies: occupational factors related to the particular knowledge, cultures and practices of different professionals; organisational factors related to the working patterns, capabilities and resources of different agencies; and compatibility and coordinating factors related to how occupational and organisational factors are aligned, or differences reconciled. These represent wider systemic factors that influence the safety of care transitions.

Current thinking in the field of patient safety conceptualises the threats to safety as stemming not from individual negligence, malice or incompetence, alone, but as being brought about or made possible by the influence of ‘upstream’ factors located, for example, in the way groups work together, the design and management of work, and the wider organisation of care [15, 16]. This promotes analysis of the links between active errors and upstream latent factors. Although this line of thinking has been applied extensively to healthcare, the focus has typically remained within care domains, such as the ward or operating department. As a patient safety problem, hospital discharge is therefore significant because it highlights the potential for latent factors to be located across the wider care system at the inter-organisational relationships, thereby presenting more complex and challenging sources of risk.

Despite increased understanding of the types of risk patients can experience during hospital discharge, there remains only partial evidence about the interaction between proximal contributory factors, and distal latent factors. There is also limited understanding about how patients and staff involved in discharge planning and care transition perceive the relationship between more active and latent factors, and what this might tell us about stakeholders’ different perceptions and understanding of hospital discharge. This qualitative study investigated the views of healthcare professionals and patients and their carers about the threats to safe hospital discharge with aim of identifying contributory and latent factors.

The results section first describes stakeholders’ perceptions of safety events experienced during discharge planning and care transition. It then describes what stakeholder saw as the immediate or proximal contributory factors associated with these safety events, and finally describes the perceived distal factors that might be interpreted as the underlying root causes. The study design anticipated that stakeholders might have different experiences and perceptions of the threats to safe discharge according to the differences in the study sites (e.g. local demographics and care systems variations) and patient groups (e.g. different care needs for stroke and hip fracture patients). However, the study found relatively common and consistent findings across both the care settings and patient groups, suggesting a degree of generality, and where notable differences were identified these are highlighted below. In addition, illustrative quotes are provided within the text and a further table to quotes is provided (Table 2).

Hospital discharge is a vulnerable and high-risk stage in the patient journey, requiring the interaction and coordination of multiple health and social care professionals and organisations. It is the complexity of these interactions that appears to underscore the quality and safety of patient care. Through exploring the experiences and perceptions of different stakeholders, this complexity is brought to light and through these accounts it is possible to better understand the different threats to safe hospital discharge, and what stakeholders understand as the factors that condition or bring about safety threats and the relationships between them [12]. Through better recognising these perceptions and viewpoints, it becomes possible to develop and target interventions that address the concerns of frontline clinicians.

Patient safety research has been influenced greatly by theories and models within the ergonomics and human factors to encourage greater analysis of the relationship between ‘active’ errors in frontline practice, and ‘latent’ factors found in the work environment, organization or care system [15]. Although this is a powerful analytical framework for safety scientists, it did not easily map onto the descriptive and explanatory narratives of participants. Participants appeared to provide highly detailed and specific illustrations of safety events, but they rarely categorised these incident in terms of specific errors or contributory factors. Moreover, participants rarely offered clear or linear casual accounts, e.g. ‘A led to B which led to C’ , rather they developed more complicated and non-linear accounts; discussed further below. In seeking to reflect the more complex ways in which participants talked of the threats to safe discharge, the approach taken in this study was to analyse and categorise accounts in terms of broader, and less pre-determined, ‘proximal’ and ‘distal’ factors, which allowed for more open interpretation of the assumed causal relationships underpinning respondents accounts.

Looking closer at the categories described, and the relationships between them, the study identifies a number of prominent assumed casual relationships that might be the focus of further research and intervention (see Fig. 2). Although each of the identified proximal factors clearly has an important bearing on different aspects of safety, for example the ordering of medicines has a bearing of medicines safety, the analysis suggests ‘patient assessment’ and ‘follow-up and monitoring’ was seen more often, and by more stakeholders, as having a bearing on discharge safety. Specifically, patient assessment was seen in various ways as contributing to all prominent safety issues, and was associated with other proximal risks, such as ordering of equipment or medicines. Similarly, follow-up and monitoring of the patient after discharge was associated with common safety issues. These might therefore provide two core activities or priorities for safety enhancement.

Turning to the wider or underlying distal factors, it was more difficult to detect clear or direct causal assumptions, but a number of common risk factors were described. In particular, these highlight the importance of discharge planning, especially the involvement of all relevant stakeholders in decision-making, the timing or planning activities, and the completion of tasks allocated during planning. Linked to this were similar problems with external referrals. Together these planning and communication activities were seen to complicate or condition various proximal factors, especially the provision of follow-up care, which is largely dependent upon the quality of planning and accuracy of referrals. It is also the case that the completion of patient tests and the quality of assessment could be influenced by the planning process, such as the inclusion of relevant clinical perspectives. Yet, this is also a two-way relationship as failure to complete assessment or tests invariably undermine discharge planning processes. The other commonly described distal factor was organisational pressure, linked to resource constraints. It was described how these created the conditions, through cultural or managerial expectations, in which discharge planning might be pressurised, and therefore incomplete, partial or substandard. Similarly, patient assessment, patient education, and ordering of equipment and medicines were complicated by organisational pressures. As such, the views of different stakeholders suggest greater attention to the quality of discharge planning (format, scheduling, involvement) in the context of wider organisational pressures might be key priorities for safety enhancements.

Reflecting further on the study findings, the views of participants reinforce the importance of communication in the processes of discharge planning and care transition. The wider literature on hospital discharge repeatedly suggests that effective and timely communication can reduce system complexity and support coordination, for example, in discharge planning or the use of checklists [4, 5, 8, 9, 12, 14, 22]. The wider literature on communication highlights a range of facilitating or inhibiting factors, ranging from the form and structure of language or knowledge being communicated to the characteristics of both ‘donor’ and ‘recipient actors’, such as their motivations, accessibility, levels of trust, values, hierarchies and absorptive capacity. Similarly, power hierarchies and cultural difference between actors can impact communication [2, 23]. As such, efforts to promote communication and coordination at the areas identified above might be priorities for safety improvements.

It is important, however, to be cautious in the use of participant accounts alone in the analysis of patient safety. As noted above, participants rarely provided clear or unambiguous safety narratives, rather they highlighted uncertainty and ambiguity in perception and understanding of the threats to safety [20]. In many instances participants provided a number of highly detailed and developed accounts of safety incidents, but when asked about risk factors in more abstract terms they would struggle to give an illustration of the consequences, for example, of an incomplete discharge plan. This might be explained by the difficulty that stakeholders have in understanding activities or conditions that occur in care settings other than their own. So for example, it was difficult for community social care providers to describe in detail why equipment might be missing, but they would infer or assume it was related to either the equipment supply or ordering processes. Similarly, those in the hospital environment had limited appreciation of the safety events that transpired in the community, such as the significance of an undiagnosed infection or ulcer. In other words, participants' understanding of discharge safety was shaped by their distinct position within the care process and the 'sight-line' or scope of perception this afforded for understanding either the preceeding causes of an event, or the consequences of their actions.  As such, the way in which stakeholders experienced, perceived and made sense of safety issues rarely involved linear chains of causality, rather they could be seen as reflecting assumptions prevalent in one part of the health and social care system. Moreover, these assumptions could be seen to reflect implicit and explicit forms of inter-group blame [24], or the tendency to allocate responsibility to other actors in the care system. For example, social care professionals often found fault with hospital staff or GPs, similarly ward nurses and therapists often criticised the way in which doctors dominated decision-making. These aspects of participants’ accounts reveal cultural differences and tensions between stakeholder groups, and the influence of politics and power in shaping the integration and coordination of care at the interface of the hospital and the wider care system. In other words, participants’ understanding of the threats to safety might be seen as reflecting and perpetuating underlying tensions and disagreements between professional groups about how care should be organised, and how certain groups create risks that undermine patient safety. As such, it is important to caution against using stakeholder perceptions and accounts directly without considering these psychological, cultural and political dimensions. Moreover, cultural and political dimensions might also be seen as an underlying social threat to safety that exacerbates many of the identified complications and risk factors. In other words, the accounts examined in this study provide insight into discharge risks, processes and cultures in their own right, while the assumed causal relationships identified provide the basis for future empirical study.

Hospital discharge is widely accepted as a high risk and vulnerable stage in the patient journey. With comparatively limited research on this care process, this paper investigated stakeholder perceptions and narratives about the threats to safe discharge. It looked, in particular, at the different types and categorise of risk and the assumed causality, in terms of proximal and distal factors. The study identified: (1) ‘direct’ patient harms comprising falls, infection, sores and ulceration, medicines-related issues, and relapse; (2) proximal ‘contributing’ factors including completing of tests, assessment of patient, management of equipment and medicines, care plan, follow-up care and patient education; and (3) distal ‘latent’ factors including discharge planning, referral processes, discharge timing, resources constraints, and organisational demands. Looking at the assumed relationships between these factors, stakeholder perspectives suggest patient assessment in hospital and follow-up and monitoring in the community setting were the main common immediate causal concerns of participants, with problems with care planning, referrals and organisational pressures as being the underlying factors. Focusing on these key areas might represent optimal areas for management or service intervention to promote patient safety during hospital discharge.

GP, General Practitioner; HCA, Health Care Assistant; NHS, National Health Service; NIHR, National Institute for Health Research.