SHM Converge Scientific Abstract ePoster Gallery-The Skilled Nursing Facility Discharge Checklist: A Resident-Driven, Standardized Approach to Improve Hospital to Skilled Nursing Facility Transitions

The Skilled Nursing Facility Discharge Checklist: A Resident-Driven, Standardized Approach to Improve Hospital to Skilled Nursing Facility Transitions

Back to course

Pdf Summary

This project addressed communication gaps during hospital-to-skilled nursing facility (SNF) transitions, a common and high-risk process affecting millions of patients each year. The team developed a standardized, resident-driven SNF Discharge Checklist to improve handoffs between hospital medicine residents and SNF providers at UCSF.

The initiative had four phases:  
1. <strong>Needs assessment</strong> using surveys of internal medicine residents and SNF providers to identify communication problems.  
2. <strong>Checklist development</strong> through multidisciplinary collaboration, creating an electronic health record-based dotphrase for SNF discharge summaries.  
3. <strong>Improving use</strong> via awareness emails, reminder pages, gamification, and auto-population into discharge summaries.  
4. <strong>Evaluation</strong> through follow-up surveys and utilization tracking.

Results showed that residents reported greater knowledge and confidence about what information should be included in SNF handoffs after implementation. The checklist was widely adopted, with 545 of 697 patients discharged to SNF (78%) using the dotphrase from October 2023 to February 2025. However, SNF providers did not report a significant improvement in the completeness of resident discharge summaries, and there was no significant reduction in 30-day readmission rates.

Overall, the project successfully created, implemented, and sustained a standardized SNF discharge checklist now used across UCSF hospital medicine services. While the checklist improved resident self-efficacy and communication awareness, further research is needed to determine whether such standardization reduces medical errors, improves patient safety, or lowers readmissions.

Asset Subtitle

Justin C. Zhang

Meta Tag

Author List Bingyan Shi, James D. Harrison, Justin C. Zhang, Lillian Peng, Maham Awan, Omid Shah, Priyanka Dutta, Tamara Sanchez-Ortiz, Tianyu Chen

Category Innovations

Concept Hospital to Skilled Nursing Facility Discharge Handoff

Concept Discharge Checklist

Concept Communication Gap

Concept Skilled Nursing Facility

Concept Multidisciplinary Team

Distinguished Non-Finalist

Presenter Organization Ucsf

Presenting Author Justin C. Zhang

Track Transitions of Care

Keywords

hospital-to-SNF transitions

discharge checklist

handoff communication

skilled nursing facility

resident self-efficacy

discharge summary

electronic health record

quality improvement

patient safety

readmission rates

Hospital to Skilled Nursing Facility Discharge Handoff

Discharge Checklist

Communication Gap

Skilled Nursing Facility

Multidisciplinary Team