Ready to Go Home? Assessment of Shared Mental Models of the Patient and Discharging Team Regarding Readiness for Hospital Discharge
BACKGROUND: A critical task of the inpatient interprofessional team is readying patients for discharge. Assessment of shared mental model (SMM) convergence can determine how much team members agree about patient discharge readiness and how their mental models align with the patient’s self-assessment.
OBJECTIVE: Determine the convergence of interprofessional team SMMs of hospital discharge readiness and identify factors associated with these assessments.
DESIGN: We surveyed interprofessional discharging teams and each team’s patient at time of hospital discharge using validated tools to capture their SMMs.
PARTICIPANTS: Discharge events (n = 64) from a single hospital consisting of the patient and their team (nurse, coordinator, physician).
MEASURES: Clinician and patient versions of the validated Readiness for Hospital Discharge Scales/Short Form (RHDS/SF). We measured team convergence by comparing the individual clinicians’ scores on the RHDS/SF, and we measured team-patient convergence as the absolute difference between the Patient-RHDS/SF score and the team average score on the Clinician-RHDS/SF.
RESULTS: Discharging teams assessed patients as having high readiness for hospital discharge (mean score, 8.5 out of 10; SD, 0.91). The majority of teams had convergent SMMs with high to very high interrater agreement on discharge readiness (mean r*wg(J), 0.90; SD, 0.10). Yet team-patient SMM convergence was low: Teams overestimated the patient’s self-assessment of readiness for discharge in 48.4% of events. We found that teams reporting higher-quality teamwork (P = .004) and bachelor’s level–trained nurses (P < .001) had more convergent SMMs with the patient.
CONCLUSION: Measuring discharge teams’ SMM of patient discharge readiness may represent an innovative assessment tool and potential lever to improve the quality of care transitions. Journal of Hospital Medicine 2020;15:XXX-XXX.
© 2020 Society of Hospital Medicine
Preparing patients for hospital discharge requires multiple tasks that cross professional boundaries. Clinician’s roles may be ambiguous, and responsibility for a safe high-quality discharge is often diffused among the team rather than being defined as the core responsibility of a single member.1-8 Without a shared understanding of patient resources and tasks involved in anticipatory planning, lapses in discharge preparation can occur, which places patients at increased risk for harm after hospitalization.3-7 As a result, organizations like the Centers for Medicare & Medicaid Services (CMS) have called for team-based patient-centered discharge planning.8 Yet to develop more effective team-based discharge planning interventions, a more nuanced understanding of how healthcare teams work together is needed.2,3,9
Shared mental models (SMMs) provide a useful theoretical framework and measurement approach for examining how interprofessional teams coordinate complex tasks like hospital discharge.10-13 SMMs represent the team members’ collective understanding and organized knowledge of key elements needed for teams to perform effectively.9-11 Validated questionnaires can be used to measure two key properties of SMMs: the degree to which team members have a similar understanding of the situation at hand (team SMM convergence) and to what extent this understanding is aligned with the patient (team-patient SMM convergence).10,11 Researchers have found that teams with higher-quality SMMs have a better understanding of what is happening and why, have clearer expectations of their roles and tasks, and can better predict what might happen next.10,12 As a result, these teams more effectively coordinate actions and adapt to task demands even in cases of high complexity, uncertainty, and stress.10-13 Prior studies examining healthcare teams in emergency departments,14-16 critical care units,17,18 and operating rooms19 suggest high-quality SMMs are needed to safely care for patients.13 Yet there has been limited evaluation of SMMs in general internal medicine, much less during hospital discharge.9,13 The purpose of this study was to examine SMMs for a critical task of the inpatient team: developing a shared understanding of the patient’s readiness for hospital discharge.20,21
