Blog Posts

hospital medicine

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.”


Featured Clinician: Pankaj Malhotra, MD

Posted on Mon, Dec 05, 2016
Featured Clinician: Pankaj Malhotra, MD

The heart and soul of our practice are our clinicians. Meet Pankaj Malhotra, MD, regional medical director of the hospital medicine program at Doctors Hospital of Manteca in Manteca, Calif.

Years with EmCare: 3 years.

Years practicing medicine: 13 years.

Why did you decide to become a doctor? Believe it or not, to help people.

Why did you choose your specialty? I chose hospital medicine because it's the best way to practice pure medicine and most satisfying in terms of helping patients.

What career did you want to pursue when you were younger? I wanted to be a design engineer.

Describe one of your greatest professional accomplishments. I’m too humble to describe it.

What is in the pockets of your lab coat? Schedules and physician roster for my sites, car keys, phone.

What would be your ideal category on “Jeopardy”? Common Sense

How do you stay organized at work? I take a lot of notes.

What are your tips for “leaving work at work” and not getting burned out professionally? I treat work as a hobby, not a chore.

How are you Making Healthcare Work Better®? I focus on one patient at a time, keep learning and always involve patients in the decisions.

What’s the best advice you’ve received about work or life? “The glass can be even a quarter full.”

What do you enjoy outside of work? Travelling and family time.

What’s your favorite inspirational quote? Men and steel are alike. When they lose their temper, they lose their worth.

What qualities make a successful doctor? Listening to patients, listening to the parents, listening to the nurses and keeping an open mind.

How would your co-workers describe you? I will let my co-workers answer that question!

If you could have dinner with anyone, living or historical, who would you choose and why? Chanakya, who was a 4th century teacher, philosopher, economist, jurist and royal advisor in India.

What’s the most interesting place that you’ve been? Rome.

What are you currently reading? Jeppesen Private Pilot Manual

What’s your favorite TV show? Malcolm in the Middle

What personal accomplishment are you most proud of? I will let them remain personal.


Implementing Lean Processes in Inpatient Units

Posted on Wed, Nov 23, 2016
Implementing Lean Processes in Inpatient Units

By Francisco Loya, MD, Nathan Goldfein, MD, Roxie A. Jackson, RN, MSHL, LHRM and Stacy Bruneau, RN

Lean focuses attention on expediting operational and service factors in the inpatient setting so more time can be devoted to patient care. Traditionally, inpatient services were expected to be methodical and slow to ensure appropriate patient care. Today, hospitalists are charged with efficiently coordinating all aspects of care, in essence continuously improving processes to expedite care to the patient.

With so much relying on smooth patient flow, lean can help reduce lengths of stay, improve management of resources and utilization, and improve satisfaction for patients, physicians and all stakeholders. The development of hospital medicine in and of itself is a grand example of a lean philosophy. Hospital medicine was born of the need for quality improvement and a more efficient way to manage inpatient care.

Before hospitalists came into being, inpatient care was managed by the patient’s primary care physician (PCP). The PCP would endeavor to round in the morning before office hours and again after hours. In addition to being very inconvenient and costly for the PCP, this process also placed significant limits on inpatient care management that could have potentially expedited care and helped the patient go home sooner.

As hospital payments began to be based on a standard diagnosis-related group (DRG) rate, it became obvious that the intermittent access to the PCP for admissions and discharges was not efficient. Hospitals without hospitalists found it increasingly difficult to operate within Medicaid and Medicare guidelines for length of stay, utilization and costs.

Maybe even more importantly, with increasing volumes in the emergency department, ED bed capacity became an issue that required a broad view of patient flow. When inpatient beds were filled with patients waiting for their PCPs to come by after work to discharge them, the ED was left with patients boarding in ED beds, leaving no room to see new patients who were waiting for emergency care. Hospitals needed a way to manage the discharge so that the patient was moved out of the inpatient bed at the appropriate time and on to a more suitable care setting for the next stage of care.

Visualize the value stream map from the perspective of the hospital, the ED, the PCP and the patients. The wasted time and steps (wait times, travel) brought no value to the process. The concept of hospital-based physicians who would specialize in inpatient care seemed to be a lean approach to a convoluted process.

This lean-based concept for care has had a cost saving effect from reduced lengths of stay and better management of resources and utilization. Other benefits have included improving satisfaction for patients, families, referring physicians, hospital staff, ancillary services and more.

The following results are some of the benefits of a lean strategy for inpatient services:

  • Reduced waste (reduced length of stay (LOS) for inpatients, unnecessary time in the hospital)
  • Reduced defects (reduction in readmission rates)
  • Reduced redundancy (fewer patient tests)
  • Added value (availability to a physician in the hospital 24/7)

This lean approach to managing inpatients with hospitalists improves operational efficiency and service to the patient. Managing admissions and discharges on a just-in-time basis can make a powerful impact on the patient’s length of stay and the hospital’s patient flow.

Lean helps identify redundancies, poor organization, data needs and best use of resources from beds to staffing. Some specific targets for performance improvement that may be achieved by implementing lean methodologies in the inpatient unit include:
  • Improved clinical outcomes
  • Lower mortality rates
  • Reduced average lengths of stay
  • Improved patient outcomes
  • Improved ED throughput
  • Improved bed utilization
  • Decreased cost per case
  • Reduced readmission rates
  • Improved patient experience
  • Expedited care
  • Expedited admissions
  • Better continuity of care
  • Improved interdepartmental collaboration and relationships
  • Increased physician retention

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by some of the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques. EmCare leads scores of lean projects per year with client hospitals across the country.

The impact of a lean approach to hospital medicine is one of many subjects included in the book, which is a compilation of lean experiences and advice from nearly 30 practicing experts. The book is accompanied by a free, downloadable workbook with practical tips and exercises to help you break down barriers to getting lean in your organization. It’s the perfect reference book for someone who needs to understand what lean is about, how to make it work, how to overcome road blocks and how to gain buy-in.

To learn more about this case study and to download your free copy of “Making Healthcare Work Better™ with Lean,” visit our website.

Francisco Loya, MD, MS, is Chief Executive Officer of EmCare Hospital Medicine. Nathan Goldfein, MD, is Vice President of Operations with EmCare Hospital Medicine and the director of the Hospital Medicine program at Gerald Champion Regional Medical Center in Alamogordo, N.M. Roxie A. Jackson, RN, MSHL, LHRM, is Director of Clinical Services with EmCare. Stacy Bruneau, RN, is a Divisional Director of Clinical Services for EmCare.


Webinar: The Future of OB Hospitalist Programs: The Unexpected Deliverables

Posted on Wed, Sep 07, 2016
Webinar: The Future of OB Hospitalist Programs: The Unexpected Deliverables

As patient safety, clinical quality and outcomes consume increasing portions of the financial risk and penalties, OB hospitalists programs are growing and evolving to help risk for women and children’s services.

You might expect that with an OB hospitalist onsite 24/7, hospitals are better equipped to manage obstetric and gynecologic care and emergencies, providing the ultimate in patient safety while reducing liability and risk. That’s true. But there are unexpected benefits as well.

Join us September 21 as Wayne L. Farley, Jr., D.O., FACOG, presents “The Future of OB Hospitalist Programs: The Unexpected Deliverables,” a webinar hosted by Becker’s Hospital Review.

Participate in the webinar to learn: 

  • What this specialty has achieved since its inception just over 10 years ago
  • The unexpected beneficiaries: medical staff physicians, nursing, hospital administration and career OB hospitalists
  • Why a safety-focused hospital shouldn’t go without an OB hospitalist program
  • How OB hospitalists programs are evolving and predictions for the future
  • Obstacles to implementing an OB hospitalist program
  • Key considerations for outsourcing the program

Register to learn what your hospital needs to know about the future of OB hospitalist programs.

Wayne Farley

Dr. Wayne Farley is Chief Medical Officer Women’s and Children’s Services for Questcare, an affiliate of Envision Healthcare. In this role, Dr. Farley facilitates engagement between Questcare’s senior executive team and client hospital leadership. He provides medical oversight, expertise and leadership to ensure the delivery of affordable, quality healthcare services. Additional responsibilities include the strategy, development and implementation of innovative clinical programs that include collaboration with client facility leadership.

Following completion of residency at Texas Tech University Health Sciences Center, Dr. Farley practiced OB/GYN in Texas for 18 years. In 2008, he left private practice to help develop Questcare Obstetrics.



The 40-Year Old Med Student

Posted on Mon, Aug 22, 2016
The 40-Year Old Med Student

By Nathan Goldfein, MD

If you ask a physician, “When did you first realize you wanted to be a doctor,” chances are good they will say, “Since I was a little kid.” But there are plenty of doctors for whom medicine was not a foregone conclusion. I was one of those who made the choice to pursue medicine later in life.

It wasn’t that I didn’t like medicine; it was just that I hated school. Throughout my grade school years I struggled and struggled. After a lot of tears and testing, and many teachers saying that I was stupid and incapable of succeeding in a formal education setting, I was eventually diagnosed with dyslexia.

With this discovery of my dyslexia came a lot of well-meaning advice, which sometimes actually stood in the way. Despite my parents being told that I would probably not make it in college, I did go to college and managed to pass. Initially I chose biochemical engineering as my major. However, I heard that the pay was lousy and that I would need to do additional schooling. I went to my counselor and asked, “What can I complete in four years and get a good job?” I was told only engineering. I switched to mechanical engineering and loved it! Throughout my life the way I compensated for my learning disability was to get creative and develop innovative ways to solve problems. Now I had found a career where I could put this skill set to good use.

Once out of school, I worked on projects designing missiles, satellites and air brakes, earning 10 patents in the process. I moved on to develop more than 150 innovative chemical products, including a biosurfactant that eats oil after it’s spilled on dirt – a breakthrough product for mitigating oil spills. I also developed The Classic product line, which included the first waterless wash and wax. I later sold that company to Pennzoil.

Shortly thereafter, I changed course completely and started my journey into medicine. Why make such a drastic shift to become a physician, especially in light of my learning disability? For starters, my father was a doctor so I already knew a bit about the profession, but beyond that it essentially came down to two life-changing experiences.

The first was being in a situation where I wanted to help someone but couldn’t. I was on a flight when a passenger had a heart attack. I felt helpless because I didn’t know how to help him. It was an awful feeling.

The second was a lingering regret from earlier in my life. In 1986, when I was designing and manufacturing air brake systems, NFL players went on strike. I was playing Texas League football in Houston at the time. I wanted to try out for the Houston Oilers, but didn’t. I always regretted not trying and vowed not to ever let that happen again. The bottom line was that I was interested in medicine and didn’t want another opportunity to pass me by. Although I was sure I wouldn’t get into medical school, let alone finish, I didn’t want to fast-forward to my 70s, sitting in a rocking chair, filled with another regret about a chance I didn’t take because I was afraid of failure.

With that in mind, I started working on my med school prerequisites at age 38. I took the MCAT and passed, despite not completing the whole test because of the dyslexia. At 40, when most guys buy a sports car or go skydiving (which I also did) as their midlife crisis, I started medical school. I attended University of Arizona School of Medicine and nearly flunked anatomy. The complicated words and dyslexia didn’t mix well. Thank God they didn’t take off for spelling or I wouldn’t be a physician today. As I took more clinical classes, I began to hit my stride. Clinical classes allowed me to use my problem-solving skills from my years as an engineer.

During my fourth year of med school, I still couldn’t find a specialty that I wanted to pursue until I did a hospital medicine rotation. I loved it! I specialized in ICU medicine, and “suicide matched” to the one and only residency program that I applied to: the University of New Mexico. I liked ICU work so much that I traded ward shifts and clinic shifts for ICU shifts.

Hospital medicine requires problem-solving skills and developing innovative ways to provide care, especially in the ICU where you’ll find the sickest patients. You won’t read about how to provide this level of care in textbooks; it’s an “in the trenches” kind of education.

Looking back, I know that I’m a better physician because of my engineering background, and even because of my dyslexia, because I’ve had to find ways to compensate for my limitations. I’m a blessed guy. I’ve worked hard, played hard and have the best family, which includes my wife, Rosa Linda (who I met on an airplane) and our three children: Ahava, Ziva and Samuel.

My advice for those thinking about a career in medicine is simple: You’ll regret what you don’t do more than what you do. It’s always better to try and fail then play it safe and never take the risk.

Nathan Goldfein, M.D., is Vice President of Operations for EmCare Hospital Medicine and the director of the hospital medicine program at Gerald Champion Regional Medical Center in Alamogordo, N.M.

< Previous Results 1 - 5 of 258 Next >