Unit-based care teams offer inherent benefits to hospitalist services, including opportunity for improved efficiency, interdisciplinary collaboration, and enhanced patient experience. However, many barriers exist to creation of these care teams such as high occupancy rates and conflicting interests among stakeholders. Failure to account for such barriers has led to unsuccessful initiatives to achieve regionalization, including four prior attempts at our institution.
To create unit-based, interprofessional general medicine care teams via engaging hospital leadership and other stakeholders, aligning with institutional goals, and applying principles of change management.
In 2013, we implemented a unit-based care model for the general medicine service at our 750 bed academic medical center. In the year prior to implementation, hospital leadership and key stakeholders from the Emergency Department (ED), bed control, nursing, and medicine residency were engaged to identify and address potential barriers and to align the unit-based care model with hospital goals, including early discharges and improved throughput in response to high patient census. To address identified barriers, a model of shared responsibility was created such that the ED and bed control staff worked to optimize regionalization while inpatient care providers worked toward earlier patient discharges to open inpatient beds and proactive communication regarding time of likely discharges. To improve daily capacity to accept patients on any unit at any time, inpatient physician teams were reorganized into daily admitting, day and evening shifts. In addition, several structures were put in place to facilitate teamwork, patient-centeredness, and discharge planning, including a brief morning huddle to organize rounds and to confirm planned morning discharges, patient- and family-centered bedside rounds, structured interprofessional discharge planning, and an afternoon huddle for patient handoff between the day and evening teams and identification of next day discharges. Weekly reports were implemented to share key metrics with leadership and stakeholders and to hold inpatient teams accountable for their performance.
Since implementation, teams and units have maintained the target for > 80% regionalization, have increased discharge before noon from a baseline of 4.9% to 12% (p<0.001), and have increased overall patient satisfaction (89% vs. 92%, p=0.016), as well as that of family and visitors (86 vs. 89%, p<0.001).
Creation of unit-based care teams is feasible in hospitals with high occupancy but requires engagement of hospital leadership, various stakeholders including those outside of one’s own discipline and department, and alignment with other institutional goals. Unit-based care teams can form the foundation for further process improvement to enhance efficiency, patient safety, and the experience for patients and their families.