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Objective: To identify barriers experienced and perceived at discharge by physicians, nurses, patients and relatives., Design: We developed questionnaires based on focus group interviews with hospital and community care providers, and individual interviews with patients and relatives. A survey was conducted among patients, relatives and related nurses and physicians from hospital and community care., Setting: One university hospital and the related community care area in the Netherlands., Participants: Thirty health-care providers and eight patients and/or relatives participated in focus group and individual interviews. Questionnaires were returned by 344 health-care providers and 206 patients and relatives., Results: Information from the hospital to community care is often incomplete, unclear and delayed. Especially hospital physicians (52%) and general practitioners (GPs; 63%) experience the quality of information exchanged from the hospital to the GP as poor. Coordination of care is often frustrated by a lack of care provider knowledge and collaboration. Hospital physicians (47%) and GPs (71%) feel that hospital physicians are often not sufficiently aware of the patient's home situation. Respectively, 59 and 81% experience that the GP is often not clearly informed about expected tasks and responsibilities at discharge., Conclusions: This is the first study that provides a clear picture of the experiences and perceptions of stakeholders regarding handovers at hospital discharge. Lack of knowledge, understanding and interest between hospital and community care providers are important causes for ineffective and unsafe discharge. The study suggests that improvement efforts should be focused more on these aspects, as primary conditions for improving hospital discharge.

Background: Organizational culture is seen as having a growing impact on quality and safety of health care, but its impact on hospital to community patient discharge is relatively unknown., Objectives: To explore aspects of organizational culture to develop a deeper understanding of the discharge process., Research Design: A qualitative study of stakeholders in the discharge process. Grounded Theory was used to analyze the data., Subjects: In 5 European Union countries, 192 individual and 25 focus group interviews were conducted with patients and relatives, hospital physicians, hospital nurses, general practitioners, and community nurses., Results: Three themes emerged representing aspects of organizational culture: a fragmented hospital to primary care interface, undervaluing administrative tasks relative to clinical tasks in the discharge process, and lack of reflection on the discharge process or process improvement. Nine categories were identified: inward focus of hospital care providers, lack of awareness to needs, skills, and work patterns of the professional counterpart, lack of a collaborative attitude, relationship between hospital and primary care providers, providing care in a "here and now" situation, administrative work considered to be burdensome, negative attitude toward feedback, handovers at discharge ruled by habits, and appreciating and integrating new practices., Conclusions: On the basis of the data, we hypothesize that the extent to which hospital care providers value handovers and the outreach to community care providers is critical to effective hospital discharge. Community care providers often are insufficiently informed about patient outcomes. Ongoing challenges with patient discharge often remain unspoken with opportunities for improvement overlooked. Interventions that address organizational culture as a key factor in discharge improvement efforts are needed.

Background: Safe patient transitions depend on effective communication and a functioning care coordination process. Evidence suggests that primary care physicians are not satisfied with communication at transition points between inpatient and ambulatory care, and that communication often is not provided in a timely manner, omits essential information, or contains ambiguities that put patients at risk., Objective: Our aim was to demonstrate how process mapping can illustrate current handover practices between ambulatory and inpatient care settings, identify existing barriers and facilitators to effective transitions of care, and highlight potential areas for quality improvement., Methods: We conducted focus group interviews to facilitate a process mapping exercise with clinical teams in six academic health centres in the USA, Poland, Sweden, Italy, Spain and the Netherlands., Findings: At a high level, the process of patient admission to the hospital through the emergency department, inpatient care, and discharge back in the community were comparable across sites. In addition, the process maps highlighted similar barriers to providing information to primary care physicians, inaccurate or incomplete information on referral and discharge, a lack of time and priority to collaborate with counterpart colleagues, and a lack of feedback to clinicians involved in the handovers., Conclusions: Process mapping is effective in bringing together key stakeholders and makes explicit the mental models that frame their understanding of the clinical process. Exploring the barriers and facilitators to safe and reliable patient transitions highlights opportunities for further improvement work and illustrates ideas for best practices that might be transferrable to other settings.

Background: Much of the research on improving patient handovers has focused on enhancing communication within the hospital system, but there have been relatively few efforts aimed at addressing the challenges at the interface between the hospital and the primary care setting., Methods: A qualitative thematic analysis using a clinical microsystems lens applied to 28 semi-structured key stakeholder interviews in the Netherlands. Data were organised into seven 'virtual' clinical microsystem datasets composed of patients, hospital-based physicians, hospital-based nurses and community-based general practitioners., Results: Five themes that contributed to effective or ineffective handovers emerged from our analysis: (1) lack of adequate information; (2) healthcare professionals' availability and opportunity for personal contact; (3) feedback, teaching and protocols related to handovers; (4) information technology facilitated communication solutions; and (5) the role and responsibility of patients. Our analysis suggests that each healthcare professional attempted to provide the best care possible, but did this largely in isolation, and without the benefit of the knowledge and expertise of the other members of the microsystem., Conclusions: The microsystem approach offers an innovative organisational construct and approach to assess the gaps in 'hospital to community' patient handovers, by viewing the hospital to the community interface as a clinical microsystem continuum. Our application of the microsystem approach confirms and extends earlier findings about the impact of barriers on the continuity and safety of patient transitions and their impact on the quality of patient care.