Table 6.

Implementation barriers and strategies to promote adoption.

Implementation barriers			Strategies to promote adoption
Discharge video
	Timing and access of video after admission to the unit	Make videos available via the patient portal, bedside display, and television Engage nurses to have patients watch videos as EDDa approaches
	Too generic and impersonal	Have clinical unit leaders create unit-specific videos Create videos for each attending, play video for patient’s current attending by linking to the treatment team in the EHRb Translate videos into common languages (eg, Spanish) using medical interpreters
Discharge checklist
	Timing and administration	Determine optimal timing of checklist administration for specific patient categories (eg, admissions for acute on chronic disease exacerbations, awaiting procedures, undifferentiated diagnoses) Demonstrate impact on key hospital priorities and process metrics (EDD accuracy, early hospital discharges)
	Patients’ belief that clinicians will address all items	Encourage patients to review and update the checklist during their hospitalization Allow patients to update checklist responses as EDD approaches or changes
	Checklist responses out-of-date owing to discharge delays	Identify workflow to update checklist after initial submission (eg, notification via the patient portal, email, or mobile app)
Dashboard discharge column
	Variable EHR data entry of key data elements (EDD, medical, nonmedical barriers)	Demonstrate how EDD can be viewed by patients (patient portal, bedside display) and clinicians (bedside display, dashboard) Add a confidence indicator that estimates the likelihood that EDD will equal ADDc to manage patient and clinician expectations Demonstrate the value of structured EHR data entry for driving dashboard logic (flagging red when EDD not entered) Encourage checklist completion for patients at high risk for readmission by incorporating patient-specific readmission risk scores from EHR into logic Display barriers to discharge on the dashboard
	Competing QId interventions	Understand current institutional priorities and emerging workflows for identifying and escalating discharge barriers Propose enhancements based on lessons learned from concurrent QI efforts to explain how the use of a checklist can prepare patients for postdischarge care (increasing patient satisfaction, reducing readmission rates) while maintaining or reducing the length of stay (by proactively identifying and overcoming barriers to timely discharge)
	Poor specificity of patient-reported concerns viewed in the dashboard	Provide a link to discharge checklist questions and patient’s responses Link patient-reported concerns to specific clinical actions (eg, if poor understanding of the main diagnosis, update after visit summary with condition-specific educational materials)
Secure postdischarge messaging
	Physician resistance	Frame the initiation of secure messaging thread as an opt-in process Align with value-based incentives for clinical services (readmissions) Communicate success stories from early adopters to assuage fears (eg, excessive text messages from patients)
	Managing patient expectations about whether physicians will initiate secure messaging	Educate patients about the opt-in process for attendings Encourage patients to request attendings to use this feature for clearly defined reasons (eg, concern about obtaining a key medication)

^aEDD: expected discharge date.

^bEHR: electronic health record.

^cADD: actual discharge date.

^dQI: quality improvement