Tackling Throughput With a Novel Care Team Rounding Model

Background Improving length of stay (LOS) is essential to decongesting hospitals and maintaining financial viability. Local problem The baseline LOS from March 2022 to February 2023 was 7.82 days with an observed to expected ratio (O/E) of 1.75 on a medicine unit at an urban academic hospital. Methods A Lean value-stream mapping exercise identified delays in advancing the inpatient plan due to delayed communication between physicians (MDs) and staff. Our Lean team held a Kaizen event where an interdisciplinary team developed care team rounds (CTRs), a new model of rounding, which integrated MD presentations with nurse input and fostered interdisciplinary staff discussion between the unit medical director (UMD), nurse manager (NM), charge nurse, case manager (CM), and social worker (SW). Interventions In the first Plan-Do-Study-Act (PDSA) cycle, all participants in CTRs walked the length of the unit together with a workstation on wheels and saw each patient at bedside unless contraindicated. However, due to negative feedback from the staff regarding inefficient use of time for CM and SW and disruption of the unit workflow due to the large group in the hallway, the second iteration took place at the nursing station, with CMs and SWs able to have a computer and phone during rounds. The aims were to reduce LOS, improve patient communication (determined by the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] survey), and improve communication and workflow (qualitative analysis). Results The initial O/E ratio for LOS during the first PDSA cycle decreased from a baseline average of 1.75 (7.82 days) to 1.65 (7.88 days). Ultimately, the O/E for LOS reverted to 1.77, with a mean of 7.77 days for the intervention time period (March 2023 to Oct 2023); there was no significant decrease in LOS. There was also no trend in HCAHPS patient satisfaction scores, though low number of patient survey responses limited data. Thirty-one percent of non-nursing staff reported an earlier initiation of the care plan, 58% reported improved communication with nursing, 63% wanted to discontinue CTRs, 23% wanted to continue with changes, and 11% wanted to continue without changes. The MDs primarily voiced concerns about insufficient time for education, whereas the CM and SW felt that too much time was devoted to education. Registered nurses felt the timing of CTRs interfered with morning tasks, though they did improve communication with CM and SW, but not providers. Conclusions Ultimately, lack of staff buy-in and insufficient evidence of improvement led to the suspension of CTRs. The inpatient medicine service presents a challenge in balancing the unique workflows of each team member while expediting communication between disciplines. Combining workflows expedites communication; however, it also leads to less efficient use of time. Future initiatives should use the lessons learned during this trial to strike the correct balance. Plain Language Summary When the quality team and unit leadership at Mount Sinai Morningside noted that patients were staying in the hospital longer than they were expected to, they embraced the Lean methodology to identify waste and improve quality and efficiency. Longer hospital stays congest hospitals, add more healthcare costs that may not be reimbursed, and may indicate avoidable delays in patient care. One key intervention they hoped would decrease the length of stay (LOS) was developing more comprehensive interdisciplinary care team rounds (CTRs) that brought together leadership, physicians, nurses, social work, case management, and interns in walking bedside rounds. Using the Plan-Do-Study-Act process, the CTRs evolved with each improvement cycle to address concerns and feedback. Although some added benefits arose from this new CTR model—most notably in reports of better communication with nursing, social work, and case management—there were also many drawbacks and challenges. Barriers included more limited educational opportunities for residents and time management for clinical staff with unique workflows. Ultimately, there was no decrease in LOS or measurable improvement in patient satisfaction and staff preferred to return to their original rounding routine, so the project was discontinued. However, the lessons learned throughout this initiative may benefit another facility, and this CTR model could be more successful in a non-teaching hospital.