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Geographic Rounding – The Good, the Bad and the Ugly

Posted on Wed, Mar 08, 2017
Geographic Rounding – The Good, the Bad and the Ugly

Hospitalists have become vital members of the care teams throughout the United States. As healthcare organizations have welcomed this new physician role, many have been faced with the challenge of successfully integrating the role into their overall operations. One solution that has emerged over the past few years is geographic rounding.

Asim Usman, M.D., SFHM, divisional medical director for EmCare's West Division, led a panel discussion on geographic rounding at the 2016 EmCare Annual Leadership Conference in Las Vegas. He highlighted the experience and success Santa Rosa (Calif.) Medical Center (SRMC) had with geographic rounding. SRMC representatives Al Gore, M.D.: director of utilization management, Chris Stier, R.N.; nurse manager, Briana Rogers, EmCare’s division client administrator, and Carsi Padrnos, director of clinical services, joined Dr. Usman as panel members.

Dr. Usman explained that geographic rounding designates a system of hospitalist patient assignments by geographic location. He acknowledged that geographic rounding has become a buzzword in the healthcare industry: “It sounds cool, and it seems to make sense, so everybody wants it. But does a hospital really know what geographic rounding means and what it is asking for? Does the hospital understand the challenges that come with implementing it? Can the hospital’s culture support the successful implementation of the concept? This is the ‘bad’ of geographic rounding.”

What about the “ugly” side of geographic rounding? Recognizing that no one likes change, the concept is complex, involving several key stakeholder groups that are being asked to change their behavior regarding workflow. In addition, specific metrics and data will be used to hold individuals accountable for either supporting or hindering geographic rounding’s success.

To demonstrate the challenges of implementing geographic rounding and the resulting “good” aspects of the concept, SRMC’s experience was highlighted. SRMC has partnered with EmCare for the management of its emergency medicine and hospital medicine programs. EmCare’s Rapid Admission Process & Gap Orders™ (RAP&GO) solution is used to improve efficiency in the emergency department (E.D.) and to enhance patient flow by facilitating the movement of patients requiring hospitalization to inpatient beds as quickly as possible.

Dr. Usman noted that when EmCare started working with SRMC, the hospitalist program was disjointed, with only four full-time hospitalists on staff. With 200 beds, the hospital’s average daily census is about 120. Currently, six hospitalists cover the service daily, with one swing shift and one night shift.

In theory, geographic rounding should promote more positive experiences – timely, coordinated care and organizational efficiencies. The hospital’s goals for geographic rounding, created by the hospital medicine physicians, included:
 

  • Improved physician response time
  • Improved patient and family access
  • Limited physician movement in the hospital to facilitate team rounding (physician, RN, social worker)
  • Participation in discharge huddle
  • Building physician and nurse relationships
  • Improved consultant access
  • Increased patient satisfaction

To evaluate the success of geographic rounding, the hospital utilized the following metrics:
 
  • Average length of stay
  • 30-day readmission rate
  • Medical staff satisfaction
  • Patient satisfaction
  • Physician satisfaction

Stier’s nursing unit was selected as the pilot site for geographic rounding. He said the major objective was to locate at least 70 percent of a hospitalist’s patients on a single unit. Some of the first major challenges included a limited number of full-time hospitalists in the program – necessitating the use of locum tenens physicians who were not necessarily familiar with or willing to buy into the concept – as well as a high patient load, the existing method of patient distribution and “floor fatigue.” Huddles became a key component of the successful implementation of geographic rounding by creating a culture of accessibility and collaboration.

“Nurses want physicians there, consultants want to be able to reach the hospital medicine physician, and patients want to have their physician readily available,” Dr. Usman said. “When you go into a new facility and bring a new team of 16 hospital medicine physicians to interact with 300 nurses, how do you develop a geographic rounding program?” The five- to 10-minute daily discharge huddles, held in the morning with efficient delivery of critical information, helped to engage physician and staff confidence in the concept.

Ongoing feedback and communication among all care team members was key to its evolution. Participants identified what was working well and what was not. As the new geographic rounding program matured and discharge huddles involving the hospitalist, nurses and social workers became standard procedure, the hospital began to see significant improvements in organizational efficiencies such as pharmacy utilization, DME orders and delivery, reduced callbacks and a substantial decrease in the distance hospitalists traveled within the hospital to see their patients. Physicians noted that the volume of telephone calls also decreased dramatically, indicating that it was most likely due to more consistent physical presence of physicians, which resulted in fewer workflow interruptions.

Rogers noted that education and collaboration were necessary for a successful launch of the program. Aligning the hospitalists clinically with the mix of patient diagnoses also was important. The hospital set up financial models to ensure appropriate staffing practices were in place to meet patients’ needs. Flexibility also was paramount. When staff members were flexible, they were able to learn from their experience and make adjustments to improve the process.

Dr. Usman pointed out that timing is important for launching a geographic rounding program: “When you go into a new program with 60 percent locums, it’s probably not the best time to start most new initiatives. We waited about eight months to get appropriate hospitalist staffing in place before we began the program.”

Padrnos explained that the geographic rounding initiative at SRMC brought together three factors: a multidisciplinary approach, the opportunity to impact patients, and a multitude of challenges for presenting providers. One of the biggest challenges was the high degree of interest the hospital had in the program compared to the low degree of interest from legacy hospitalists. Padrnos and the team made sure that all of the providers were involved from the start of the initiative and throughout the entire process.
A variety of implementation strategies were employed, including:
 
  • Setting clear goals
  • Involving providers at every stage of the initiative through regularly scheduled meetings with all team members
  • Testing small changes to gauge effectiveness
  • Designing a mixed model of solutions
  • Implementing frequent and ongoing communications, including memos
  • Creating a daily distribution board that included the hospital’s current census and newly hospitalized patients, a list of the hospitalists’ admissions and discharges, a list of the hospitalists’ current patient assignments by unit, average length of stay for the previous month and month-to-date length of stay
  • Using surveys with multiple stakeholders to measure the initiative’s success and to identify opportunities for improvement

The results of the geographic rounding initiative at SRMC have been impressive:
 
  • Length of stay has fallen from a baseline of 5.83 to 4.44 days
  • 30-day readmission rate has decreased from a baseline of 14.6 percent to 9.8 percent
  • Patient satisfaction has increased from a baseline of 67.7 percent to 78.1 percent

In addition, surveys the hospital administered to providers 30 and 90 days post-implementation addressed the specific goals they originally established for the initiative. The 30-day survey showed that the 10 respondents had little to no interest in the program. After 90 days, 60 percent of the five respondents said they were satisfied with geographic rounding and 100 percent said they were satisfied with the discharge huddle.

Dr. Gore concluded by saying, “The keys to our success with geographic rounding came down to teamwork and patience.”

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