American College of Physicians: Internal Medicine — Doctors for Adults ®


One hospital gets smart about discharge paperwork

From the June ACP Hospitalist, copyright © 2013 by the American College of Physicians

By Stacey Butterfield

Where: Anne Arundel Medical Center, a 400-bed acute care hospital in Annapolis, Md.

The issue: Clearly communicating discharge information to patients.


Clear, concise instructions have not been a traditional component of hospital discharge. “Usually you leave with a big old wad of papers that somebody shoves in [a] bag on your way out the door,” said Sherry Perkins, PhD, RN, chief operating officer of Anne Arundel Medical Center.

As part of an effort to be more patient- and family-centered, a committee of clinicians, administrators and patient and family advisors at Anne Arundel recently examined the content of those wads of papers.

“I personally looked at hundreds of discharge instructions and you start to feel embarrassed,” said Dr. Perkins. “We're better than most [hospitals] and we saw these problems—somebody after joint surgery leaving with ambiguous [warfarin] orders. We saw a patient go to a nursing home with an error in the medication reconciliation.”

With the aid of an “Always Event” grant from the Picker Institute, the committee developed a plan to more clearly communicate important information to patients leaving the hospital.

How it works

The project is called SMART discharge: Symptoms (to watch for), Medication (instructions, changes, reconciliation), Appointments (after discharge), Results (pending at discharge) and Talk (about any other concerns). The project leaders felt that these five categories were easily memorized and included all the key areas that patients and clinicians should cover at discharge.

“We built the essentials of what we call the SMART discharge protocol on the evidence from Project RED and others, but our goal was to simplify it,” said Dr. Perkins. (Project RED, or Re-Engineered Discharge, is a research group at Boston University Medical Center that develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates.)

Starting on three units in December 2011, the SMART template has been incorporated into a whiteboard in each patient's room, a worksheet for patients and families, and the hospital's electronically generated after-visit (or discharge) summary (AVS). Patients and their families can use the whiteboard or the worksheet during hospitalization to list questions they have or take notes on instructions from clinicians.

Clinicians also use SMART to communicate. “All the clinicians work off the same framework during rounds or other communication with the patient,” said Dr. Perkins. “[The whiteboard] becomes an easy visual way for clinicians to communicate short things—more like a text than a note in the record.”

Then, at discharge, the now-familiar SMART format is the organizing principle of the patient's AVS. The hospital's information technology staff modified the Epic electronic health record (EHR) to make this possible. “The patient's information flows to the AVS from other places in the record, so it becomes this distillation in the SMART format,” said Dr. Perkins.


After the implementation of the SMART discharge system on the medical/surgical, cardiac and neonatal units, Anne Arundel saw improvements in patient satisfaction, readmissions and the percentage of patients returning to the emergency department after discharge.

“We had a couple differences that were statistically significant,” said Dr. Perkins. “Not anything that knocks your socks off.” But, she noted, measures like readmissions, which are affected by numerous factors, may not be the best way to quantify the effects of the SMART system. “We're not sure which quantitative measures are going to make a difference, but we believe doing it is an ‘always event,’” she said.

Next steps

As the SMART protocol goes hospital-wide, the Anne Arundel team is still working to further simplify both clinician training on the protocol and the SMART AVS itself. “Our discharge order sets are being rewritten so that the doc or nurse practitioner or physician assistant is required to complete essential fields so that the AVS gets cleaner and cleaner,” said Dr. Perkins.

Words of wisdom

Dr. Perkins encourages other hospitals to borrow the whole SMART system (tools are available online) or find their own ways to modify EHR systems to produce more patient-friendly documents. “Don't become a slave to the record; make the record a slave to you,” she said.


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