Background: Throughput is a hospital priority. Decreasing length of stay is essential to decongesting overcrowded hospitals and maintaining financial viability.
Purpose: The purpose of the project was to improve throughput through enhanced interdisciplinary communication.
Description: We used the LEAN methodology of process improvement to perform a Value Stream Mapping exercise, which brought diverse clinical staff together to map the current state of inpatient throughput. The exercise identified efficient throughput delays each morning in the initiation of the clinical plan due to a lack of communication between the providers and the nurses (RNs), case managers (CM), and social workers (SW). A Kaizen (LEAN continuous improvement project) was then used to develop Care Team Rounds (CTR), an interdisciplinary working rounds on a medicine units with a geographically located teaching team. CTR combined house staff presentations on the patients and discussion of plan of care with the attending with a report out by the RNs. CTR were also attended by the unit medical director, nurse manager, charge nurse, CM, and SW. The initial iteration involved seeing all patients. However, due to negative feedback from the staff regarding timing, the second iteration was held at the nursing station with the opportunity to see patients as needed. Our primary aim was to reduce LOS over six months by 10%. Our secondary aim was to improve patient communication as measured by the HCAHPS scores as well as to improve communication and workflow as reported by the care team. The non-nursing staff provided feedback via a survey tool. A qualitative analysis based on a focus group was used to assess the RN perspectives.CTR were trialed between March and November of 2023. Though the initial length of stay (observed over expected) decreased from 1.97 to 1.35, it subsequently reverted back to baseline. Overall there was not a significant change in length of stay. The HCAHPS scores did not indicate a significant trend, though the data was limited due to the low numbers of surveys on the unit and a delay in data reporting. In the survey of non-nursing staff, 40% said that CTR led to the initiation of the plan of care earlier in the day. 68% reported that the CTR improved communication with nursing. Overall, 65% wanted to return to the prior workflow, 23% wanted to continue with CTR with changes, and 12% wanted to continue with CTR. The main concerns from the attending physicians and residents were that there was insufficient time for education. The main criticism from CM and SW was that too much time was spent on education. RN focus groups revealed that while CTR improved communication with SW and CM, RNs felt the timing and length of CTR interfered with morning tasks. RNs reported that communication with providers did not change with CTR, and they continued to get information about the care plan from provider notes and through electronic communication (i.e., EPIC chat).
Conclusions: We described a multi-step, interdisciplinary quality initiative to improve throughput that was evaluated using different methods. Despite these efforts, neither an improvement in throughput nor communication was demonstrated. CTR were not popular among the majority of staff. The inpatient medical service is challenging; we must balance the unique needs of each team member with the need to expedite communication. Combining workflows expedites communication; however also leads to less efficient use of time. Future initiatives will use lessons learned during this trial to strike the correct balance.