Background: Interprofessional teamwork in healthcare organizations is crucial to the delivery of quality patient care. Efforts to improve teamwork on hospital medicine units commonly fail due to clinicians and other care team members (case managers and pharmacists) are responsible for patients scattered across numerous floors and units. UK HealthCare developed and implemented the Interprofessional Teamwork Innovation Model (ITIM©) on a 30-bed hospital medicine unit.
Purpose: The Interprofessional Teamwork Innovation Model (ITIM©) optimizes communication among providers caring for hospitalized patients on hospital medicine units. Daily bedside rounds include the primary nurse, nurse case manager, pharmacist, and hospitalist aiming to increase value.
Description: The core team developing and implementing ITIM© included a hospitalist nurse dyad leadership with front line nursing staff, nurse case managers, pharmacists, and hospitalists. Core team met weekly to develop and refine ITIM©. Importantly, everyone was informed that failures were to be expected; i.e., a normal part of quality improvement, but would trigger adjustment and revised attempts with rapid Plan-Do-Study-Act (PDSA) cycles of change. Daily ITIM©rounds reflect a team care by a physician, bedside nurse, pharmacist, and nurse case manager. This team closely collaborates in the same physical workspace while caring for patients and together performs patient and family-centered bedside rounds.
Outcome measures included length of stay, 30-day readmission rate, and average cost per patient. The analysis evaluated care delivered from March 1, 2015, to February 29, 2016, and compared 988 inpatients exposed to the intervention (ITIM©) to a control group of 8,235 inpatients with the same MS-DRGs admitted to other hospital medicine teams. The Case Mix Index (CMI) measure of illness severity was used to standardize all patients to a CMI of 1.0. The CMI adjusted length of stay was 0.13 days less in the ITIM© group than the control group, generating 126 opportunity days. There was 1.8% absolute reduction of all-cause 30 -day readmission rate. CMI-adjusted direct cost per patient was $866/patient lower (855,608 $ total savings). Calculation of costs for the intervention included the additional costs of increased staffing associated with ITIM©(pharmacist and additional case manager). Approximately 20% of the cost savings was due to a reduction in pharmacy costs through management of medications by the pharmacist on rounds. Based on the success of ITIM©, UK HealthCare is spreading this model to other hospital medicine teams at the new university hospital.
Conclusions: The ITIM© approach to teamwork with bedside rounding and facilitated communication yields a shared mental model for everyone caring for a hospitalized patient. This resulted in dramatic cost savings, enhanced efficiency of care with lower length of stay and safer care transitions with decreased readmissions. Investment in additional staffing (nurse case manager and pharmacist to join the hospitalist as they rounded with the bedside nurses) proved cost-effective. Beyond cost savings, ITIM© boosted the overall value equation as quality also increased.
We are seeing dramatic improvements in outcome measures and believe that geographically-based team rounding can succeed on adult hospital units. This innovative approach represents true “interprofessional practice” with shared communication and decision-making among the team.