Properly designed, hospital units have potential to optimize outcomes for patients, staff, and trainees. Such units would be of great value if they converge high high–performing teams with active management while promoting principles of safety, timeliness, effectiveness, efficiency, equitable care, and patient–centeredness.
We sought to redesign a medical ward to systematically integrate physician trainees into an Accountable Care Unit (ACU) model with a specific focus on team performance and training using Structured Interdisciplinary Bedside Rounds (SIBR) to promote communication, mutual accountability, and patient–centered care.
We transformed a medical unit into an ACU at a large university hospital. We define an ACU as a ward responsible for the clinical, service, and cost outcomes generated and highlight its four key features: (1) unit–based teams, (2) SIBR, (3) unit–level performance data, and (4) nurse–provider management partners accountable for unit outcomes. Each month the ACU leadership sets expectations with attending staff, frontline nursing staff, and trainees. Expectations include using first–names as a basis for communication, sharing accountability for verbalizing and advancing a daily plan of care for each patient, adhering to the SIBR script and quality–safety checklist, maintaining an atmosphere of constructive feedback, and cross monitoring individual and team performance. We launched an ACU on September 1, 2011 at Emory University Hospital, a 579–bed teaching hospital. The first ACU is a 24–bed unit staffed by two unit–based physician teams—each composed of one hospital medicine attending, one resident, three interns, and two medical students. Each unit–based team has 85% of its daily patient census cohorted to the ACU. Team rounding (SIBR) occurs every day, starts punctually in the mid–morning, and requires 30–60 minutes per team. SIBR always includes the bedside nurse, the physician team, and the nurse manager; weekdays, a clinical pharmacist and social worker join (Figure). Unit–level outcomes (mortality, infection rates, glycemic control, patient satisfaction, and length–of–stay) are reported to the physician and nurse management partners.
Redesigning hospital care using the structure, process, and management model of an ACU appears feasible in a teaching hospital and may represent a valuable way for hospital medicine programs to align patient–centeredness, quality, and leadership while simultaneously teaching housestaff to work in a highly efficient team–based care model. Improved outcomes will depend on process factors of the system change such as leadership skills of unit management and developing nursing and physician co–management best–practices.
Figure 1Structured interdisciplinary bedside rounds diagram.