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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.”


Implementing Lean Processes in the ED Improves Metrics

Posted on Wed, Oct 19, 2016
Implementing Lean Processes in the ED Improves Metrics

By Christine Kelly, RN, MBA, FACHE; Amanda Maxim, RN, BSN, MBA; Jan Beck, RN, BSN; and Shayne Middleton, RN, BSN, CEN

Nowhere is a glitch in the patient experience more pronounced than in the emergency department (ED). The ED team's ability to provide fast, efficient, quality care has a signifcant impact on each patient’s perception of care and the management of life-threatening injuries.

The processes in use today to manage patient flow from arrival to treatment to disposition are widely seen as inefficient and cumbersome. These inefficiencies often lead to long wait times and a lack of attention to patient needs and, potentially, prevent needed access to care. Recent publicity surrounding patients leaving without treatment, deaths in waiting rooms and overcrowding has become a catalyst for change in the industry. As a result, we are seeing a significant increase in the use of lean at hospitals nationwide.

It’s important to understand that achieving lean in the ED may rely heavily on improving processes in other departments. Lean can be most effective for improving patient throughput, but this means looking at the ED as one part of the delicate ecosystem of hospital care. While lean implementation may start in the ED, to be most effective it needs to extend through all patient flow paths.

When lean is applied to the front-end processes, patients can be seen more quickly. Lean in radiology and ancillary services also can facilitate patient treatment and diagnoses more quickly. Extending lean into the inpatient setting helps cut unnecessary hours off of the length of stay, which opens inpatient beds for new patients to be transferred from the ED. Lean for the OR helps ensure efficient operation of surgical services, allowing accommodation of emergency cases. Lean methodology works best when it encompasses the entire path of patient care.

Implementing Lean in the ED

A lean consultant was asked to conduct an emergency department lean rapid redesign workshop with the goal of improving operational efficiency.

Patients were experiencing an increased length of stay due to delayed diagnostics. Further, without use of pre-emptive orders at triage, it was taking 35 minutes from arrival to order entry by a primary care nurse if immediate bedding took place (and longer if no beds were available).

  • Patient presents to triage = 30 minutes; to room 110 minutes, wait for provider 60 minutes, Medical Screening Exam = 10 minutes, 5 minutes to order entry = total of 215 minutes from door to order entry
  • Provider order entry was 74 minutes from arrival
  • With pre-emptive ordering at triage, 24 minutes to order entry
  • LWOTs were two times the national best practice of 2.0 percent
  • Decreased efficiency ancillary services secondary to wasted time/trips to the ED

Contributing conditions:

  • No prioritization of services ordered – X-ray may collect the patient prior to lab draw, resulting in delay in results due to collection time
  • Transport of lab specimen delayed, placed in box on counter
  • No communication between ancillary departments
  • Pre-emptive orders not consistently used by nursing
  • Inconsistent "pull ‘til full"
  • Some physicians delaying medical screening exam on low-acuity patients, some saving for advanced practice providers

The Lean Solution

The consultant worked with the hospital’s nurse leaders to reach the following goals:

  • Implement bedside triage and registration process 100% of time, with “Pull ‘til Full” concepts (Patient-Centric Care) implemented across all shifts/staff
    • Minimize redundancy
    • Standardize triage process
    • Target arrival to provider time: 40 minutes
    • Bed to provider time: 25 minutes
  • Create more organized patient flow with space for simultaneous processes to take place, eliminating wait time and redundancy
    • Adequate resources in the right place
    • Keep vertical patients vertical and give the beds to the sick
    • Use discharge sub-waiting area
  • Consider plant flow redesign with existing spaces to include reassignment of current rooms for more efficient flow
    • Use of triage preemptive protocols 70 percent of the time
    • Improved ancillary communication
    • Collection to receipt of specimen to take only 5 minutes 90 percent of the time
    • Door-to-doc time to meet 40-minute benchmark
  • Educate ED, evaluate cost and benefits, recognize waste, plan-do-study-act, gemba walks
    • Reinforce "pull ‘til full" policy with 100% use of bedside computers
    • Educate nurses/providers in use of pre-emptive protocols
    • Flag on specimen box as visual cue for specimen awaiting transport, ED to assist
    • Lab access to private tracker board to allow comments
    • Lab to notify nursing when draw complete so tracker can be updated for X-Ray
    • Educate Radiology staff on use of tracker notifications
    • Metric comparisons

After implementation, the team’s results included:

  • Streamlined patient flow
  • Decreased throughput time
  • Decreased left without being seen (LWBS) rate
  • Improved patient and employee satisfaction
  • Improved quality in delivery of care
  • Reduced financial losses

EmCare recently published “Making Healthcare Work Better™ with Lean,” a book and supporting workbook developed by the company’s clinicians and operational experts to help hospital leaders and process improvement teams better understand and implement lean process improvement techniques.

This case study is one of many 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.

Christine Kelly, RN, MBA, FACHE, is Vice President of Clinical Services for EmCare. Amanda Maxim, RN, BSN, MBA, is Vice President of Clinical Quality for Valesco Physician Services, Inc. Jan Beck, RN, BSN, is a Director of Clinical Services for EmCare. Shayne Middleton, RN, BSN, CEN, is a Divisional Director of Clinical Services for EmCare.