Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2024


Doctor of Nursing Practice (DNP)

Primary Advisor

Anthony Roberson


Discharge Planning; Psychiatric Inpatients; Standardized Discharge Protocol; Patient Satisfaction


Background: The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires healthcare facilities to provide patients with information that integrates care goals and treatment preferences into discharge planning upon admission (, 2019). However, researchers highlighted that over half of psychiatric inpatients were discharged without comprehensive discharge planning (Smith et al., 2021). Additionally, approximately 40% of hospital-based acute care for psychiatric patients comprises adult emergency department visits within 30 days post-discharge, with readmission rates for schizophrenia being 10% higher than those for non-psychiatric conditions, leading to substantial financial burdens (Everett et al., 2022). Although research supports the benefits of standardized discharge protocols in enhancing patient care and satisfaction while reducing readmissions and financial burdens (Gowda et al., 2019; Owusu et al., 2022; Rodgers et al., 2022; St. John et al., 2020; Xiao et al., 2019), there is limited focus on discharge planning in psychiatric inpatient settings. Therefore, implementing a standardized discharge protocol in a psychiatric unit is critical to fill the gap.

Objectives: The purpose of this quality improvement project was to improve patient satisfaction by implementing the Anne Arundel Medical Center (AAMC) SMART discharge protocol within a psychiatric inpatient unit.

Methods: The quality improvement (QI) project was implemented in a 16-bed psychiatric unit in a 400-bed non-profit academic medical center. All nurses completed AAMC SMART discharge protocol training by November 30th, 2023. During the implementation period, nurses ensured patients received the SMART journal worksheet and documented its provision under patient education in the Electrical, Process, Instrumentation, and Control Systems (EPIC) electronic health record (EHR) system within 24 hours of admission while maintaining ongoing monitoring and auditing. The AAMC SMART discharge protocol comprised five components: symptoms, medications, appointments, results, and addressing patient questions and concerns (IHI, 2023). Baseline data on patient experience, focusing on three discharge-related questions from the Press Ganey's Inpatient Behavioral Health (PGIBH) survey, were collected from August 1st to October 31st, 2023. Monthly data collection continued for implementation from December 1st, 2023, to February 29th, 2024. Patients who completed the survey three months before and after the implementation of the AAMC SMART discharge protocol were included in the analysis. A chi-square test assessed the results between three specific discharge-related questions from the PGIBH survey before and after the implementation.

Results: Post-intervention, the completion rate for SMART education in EPIC rose from 1.86% to 91.39%. Despite this increase, patient satisfaction did not increase correspondingly. Post-intervention analysis of PGIBH survey results across various domains showed no significant enhancements in satisfaction: discharge overall (χ² = 1.326, p = 0.249), understanding of discharge medication instructions (χ² = 0.412, p = 0.521), information about care after discharge (χ² = 0.545, p = 0.460), and discharge instructions for assistance (χ² = 0.586, p = 0.108). However, there was an increase in top box scores for PGIBH surveys related to discharge, ranging from 0.8% to 7.25%, and average survey scores increased by 0.07 to 0.17 points when comparing December 2023 to February 2024 with October 2022 to February 2023. These findings suggest that implementing the SMART discharge protocol may have positively impacted patient experience. Conclusions: The correlation between the discharge protocol and improving patient experience was inconclusive. Implementing the AAMC SMART discharge protocol in the psychiatric inpatient unit did not improve patient discharge satisfaction scores despite an increased SMART completion rate. However, post-implementation survey top box scores related to discharge and average survey scores improved compared to the same months in the previous year. The lower patient experience score in the post-implementation period compared to pre-implementation months might be associated with a higher involuntary admission rate, a younger population, more female participants, schizoaffective disorder, and severe depressive disorder with psychotic features. The post-implementation period had a 6.46% higher involuntary admission rate than the pre-implementation period, and the involuntary admission rate more than doubled between February 2024 and October 2023. The average length of stay for involuntarily admitted patients was one day longer during the post-implementation months compared to the pre-implementation months. Additionally, the previous year's data analysis showed that patient experience scores related to discharge were lower from December to February, with top box scores for three discharge questions being 3.43% to 17.6% lower than from August to October 2022. Notably, the top box score in October 2022 was more than twice as high as in February 2023. These results indicated that additional factors, not fully captured during the limited three-month monitoring period of the quality improvement project, may have influenced outcomes. With a post-intervention completion rate below 51%, potential nonresponse bias may have affected the results. Furthermore, data collected from a single site may not represent broader demographics and experiences. Further education, along with a higher completion rate of the PGIBH survey, an extended evaluation period of at least one year, and data gathered from multiple locations, is needed to gain deeper insights into the impact of SMART education on patient satisfaction. For sustainability, standardized discharge protocol should be incorporated into the continued training curriculum for all nurse staff, ensuring consistent discharge education that improves patient experience, lowers readmission rates, and reduces healthcare costs, as the literature supports.

Open Access


Available for download on Sunday, June 09, 2024