systematic literature review narrative synthesis

• Research article
• Open access
• Published: 12 March 2019

A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients’ safety

• Christine Maria Schwarz 1 ,
• Magdalena Hoffmann   ORCID: orcid.org/0000-0003-1668-4294 1 , 2 ,
• Petra Schwarz 3 ,
• Lars-Peter Kamolz 1 ,
• Gernot Brunner 1 &
• Gerald Sendlhofer 1 , 2  

BMC Health Services Research volume  19 , Article number:  158 ( 2019 ) Cite this article

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The medical discharge letter is an important communication tool between hospitals and other healthcare providers. Despite its high status, it often does not meet the desired requirements in everyday clinical practice. Occurring risks create barriers for patients and doctors. This present review summarizes risks of the medical discharge letter.

The research question was answered with a systematic literature research and results were summarized narratively. A literature search in the databases PubMed and Cochrane Library for Studies between January 2008 and May 2018 was performed. Two authors reviewed the full texts of potentially relevant studies to determine eligibility for inclusion. Literature on possible risks associated with the medical discharge letter was discussed.

In total, 29 studies were included in this review. The major identified risk factors are the delayed sending of the discharge letter to doctors for further treatments, unintelligible (not patient-centered) medical discharge letters, low quality of the discharge letter, and lack of information as well as absence of training in writing medical discharge letters during medical education.

Conclusions

Multiple risks factors are associated with the medical discharge letter. There is a need for further research to improve the quality of the medical discharge letter to minimize risks and increase patients’ safety.

Peer Review reports

The medical discharge letter is an important communication medium between hospitals and general practitioners (GPs) and an important legal document for any queries from insurance carriers, health insurance companies, and lawyers [ 1 ]. Furthermore, the medical discharge letter is an important document for the patient itself.

A timely transmission of the letter, a clear documentation of findings, an adequate assessment of the disease as well as understandable recommendations for follow-up care are essential aspects of the medical discharge letter [ 2 ]. Despite this importance, medical discharge letters are often insufficient in content and form [ 3 ]. It is also remarkable that writing of medical discharge letters is often not a particular subject in the medical education [ 4 ]. Nevertheless, the medical discharge letter is an important medical document as it contains a summary of the patient’s hospital admission, diagnosis and therapy, information on the patient’s medical history, medication, as well as recommendations for continuity of treatment. A rapid transmission of essential findings and recommendations for further treatment is of great interest to the patient (as well as relatives and other persons that are involved in the patients’ caring) and their current and future physicians. In most acute care hospitals, patients receive a preliminary medical discharge letter (short discharge letter) with diagnoses and treatment recommendations on the day of discharge [ 5 ]. Unfortunately, though, the full hospital medical discharge letter, which is often received with great delay, is an area of constant conflict between GPs and hospital doctors [ 1 ]. Thus the medical discharge letter does not only represent a feature of process and outcome quality of a clinic, but also influences confidence building and binding of resident physicians to the hospital [ 6 ].

Beside the transmission of patients’ findings from physician to physician, the delivery of essential information to the patient is an underestimated purpose of the medical discharge letter [ 7 ]. The medical discharge letter is often characterized by a complex medical language that is often not understood by the patients. In recent years, patient-centered/patient-directed medical discharge letters are more in discussion [ 8 ]. Thus, the medical discharge letter points out risks for patients and physicians while simultaneously creating barriers between them.

A systematic review of the literature was undertaken to identify patient safety risks associated with the medical discharge letter.

Search strategy

A systematic literature search was conducted using the electronic databases PubMed and Cochrane Database. Additionally, we scanned the reference lists of selected articles (snowballing). The following search terms were used: “discharge summary AND risks”, “discharge summary AND risks AND patient safety” and “discharge letter AND risks” and “discharge letter AND risks AND patient safety”. We reviewed relevant titles and abstracts on English and German literature published between January 2008 and May 2018 and started the search at the beginning of February 2018 and finished it at the end of May 2018.

Eligibility criteria

In this systematic review, articles were included if the title and/or abstract indicated the report of results of original research studies using quantitative, qualitative, or mixed method approaches. Studies in paediatric settings or studies that do not handle possible risks of the medical discharge letter were excluded, as well as reports, commentaries and letters. Electronic citations, including available abstracts of all articles retrieved from the search, were screened by two authors to select reports for full-text review. Duplicates were removed from the initial search. Nevertheless, during the search of articles the selection, publication as well as language bias must be considered. Thereafter, full-texts of potentially relevant studies were reviewed to determine eligibility for inclusion. In the following Table  1 inclusion and exclusion criteria for the studies are listed. Afterwards, key outcomes and main results were summarized. Differences were resolved by consensus. Finally, a narrative synthesis of studies meeting the inclusion criteria was conducted. Reference management software MENDELEY (Version 1.19.3) was used to organise and store the literature.

Data extraction

The data extraction in form of a table was used to summarize study results. The two authors extracted the data relating to author, country, year, study design, and outcome measure as well as potential risk factors to patient safety directly into a pre-formatted data collection form. After data extraction, the literature was discussed and synthesized into themes. The evaluation of the single studies was done using checklists [STROBE (combined) and the Cochrane Data collection form for intervention reviews (RCTs and non-RCTs)]. Meta-analysis was not considered appropriate for this body of literature because of the wide variability of studies in relation to research design, study population, types of interventions and outcomes.

Then a narrative synthesis was performed to synthesize the findings of the different studies. Because of the range of very different studies that were included in this systematic review, we have decided that a narrative synthesis constitutes the best instrument to synthesise the findings of the studies. First, a preliminary synthesis was undertaken in form of a thematic analysis involving searching of studies, listing and presenting results in tabular form. Then the results were discussed again and structured into themes. Afterwards, summarizing of included studies in a narrative synthesis within a framework was performed by one author.

This framework consisted of the following factors: the individuals and the environment involved in the studies (doctors, hospitals), the tools and technology (such as discharge letter delivery systems), the content of the medical discharge letter (such as missing content, quality of content), the accuracy and timeliness of transfer. These themes were discussed in relation to potential risks for patient’s safety. All articles that were included in this review were published before. The framework of this study was chosen following a previously published systematic review dealing with patient risks associated with telecare [ 9 ].

The initial literature search in the two online databases identified 940 records. From these records, 65 full text articles were screened for eligibility. Then 36 full-text articles were excluded because they pertained to patient transfer within the hospital or to another hospital, or to patient hand-over situations. Finally, 29 studies were included in this review. Included studies are listed in Table  2 . All document types were searched with a focus on primary research studies. The results of the search strategy are shown in Fig.  1 .

Flow chart literature search strategy

From these 29 studies, 13 studies dealt with the quality analysis of discharge letters, 12 studies with delayed transmission of medical discharge letters and just as many with the lack of information in medical discharge letters. Only few studies dealt with training on writing medical discharge letters and with understanding of patients of their medical discharge letters. The descriptive information of the included articles is presented in Table 2 . Overall quality of the articles was found to be acceptable, with clearly stated research questions and appropriate used methods.

Risk factors

In the following the identified major risk factors concerning the medical discharge letter are presented in a narrative summary.

Delayed delivery

The medical discharge letters should arrive at the GP soon after hospital discharge to ensure the quickest possible further treatment [ 4 ]. If letters are delivered weeks after the hospital stay, a continuous treatment of the patient cannot be ensured. Furthermore, the author of the medical discharge letter will no longer have current data after the discharge of the patient, which may result in a loss of important information [ 10 ]. Interfaces between different treatment areas and organizational units are known to cause a loss of information and a lack of quality in patient handling [ 11 ]. The improvement of information transfer between different healthcare providers during the transition of patients has been recommended to improve patient care [ 12 , 13 ]. Delayed communication of findings may lead to a lack of continuity of care and suboptimal outcomes, as well as decreased satisfaction levels for both patients and GPs [ 14 , 15 , 16 ]. In a review of Kripalani et al., it was shown that 25% of discharge summaries were never received by GPs [ 17 ]. This has several negative consequences for patients. Li et al. [ 18 ] found that a delayed transmission or absence of the medical discharge summary is related to patient readmission, and a study by Gilmore-Bykovskyi [ 19 ] found a strong relationship between patients whose discharge summaries omitted designation of a responsible clinician/clinic for follow-up care and re-hospitalisation and/or death. A Swedish study by Carlsson et al. [ 20 ] points out that a lack of accuracy and continuity in discharge information on eating difficulties may increase risk of undernutrition and related complications. A study of Were et al. [ 18 ] investigated pending lab results in medical discharge summaries and found that only 16% of tests with pending results were mentioned in the discharge summaries, and Walz et al. [ 21 ] found that approximately one third of the sub-acute care patients had pending lab results at discharge, but only 11% of these were documented in the medical discharge summaries.

Quality, lack of information

Medical discharge letters are a key communication tool for patient safety issues [ 17 ]. Incomplete and insufficient medical discharge letters increase the risks of readmission and myriad other complications [ 22 ]. Langelaan et al. (2017) evaluated more than 2000 medical discharge letters and found that in about 60% of the letters essential information was missing, such as a change of the existing medication, laboratory data, and even data on the patients themselves [ 23 ]. Accurate and complete medical discharge summaries are essential for patient safety [ 17 , 24 , 25 ]. Addresses; patient data, including duration of stay; diagnoses; procedures; operations; epicrisis and therapy recommendations; as well as findings in the appendix; are minimum requirements that are supposed to be included in the medical discharge letter [ 4 ]. However, it was found that key components are often lacking in medical discharge letters, including information about follow-up and management plans [ 23 , 26 ], test results [ 27 , 28 , 29 ], and medication adjustments [ 30 , 31 , 32 , 33 , 34 , 35 ]. In a review of Wimsett et al. [ 36 ] key components of a high-quality medical discharge summary were identified in 32 studies. These important components were discharge diagnosis, the received treatment, results of investigations as well as follow-up plans.

Accuracy of patients’ medication information is important to ensure patient safety. Hospital doctors expect GPs to continue with the prescribed (or modified) drug therapy. However, the selection of certain drugs is not always transparent for the GPs. A study by Grimes et al. [ 30 ] found that a discrepancy in medication documentation at discharge occurred in 10.8% of patients. From these patients nearly 65.5% were affected by discrepancies in medication documentation. The most prevalent inconsistency was drug omission (20.9%). Only 2% of patients were contacted, although general patient harm was assessed. A Swedish study of 2009 [ 37 ] investigated the quality improvement of medical discharge summaries. A higher quality of discharge letter led to an average of 45% fewer medication errors per patient.

A recent study by Tong et al. [ 38 ] revealed a reduced rate of medication errors in medical discharge summaries that were completed by a hospital pharmacist. Hospital pharmacists play a key role in preparing the discharge medication information transferred to GPs upon patient discharge and should work closely with hospital doctors to ensure accurate medication information that is quickly communicated to GPs at transitions of care [ 39 ]. Most hospitals have introduced electronic systems to improve the discharge communication, and many studies found a significant overall improvement in electronic transfer systems due to better documentation of information about follow-up care, pending test results, and information provided to patients and relatives [ 40 , 41 , 42 ]. Mehta et al. [ 43 ] found that the changeover to a new electronic system resulted in an increased completeness of discharge summaries from 60.7 to 75.0% and significant improvements in levels of completeness in certain categories.

Writing of medical discharge letter is missing in medical education

Both junior doctors as well as medical students reported that they received inadequate guidance and training on how to write medical discharge summaries [ 44 , 45 ] and recognized that higher priority is often given to pressing clinical tasks [ 46 ]. Research into the causes of prescribing errors by junior doctors at hospitals in the UK has revealed that latent conditions like organizational processes, busy environments, and medical care for complex patients can lead to medication errors in the medical discharge summary [ 47 ].

Fortunately, some study results demonstrate that information and education on writing medical discharge letters would enhance communication to the GPs and prevent errors during the patient discharge process [ 37 ]. Minimal formal teaching about writing medical discharge summaries is common in most medical schools [ 39 , 46 ]; however, a study by Shivji et al. has shown that simple, intensive educational sessions can lead to an improvement in the writing process of medical discharge summaries and communication with primary care [ 48 ].

Since the medical discharge letter should meet specific quality criteria, senior physicians and/or the head physician correct(s) and validate(s) the letter. The medical discharge letter therefore represents an essential learning target [ 8 ]. Training activities and workshops are necessary for junior doctors to improve writing medical discharge letters [ 44 , 49 ]. It might be also useful for young doctors to use checklists or other structured procedures to improve writing [ 4 ]. Maher et al. showed that the use of a checklist enhanced the quality (content, structure, and clarity) of medical discharge letters written by medical students [ 50 ].

In the following Table  3 main risk factors of the medical discharge letter are summarized.

The results of this systematic literature research indicate notable risk factors relating to the medical discharge letter. In a study by Sendlhofer et al., 360 risks were identified in hospital settings [ 51 ]. From these, 176 risks were scored as strategic and clustered into “top risks”. Top risks included medication errors, information errors, and lack of communication, among others. During this review, these potential risk factors were also identified in terms of the medical discharge letter.

Delayed sending and low quality of medical discharge letters to the referring physicians, may adversely affect the further course of treatment. However, a study of Spencer et al. has determined rates of failures in processing actions requested in hospital discharge summaries in general practice. It was found that requested medication changes were not made in 17% and patient harm occurred in 8% in relation to failures [ 52 ].

Despite the existence of reliable standards [ 53 ] many physicians are not adequately trained for writing medical discharge letters during their studies. Regular trainings and workshops and standardized checklists may optimize the quality of the medical discharge letter. Furthermore, electronic discharge letters have the potential to easily and quickly extract important information such as diagnoses, medication, and test results into a structured discharge document, and offer important advantages such as reliability, speed of information transfer, and standardization of content. Comprehensive discharge letters reduce the readmission rate and increase safety and quality by discharging of the patient. A missing structure, as well as a complex language, illegible handwriting, and unknown abbreviations, make reading medical discharge letters more complicated [ 4 ]. At least, poor patient understanding of their diagnosis and treatment plans and incomprehensible recommendations can adversely impact clinical outcome following hospital discharge. Many studies confirm that inadequate communication of findings [ 3 , 39 , 54 ] is an important risk factor in patients’ safety [ 51 ].

Most medical information in the discharge letter is not understood by patients (as well as relatives and other persons that are involved in the patients’ caring) and patients themselves do not receive a comprehensible medical discharge letter. The content of the medical discharge letter is often useless for the patient due to its medical terminology and content that is not matching with the patient’s level of knowledge or health literacy [ 55 , 56 , 57 ]. Poor understanding of diagnoses and related discharge plans are common among patients and family members and often accompanied by unplanned hospital readmissions [ 58 , 59 , 60 , 61 ]. In a study by Lin et al., it was shown that a patient-directed discharge letter enhanced understanding for hospitalization and for recommendations. Furthermore, verbal communication of the letter contents, explanation of every section of the medical discharge letter, and the opportunity for discussion and asking questions improved patient comprehension [ 7 ]. A study by O’Leary et al. showed that roughly 80–95% of patients with breast tumours want to be informed and educated about their illness, treatment, and prognosis [ 62 ].

High quality of care is characterized by a patient-centered communication, where the patient’s personal needs are also in focus [ 63 ]. Translation of medical terms in reports and letters leads to a better understanding of the disease and, interestingly, the avoidance of medical terms did not lead to deterioration in the transmission of information between the treating physicians. Moreover, it was found that the minimisation of medical terminology in medical discharge letters improved understanding and perception of patients’ ability to manage chronic health conditions [ 64 ]. In effect, it is clear that patient-centered communication improves outcome, mental health, patient satisfaction and reduces the use of health services [ 65 ].

Strengths and limitations

We have identified key problems with the medical discharge summaries that negatively impact patients’ safety and wellbeing. However, there is a heterogeneous nature of the included studies in terms of study design, sample size, outcomes, and language. Only two reviewers screened the studies for eligibility and only full-text articles were included in the literature review; furthermore, only the databases Pubmed and Cochrane library were screened for appropriate studies. Due to these constraints, there is a chance that other relevant studies may have been missed.

High-quality medical discharge letters are essential to ensure patient safety. To address this, the current review identified the major risk factors as delayed sending and low quality of medical discharge letters, lack of information and patient understanding, and inadequate training in writing medical discharge letters. In future, research studies should focus on improving the communication of pending test results and findings at discharge, and on evaluating the impact that this improved communication has on patient outcomes. Moreover, a simple patient-centered medical discharge letter may improve the patient’s (as well as family members’ and other caregivers’) understanding of disease, treatment and post-discharge recommendations.

Abbreviations

General practitioner

Randomized Controlled Trial

STrengthening the Reporting of OBservational studies in Epidemiology

United Kingdom

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Acknowledgements

Not applicable.

This research project was part of a project funded by the Gesundheitsfonds Steiermark. The funders had no role in study design, data collection and analyses, decision to publish, or preparation of the manuscript.

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All data generated or analysed during this study are included in this published article and its supplementary information files.

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Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria

Christine Maria Schwarz, Magdalena Hoffmann, Lars-Peter Kamolz, Gernot Brunner & Gerald Sendlhofer

Executive Department for Quality and Risk Management, University Hospital Graz, Auenbruggerplatz 1/3, 8036, Graz, Austria

Magdalena Hoffmann & Gerald Sendlhofer

Carinthia University of Applied Science, Feldkirchen, Austria

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CS wrote the manuscript; CS, MH and PS performed the literature search; LK contributed to the conception of this work; GB contributed to the interpretation of data and GS supervised the project. All authors were critically revising the manuscript and all authors have read and approved the final manuscript.

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Schwarz, C.M., Hoffmann, M., Schwarz, P. et al. A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients’ safety. BMC Health Serv Res 19 , 158 (2019). https://doi.org/10.1186/s12913-019-3989-1

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Guidelines Campbell, M., McKenzie, J. E., Sowden, A., Katikireddi, S. V., Brennan, S. E., Ellis, S., ... & Thomson, H. (2020). Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. bmj , 368 . Full Text Other

Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., ... & Duffy, S. (2006). Guidance on the conduct of narrative synthesis in systematic reviews.  A product from the ESRC methods programme Version ,  1 (1), b92. Full Text

Thomson H, Campbell M. “Narrative synthesis” of quantitative effect data in Cochrane reviews: Current issues and ways forward [Internet]. Cochrane Learning Live Webinar Series 2020 Feb. Full Text   

Morley, G., Ives, J., Bradbury-Jones, C., & Irvine, F. (2019). What is 'moral distress'? A narrative synthesis of the literature.  Nursing ethics ,  26 (3), 646–662. https://doi.org/10.1177/0969733017724354 Link

References Popay, J., Roberts, H., Sowden, A., Petticrew, M., Arai, L., Rodgers, M., ... & Duffy, S. (2006). Guidance on the conduct of narrative synthesis in systematic reviews.  A product from the ESRC methods programme Version ,  1 (1), b92. Full Text

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A Systematic Review and Narrative Synthesis: Determinants of the Effectiveness and Sustainability of Measurement-Focused Quality Improvement Trainings

Associated data.

Supplemental Digital Content is Available in the Text.

Introduction:

The ability of health care professionals to measure change is critical for successful quality improvement (QI) efforts. Currently, there are no systematic reviews focusing on continuing education for health care professionals in data skills for QI. The purpose of this systematic review is to define effectiveness and sustainability of QI programs for health care professionals containing a measurement skills component and to identify barriers and facilitators to effectiveness and sustainability.

The systematic review involved study identification, screening, full text review, and data extraction. Four electronics databases and grey literature sources were searched to identify studies published between 2009 and 2019 (11 years). A customized data extraction form was developed. Mixed methods appraisal tool was used for quality assessment and a thematic analysis was conducted for narrative synthesis.

Fifty-three studies from 11 countries were included. Most study designs were quantitative descriptive (17/53) and used a blended learning approach (25/53) combining face-to face and distance learning modes. The programs included basic, intermediate, and advanced data skills concepts. Overall, studies reported positive outcomes for participant reaction, learning, and behavior, but reported variable success in sustainability and spread of QI.

Discussion:

Studies discussed measurement as a key competency for clinical QI. Effectiveness definitions focused on the short-term impact of the programs, whereas sustainability definitions emphasized maintenance of outcomes and skills in the long-term. Factors that influenced effectiveness and sustainability of the included studies were strategic approach to QI, organizational support, intervention design, communication, accountability, leadership support, and learning networks.

Health care organizations worldwide continue to test new systems and ways to enhance health care quality and patient safety. 1 Organizations are using continuing education programs in quality improvement (QI) methodologies to transform care and improve patient safety, reduce variations in care outcomes, and deliver sustainable changes in the health care system. 2 The use of such programs to improve health care has also gained considerable popularity in the health care system. 3 However, the health care system is complex and professional knowledge alone is not enough to engage in QI work to bring about change. 4 Numerous QI training programs have been developed to train health care staff in QI methodology and application.

QI training can improve processes, staff knowledge, and health outcomes. 5 Measurement is an important construct in all QI efforts because unless we measure, it is impossible to demonstrate whether the change has resulted in an improvement or not. 6 For health care staff today, collecting, processing, and understanding data is a part of routine practice. 7 This makes a strong case to train health care staff in quality measurement and to develop their expertise in the use of data. 8

Although there are several systematic reviews evaluating QI training and curricula, 9 – 11 none have focused on the evaluation of measurement for improvement training components. This systematic review differs from previous reviews by focusing on QI curricula and training programs containing a significant data skills component. The concepts of effectiveness and sustainability are critical to assessing the impact of teaching measurement skills to health care staff, but these concepts are underexplored in the QI literature. Effectiveness is a micro concept and refers to the assessment of the usefulness of an output at a certain point, with little reference to context. On the other hand, sustainability is a macro concept which extends over a longer period as the new ways of working or improved outcomes become the norm, with context being an essential element. 12 The purpose of this systematic review is to address this gap in literature and define effectiveness and sustainability of QI programs for health care professionals that have a data for improvement component and to identify the associated barriers and enablers.

Protocol and Registration

Review protocol for this systematic review is registered on PROSPERO (ID: CRD42019122997). This study was approved by the IRB of our institution.

Eligibility Criteria

Studies were included if:

• Conducted in health care setting
• Intervention was QI-based training and included a measurement component.
• Study was about development, evaluation, or implementation of the program
• Population was health care staff or postgraduate students
• Based on primary research

Studies were excluded if:

• There was no measurement for improvement component in intervention
• Conference proceedings
• Population was undergraduate students

Information Sources

Systematic review protocols were scanned in Prospero and Cochrane library to ensure novelty of the review question. A scoping search of databases was conducted to inform the development of the search strategy. Databases were purposively selected to include health care and education sources. The databases were: PubMed, CINAHL Plus, ERIC (via Pro-Quest), and Web of Science. Grey literature sources included two databases: OAIster and OpenGrey along with websites of leading organizations (see Supplemental File 1, Supplemental Digital Content 1, http://links.lww.com/JCEHP/A103 ). The reference lists of eligible studies were scanned to identify additional papers.

The search strategy (see Supplemental File 2, Supplemental Digital Content 2, http://links.lww.com/JCEHP/A104 ) was optimized toward sensitivity rather than specificity because the scoping search revealed that measurement for improvement was integrated into QI studies rather than being delivered as a standalone training. 13 The authors finalized the search strategy and databases iteratively. The systematic search of the literature was conducted in January 2019 and updated in June 2020. The search was restricted to papers published in last 11 years (Search date: January 1, 2009–December 31, 2019). Foreign language papers with English abstracts were considered at the initial stage but only included in full text review if a complete translation was available.

Study Selection

The systematic review consisted of four stages: study identification, title and abstract screening, full text review, and data extraction. Study screening was completed using Covidence tool. 14 Two reviewers independently conducted title and abstract screening. The reviewers met regularly to resolve disputes. The full text review was also conducted independently by two reviewers and discrepancies resolved via discussion. The two reviewers consulted a third reviewer to assist in making the decision on one paper at the full text review stage. Because the studies were heterogenous, a narrative synthesis was performed.

The database search returned 6184 articles, which were imported into Covidence. The 2499 duplicates were removed, leaving 3685 studies eligible for screening. After screening, 110 studies were shortlisted for full text review. A total of 53 studies were included in the review. The PRISMA flow diagram is presented in Figure ​ Figure1 1 and the checklist is attached in Supplemental Digital Content 3 (see Supplemental File 3, http://links.lww.com/JCEHP/A105 ). 15

PRISMA Statement. An overview of the study selection process. The 6184 records identified through database searching were screened by 2 reviewers. Nineteen records were identified and included from grey literature sources. Exclusion reasons at each stage are shown.

Assessment of Methodological Quality

The Mixed Methods Appraisal Tool (MMAT) was used to evaluate methodological quality. 16 The validity and reliability of the MMAT has been established and is suitable for appraising mixed method studies. 17 Two reviewers assessed quality independently and results were compared. Studies meeting the screening questions of the MMAT on clarity of research questions and appropriateness of collected data were considered appropriate quality for inclusion. All 53 studies met these criteria and were included in the review. The quality assessment is presented in Table ​ Table1 1 .

Assessment of Methodological Quality Using MMAT *

Data Extraction

Two reviewers completed the data extraction independently. A customized data extraction form was developed (see Supplemental File 4, Supplemental Digital Content 4, http://links.lww.com/JCEHP/A106 ). One reviewer compared the data extraction forms and discrepancies were resolved through discussion between reviewers.

The 53 included studies were published between 2009 and 2019 and set in 11 countries. Most studies (35/53) were based in the United States. Most Study designs were quantitative descriptive (17/53) followed by mixed methods studies (16/53). The population varied widely, ranging from frontline staff, clinical and nonclinical staff, and leaders. A summary of studies is presented in Supplemental File 5, Supplemental Digital Content 5, http://links.lww.com/JCEHP/A131 .

Training Description

Less than half (14/53) of the studies were based on a collaborative approach. Duration of the collaboratives was variable, ranging from 2 months to 72 months. Half of the studies used a blended learning approach (25/53) combining face-to face and distance learning modes, whereas 21 studies relied solely on face-to-face learning modes. Four trainings were delivered online, whereas three studies did not state training modality used. Interventions included multiple training methods; the most common (39/53) one being face-to-face learning sessions. Other methods included teleconferencing (12/53), online modules (10/53), workshops (9/53), webinars (6/53), and emails (6/53).

Curriculum Description

The curricula were summarized into categories of basic, intermediate, and advanced data skills based on complexity of data concepts taught. Figure ​ Figure2 2 summarizes the three categories and highlights the data concepts part of the training and curricula in the included studies. Basic data skills include concepts of measurement and QI knowledge, which are important for all health care staff. Intermediate data skills concepts are useful for staff working in improvement teams, whereas advanced data skills concepts are useful for improvement team leads and advisors.

Measurement for Improvement Concepts. Summary of basic, intermediate, and advanced measurement and data skills taught in the QI programs.

Study Outcomes

Study outcomes are categorized as participant reaction, participant learning, participant behavior, sustainability, spread, and course design elements (see Supplemental File 6, Supplemental Digital Content 6, http://links.lww.com/JCEHP/A107 ). All studies measuring participation reaction to training and improved learning reported positive outcomes regardless of the study design. Studies measuring participant behavior also reported positive results except two quantitative descriptive studies. 63 , 65 Two randomized control trial studies 24 , 53 and a controlled interrupted time series study 50 reported not achieving the clinical outcomes being measured. A cohort study also reported not achieving the outcome of developing a culture of QI. 42 In spread, one quantitative descriptive study 49 reported no spread of QI methods. For sustainability outcomes, Glasgow et al 37 (Interrupted time series), Doyle et al 30 (Quantitative descriptive), and Cranley et al 26 (Mixed methods) reported a lack of sustainability of QI.

The Role of Measurement

The included studies reported on the role of measurement in QI for tracking progress toward goals and offering a systematic way to test changes to close performance gaps. 20 , 61 Measurement was identified as a key competency for clinical QI 21 to understand variation and improve the design health care. 4 Measurement was used to view data over time and draw conclusions regarding variations. 54 Measurement also played a role in implementation of QI methods 19 and contributed to the success of QI. 49

Knowledge about statistics and statistical process control 4 and additional support for measurement skills was reported by studies as critical. 2 , 33 , 39 Defining clear aims and measuring progress toward them was described as essential for QI. 62 Measurement was used to demonstrate patient outcomes to the host organizations 30 and provide guidance to decision makers. 49 Continuous measurement followed the processes through the project period into daily operations. 4 One study labelled measurement as one of the crucial elements of strategy for QI spread and sustainability. 31 Timely data and measurement are important for assessing progress and evaluation. 30

Challenges in identifying, collecting, and displaying appropriate measures of care impact QI program success. 4 , 18 , 63 Studies cited measurement challenges such as difficulty in obtaining measurable data 34 , 64 and presenting data in run/control chart formats. 35 Many participating hospitals were not equipped for systematic data collection. 31 Data collection and measurement was valued, 29 but perceived to be time consuming by participants. 52 , 53

Defining Effectiveness and Sustainability

The purpose of the review is to define effectiveness and sustainability and identify the barriers and enablers to success, in the context of QI programs with a focus on data and measurement for improvement. There is variability in how effectiveness and sustainability is defined in the studies. Another related concept that emerged was that of spread. It is therefore important to distinguish between effectiveness, spread, and sustainability. Effectiveness and sustainability definitions were extracted as part of the data extraction tool and summarized in Supplemental Digital Content 7 (see Supplemental file 7, http://links.lww.com/JCEHP/A108 ). The aspects addressed by these extracted definitions were then used to synthesize definitions. This was completed via consultation between three reviewers.

Effectiveness definitions focused on the short-term impact of the QI programs and were measured using participant reaction to the program, improved knowledge and skill application of participants, program participation and completion of QI projects by participants, and improvement in clinical outcomes at the end of the intervention period. Sustainability on the other hand, is defined not only as long-term outcomes beyond the intervention period, but also as a continuous process. Spread definitions focused on the diffusion of QI methods, processes, and skills from the intervention setting to nonintervention settings. We synthesized the following definitions of effectiveness, sustainability, and spread for measurement for improvement programs:

Effectiveness

Demonstrating improvement in key process, outcome, or quality measures being tracked, accompanied with an improvement in measurement knowledge, skills, and behaviors of learners during the intervention period.

Sustainability

Ongoing measurement, and development of processes and policies to maintain and improve the achieved gains in outcomes and participant skills and integration of measurement practices into routine after the intervention period, without further support from the trainers.

Active and passive diffusion of measurement skills and practices to areas and staff within and outside the organization that were not exposed to the training intervention.

Barriers and Enablers

A six-phased thematic analysis methodology (familiarization with data, initial coding, identifying themes, reviewing themes, naming themes, and reporting) was used to identify the barriers and enablers of sustainability 66 (see Supplemental file 8, Supplemental Digital Content 8, http://links.lww.com/JCEHP/A109 ). The definitions of effectiveness and sustainability synthesized were used as reference. The coding process was done manually by one reviewer and final themes were discussed and agreed with two other reviewers.

The four themes that emerged in enablers to effectiveness were intervention design, staff engagement, supportive leadership, and organizational support. Intervention design was the most important factor in the effectiveness of the program. Customizing training allows teaching of skills relevant to participant's role. 3 , 31 Considering the implementation context 3 , 39 , 52 , 53 and the challenges and opportunities of the setting 33 , 43 , 62 leads to targeted skill building. 19 A good starting point is to assess the prior knowledge and experience of participants 21 to determine training needs 31 and design a suitable range of resources 57 , 65 corresponding to diversity of experiences and knowledge levels. 64 Offering online modules 44 and online resources 53 also helps bridge this gap.

Intervention effectiveness can be enhanced using multiple learning strategies 21 and evidence-based curricula. 28 An effective intervention is responsive to participant learning styles 65 and improves the training based on feedback. 28 , 64 The best way to learn is by doing 21 and incorporating experiential learning principles 23 through demonstration projects 29 and case studies 65 builds capability. Another aspect of customized content is developing an interdisciplinary and team-based course 46 , 60 , 65 as working in teams prevents participants from becoming overburdened with measurement. 64 Having a participatory, data-driven approach contributes to effectiveness. 19 , 53 Focusing on real-time data increases 20 the program's value as participants can identify gaps in current processes. 23 , 55 Teaching practical data gathering, 21 statistical control charts, 4 data analysis, and comparison contribute to effectiveness. Feedback from fellow participants allows them to learn from each other and adds to effectiveness. 36 , 64 Similarly, informing participants about other team's progress creates healthy competition and prevents redundancy of efforts. 64

Effective coaching also plays an important role. Customized coaching experience through just-in-time coaching 28 and direct onsite, in-person support 33 improves effectiveness. Coaching is more effective when trainers can respond directly to participant concerns. 40 The ability of coaches to provide measurement support 22 in creating data collection processes 27 and data quality troubleshooting 33 adds to effectiveness. Practice facilitation 33 is also an enabler because providing private coaching between learning sessions, 44 ongoing mentorship 21 and tools and resources 39 are valued by participants. Coaches can provide customized feedback and assistance. 29 When participants perceive the training organization to be credible and have a sense of affiliation with it, they consider the training to be more effective. 23

Guiding participants in indicator selection by focusing on establishing clear, realistic, mutually agreed, 18 , 22 and clinically meaningful goals 43 , 47 , 50 is a successful strategy. Encouraging participants to focus on simple solutions 18 , 25 and making small changes 26 , 62 leads to effectiveness. In-person workshops 21 are an effective mode of training as face-to-face contact 33 is preferred by participants. Using technology for designing easy to access, self-paced and self-initiated interventions 57 improves effectiveness.

Successfully engaging health care staff is another important theme in effectiveness. Clinical staff feel empowered when they can identify and address gaps 25 and select relevant QI topics. 41 , 52 Providing dedicated time to participants to attend training sessions 34 , 41 , 42 , 45 , 53 also adds to effectiveness. Demonstrating the value of competency in QI skills 64 and offering maintenance of certification credit 59 also helps in creating enthusiasm among staff. Supportive policies of the organization such as assuring time release recognizes the training as a valued activity. 21 Leadership support is an important factor in the success of such programs. 21

There are four themes in barriers to effectiveness: incompatible intervention design, lack of staff engagement, lack of organizational support, and lack of strategic approach. Fast pace of collaboratives 18 and didactic instruction 30 which did not correspond to learning needs of all participants, especially those in support roles 3 were perceived as barriers. The number of concepts covered in the training made it difficult for participants to keep up and the terminology used was sometimes difficult to understand. 29 A single day of classroom training was an insufficient dose 50 and scheduling a full day training workshop is tiring for participants. 63 When training programs that did not incorporate advice on implementation 53 and leading change, 36 it proved to be a barrier to effectiveness.

Lack of organizational support was visible in cases where participants were not provided protected time and struggled to attend the sessions. 3 , 64 Poor data infrastructure impeded data collection 31 and obtaining baseline measures. 34 , 44 Lack of staff engagement and a negative perception about QI work and training because of previous negative experiences 18 , 45 dampened effectiveness. Some programs failed to incorporate appropriate reward systems to motivate behavior 36 and the lack of interest among participants resulted in low attendance 35 , 50 and in some cases, staff disliked new tools and processes that required learning new methods. 39 Staff struggled with learning measurement skills such as presenting data as run charts/control charts 35 , 36 which decreased collaborative effectiveness. Some did not see any value in investing time in such collaboratives 63 and believed the burdens outweighed the benefits. 29 , 36 Another barrier was the lack of a strategic approach and the participants selected projects that were incompatible with the goals of their institutions. 36 , 51

The themes observed in enablers to sustainability were taking a strategic approach, accountability, communication, learning networks, staff engagement, organizational support, intervention design, and supportive leadership. Taking a strategic approach requires connecting the program to organizational and national priorities, 21 strategic goals, 2 , 27 and teaming up with other departments 64 and organizations 53 with similar agendas. 29 As organizations prioritize and implement QI, 57 they move from sporadic efforts toward performance management systems, 5 which sustains learning. Incorporating strategies to address psychology 20 of change improves sustainability. Using a standard approach to QI ensures a common and clear improvement language. 44

Another aspect of sustainability is to recruit the right people in the project team. 4 , 22 A purposeful participant selection strategy 46 ensures inclusion of individuals who are interested in improvement work. Scale-up plans 18 with a goal of institution-wide diffusion 31 add to sustainability. It is important to integrate QI into programs and services 42 , 53 through updated job descriptions, 33 building QI responsibility into operational responsibilities 47 and continually reinforcing skills. 49 Engaging all stakeholders from an early stage 2 , 18 , 19 , 21 , 53 is also an enabler. In addition, while planning evaluations, it is important to assess learner involvement and QI project outcomes beyond completion of the programme. 52 A strategic approach requires taking a system-level view 20 , 21 of improvements with a blameless culture focusing on systems rather than individuals, 24 , 53 which considers challenges as system issues rather than staff issues. 28

Supportive organizational practices encourage QI by removing barriers, 26 investing in workforce capacity and culture change 28 and providing a conducive environment for teamwork. 38 , 45 It also commits resources 3 , 33 , 46 , 56 and provides opportunities to practice the skills learned. 19 , 22 , 27 Accountability is an important enabler for sustainability. A clear definition of responsibilities, 34 tasks 39 and individual roles 62 is key. Establishing time-bound targets 20 and regular meetings to follow through on action 62 ensures accountability. It is also beneficial to establish measurement guidelines to follow the process through the project period into daily operations. 4 This continuous sharing of numbers leads 53 to motivation and boosts sustainability. 4 The training organization can also provide external accountability 33 and ensure participants see projects to completion. 41

Focus on capacity building also improves sustainability. This includes training staff for specialized QI roles such as QI champion, 28 process coach, 31 and QI advisor. 33 A mentorship framework to support those interested in developing QI skills and encouraging permanent staff to develop coaching skills improves sustainability. 47 Effective communication contributes to sustainability. Recognizing the efforts of QI teams 26 , 34 by showcasing success stories 28 through ongoing promotional activities 56 is a rewarding strategy. Senior leader communication through board letters 31 also supports sustainability. Formal and informal dissemination are vital to communication and sustainability. Formal dissemination can include internal dissemination, 31 dissemination to local, national, and international audiences 2 and toolkits. 55 Informal dissemination can include enthusiastic employees 53 and other informal contacts. 31 Similarly, visual display of data and progress helps in disseminating the message of improvement. 59

Learning networks are an important enabler. 53 Learning from peers by sharing ideas 18 , 21 and building relationships creates a strong learning community for idea exchange. 33 These learning platforms serve as venues for knowledge transfer 57 and repositories for QI. 27 Development of collaborations between organizations leads to networking 56 and solution sharing. 33 Another area in staff engagement is generating awareness about QI 18 beyond the project team 2 , 26 , 42 and its impact on career. 22 Extended support from coaches for implementation sequencing 48 improves sustainability.

Support from leaders is crucial to sustainability. 53 This involves improving leaders' QI skills so they can develop infrastructure for QI in their organizations 28 such as establishing QI teams. 53 Senior leadership support 22 including board executives and chief of the medical staff provide legitimacy to QI. 31 A strong leadership structure championing QI on a daily basis 34 sends a message for sustainability. Leadership support allows staff to try new ideas in a safe environment that does not punish risk-taking. 56 Organizational support plays a role through various strategies such as incentivizing diffusion 48 and providing resources and autonomy to innovate. 3

Themes in barriers to sustainability include lack of accountability, poor communication, lack of leadership support, lack of staff engagement, lack of organizational support, absence of learning networks, and not having a strategic approach. When timelines, roles, and responsibilities are not established, the plan of actions can evaporate leading to slippage in agreed timeframes and a loss of momentum. 50 Because of poor institutional communication, staff lack a shared perception of problems 51 and often lack institutional knowledge to approach the relevant individuals for QI work. 60 Lack of leadership support manifests in the form of a lack of interest from top management 4 and variations in the readiness of senior leaders to engage in QI. 46

Learning networks play a vital role in sustainability; however, they are challenging to establish because few practices reach out to others to learn from them 62 and may also face difficulty in learning from practices with dissimilar QI capacity and patients. 29 Lack of organizational support is a major barrier to sustainability 53 because it represents a culture that is not conducive to making or sustaining change. 33 Presence of administrative red tape 3 , 64 can inhibit innovation and indicate that QI is not a priority for the organization. 55

Poor data infrastructure, 4 , 33 , 53 data quality, and access to data 4 decrease sustainability. Repeated data collection can be cumbersome and labor intensive in the long run. 52 Lack of resource availability 3 , 26 , 46 for QI projects is another barrier. Programs that lack ongoing organizational support are likely to be unsuccessful. 65 Health care staff have competing demands on their time, 46 , 62 , 63 , 63 which interferes with team's ability to meet and work. 3 Because QI teams are a disparate group of staff, 50 a lack of dedicated time for QI work 57 can be a barrier. Failing to engage staff, and leadership effectively and not focusing on motivation and behavior change can be a barrier to sustainability. 53 It is also important to account for the high levels of stress and emotional demands experienced by front-line staff. 1

The purpose of the systematic review is to define effectiveness and sustainability of QI programs with a significant data skills component and to identify the relevant barriers and enablers. Fifty-three studies were included in the review. There was heterogeneity in the content, teaching methods, and program design in the included studies and variability in the way effectiveness, sustainability, and spread were defined and measured in the context of QI programs. The review also highlighted variation in the ability of the programs to achieve desired outcomes. These inconsistencies in program success were attributed to various barriers and enablers to effectiveness and sustainability.

The lack of staff engagement, lack of a strategic approach, and lack of organizational support are barriers common between effectiveness and sustainability, which implies that these factors have implications for the short-term and long-term success of the programs. Poor intervention design affects the effectiveness of the program while poor communication, lack of accountability, and lack of leadership support can plague the ability to sustain the skills and results in the long-term. In enablers, intervention design, supportive leadership, engaged staff, and organizational support can affect positively on both effectiveness and sustainability of programs. Enablers that are relevant to sustainability are learning networks, communication, accountability, and a strategic approach to QI. The barriers and enablers highlight the importance of organizational, 39 learner, teacher, curricular, 35 and contextual factors 3 in the success of QI programs.

The definitions derived for effectiveness and sustainability highlight the importance of measurement. Studies reported measurement as a key competency for clinical QI. 21 Continuous measuring and remeasuring play an important role in maintaining 62 and operationalizing improvements in the long run. Selecting appropriate measures, 18 , 22 data collection 34 and using charts to display data 35 are essential to show effective change. 64 QI programs therefore need to focus on training staff in QI methods and how to measure care and use data to drive change. 62 There is an increasing expectation from health care professionals to measure, report, and continually improve the quality of care. 62 This indicates the need for a cultural shift from traditional academic-focused programs toward programs focusing on measurement and results to develop the capability of health professionals in leading improvement. 44

The findings of this systematic review also advocate for program evaluation to consider impact on participant behavior, patient outcomes, and supporting downstream learning beyond the direct participants of the programme. 43 Instead of solely relying on measuring quantitative outcomes, evaluators should also use qualitative data to assess whether program outcomes are achieved. 29

Measurement emerged as a critical element of QI training programs, which enables health care professionals and organizations to demonstrate effectiveness of improvement efforts and sustain improvements in the long run. Training health care professionals in data skills can have implications for improving health systems. However, health care systems are complex and various actors such as the health care authorities, training organizations, trainers, trainees, and trainee's organization have a collaborative role to play in ensuring effectiveness and sustainability of QI programs. Outputs of the thematic analysis in the form of effectiveness and sustainability barriers and enablers were broken down into inputs, outputs, and short- and long-term outcomes, which were then mapped onto a logic model. This was completed via consultation between three reviewers and presented in Figure ​ Figure3 3 .

Intervention success factors. Summary of QI program inputs contributing to achievement of short-term and long-term outcomes.

Limitations

A limitation of this review is that there were no stand-alone measurement for improvement training studies. The reviewers overcame this by establishing the presence of measurement component in the QI programs as an inclusion criterion. Because no search strategy is perfect, there is a risk of missing relevant studies; however, we mitigated this risk using a search strategy focused on sensitivity and iteratively testing the search strategy in selected databases.

The review highlighted that measuring the improvement in outcomes and participant knowledge establishes effectiveness while remeasuring continuously helps in sustaining outcomes in the long-term for QI programs with a significant measurement skills component. The review identified staff engagement, strategic approach to QI, organizational support, intervention design, communication, accountability, leadership support, and learning networks as factors that affect effectiveness and sustainability. The review expands current knowledge about the importance of measurement in QI training programs. Ensuring effectiveness and sustainability of measurement for improvement programs requires a collective effort from trainers, trainees, the organizations in which the interventions are implemented and policy makers.

Lessons for Practice

• ■ Measurement has a central role in demonstrating improvements and maintaining desired improvement outcomes of QI programs in the short- and long-term.
• ■ Staff engagement, strategic approach to QI, organizational support, intervention design, communication, accountability, leadership support, and learning networks influence effectiveness and sustainability of QI programs.
• ■ Effectiveness, sustainability, and spread of QI programs with a measurement component requires a collective effort from trainers, trainees, the organizations in which the interventions are implemented, and policy makers.

Supplementary Material

The corresponding author receives a PhD funding from the Health Service Executive Ireland (Project reference 57399). The study is also supported by the Irish Health Research Board (RL-2015-1588).

Disclosures: The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site ( www.jcehp.org ).

About Systematic Reviews

The Difference Between Narrative Review and Systematic Review

Automate every stage of your literature review to produce evidence-based research faster and more accurately.

Reviews in scientific research are tools that help synthesize literature on a topic of interest and describe its current state. Different types of reviews are conducted depending on the research question and the scope of the review. A systematic review is one such review that is robust, reproducible, and transparent. It involves collating evidence by using all of the eligible and critically appraised literature available on a certain topic. To know more about how to do a systematic review , you can check out our article at the link. The primary aim of a systematic review is to recommend best practices and inform policy development. Hence, there is a need for high-quality, focused, and precise methods and reporting. For more exploratory research questions, methods such as a scoping review are employed. Be sure you understand the difference between a systematic review and a scoping review , if you don’t, check out the link to learn more.

When the word “review” alone is used to describe a research paper, the first thing that should come to mind is that it is a literature review. Almost every researcher starts off their career with literature reviews. To know the difference between a systematic review and a literature review , read on here.  Traditional literature reviews are also sometimes referred to as narrative reviews since they use narrative analysis to synthesize data. In this article, we will explore the differences between a systematic review and a narrative review, in further detail.

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Narrative Review vs Systematic Review

Both systematic and narrative reviews are classified as secondary research studies since they both use existing primary research studies e.g. case studies. Despite this similarity, there are key differences in their methodology and scope. The major differences between them lie in their objectives, methodology, and application areas.

Differences In Objective

The main objective of a systematic review is to formulate a well-defined research question and use qualitative and quantitative methods to analyze all the available evidence attempting to answer the question. In contrast, narrative reviews can address one or more questions with a much broader scope. The efficacy of narrative reviews is irreplaceable in tracking the development of a scientific principle, or a clinical concept. This ability to conduct a wider exploration could be lost in the restrictive framework of a systematic review.

Differences in Methodology

For systematic reviews, there are guidelines provided by the Cochrane Handbook, ROSES, and the PRISMA statement that can help determine the protocol, and methodology to be used. However, for narrative reviews, such standard guidelines do not exist. Although, there are recommendations available.

Systematic reviews comprise an explicit, transparent, and pre-specified methodology. The methodology followed in a systematic review is as follows,

• Formulating the clinical research question to answer (PICO approach)
• Developing a protocol (with strict inclusion and exclusion criteria for the selection of primary studies)
• Performing a detailed and broad literature search
• Critical appraisal of the selected studies
• Data extraction from the primary studies included in the review
• Data synthesis and analysis using qualitative or quantitative methods [3].
• Reporting and discussing results of data synthesis.
• Developing conclusions based on the findings.

A narrative review on the other hand does not have a strict protocol to be followed. The design of the review depends on its author and the objectives of the review. As yet, there is no consensus on the standard structure of a narrative review. The preferred approach is the IMRAD (Introduction, Methods, Results, and Discussion) [2]. Apart from the author’s preferences, a narrative review structure must respect the journal style and conventions followed in the respective field.

Differences in Application areas

Narrative reviews are aimed at identifying and summarizing what has previously been published. Their general applications include exploring existing debates, the appraisal of previous studies conducted on a certain topic, identifying knowledge gaps, and speculating on the latest interventions available. They are also used to track and report on changes that have occurred in an existing field of research. The main purpose is to deepen the understanding in a certain research area. The results of a systematic review provide the most valid evidence to guide clinical decision-making and inform policy development [1]. They have now become the gold standard in evidence-based medicine [1].

Although both types of reviews come with their own benefits and limitations, researchers should carefully consider the differences between them before making a decision on which review type to use.

• Aromataris E, Pearson A. The systematic review: an overview. AJN. Am J Nurs. 2014;114(3):53–8.
• Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiropratic Medicine 2006;5:101–117.
• Linares-Espinós E, Hernández V, Domínguez-Escrig JL, Fernández-Pello S, Hevia V, Mayor J, et al. Metodología de una revisión sistemática. Actas Urol Esp. 2018;42:499–506.

3 Reasons to Connect

A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety

Affiliations.

• 1 Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.
• 2 Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria. [email protected].
• 3 Executive Department for Quality and Risk Management, University Hospital Graz, Auenbruggerplatz 1/3, 8036, Graz, Austria. [email protected].
• 4 Carinthia University of Applied Science, Feldkirchen, Austria.
• 5 Executive Department for Quality and Risk Management, University Hospital Graz, Auenbruggerplatz 1/3, 8036, Graz, Austria.
• PMID: 30866908
• PMCID: PMC6417275
• DOI: 10.1186/s12913-019-3989-1

Background: The medical discharge letter is an important communication tool between hospitals and other healthcare providers. Despite its high status, it often does not meet the desired requirements in everyday clinical practice. Occurring risks create barriers for patients and doctors. This present review summarizes risks of the medical discharge letter.

Methods: The research question was answered with a systematic literature research and results were summarized narratively. A literature search in the databases PubMed and Cochrane Library for Studies between January 2008 and May 2018 was performed. Two authors reviewed the full texts of potentially relevant studies to determine eligibility for inclusion. Literature on possible risks associated with the medical discharge letter was discussed.

Results: In total, 29 studies were included in this review. The major identified risk factors are the delayed sending of the discharge letter to doctors for further treatments, unintelligible (not patient-centered) medical discharge letters, low quality of the discharge letter, and lack of information as well as absence of training in writing medical discharge letters during medical education.

Conclusions: Multiple risks factors are associated with the medical discharge letter. There is a need for further research to improve the quality of the medical discharge letter to minimize risks and increase patients' safety.

Keywords: Discharge letter; Discharge summary; Hospital discharge; Patient safety; Risk; Systematic review.

Publication types

• Systematic Review
• Communication
• Health Personnel
• Medical Records / standards*
• Patient Discharge / standards*
• Patient Safety / standards*
• Professional Practice / standards

Grants and funding

• -/Gesundheitsfonds Steiermark