Background: Morning rounds on inpatient teaching services are a fundamental element of patient care delivery and trainee development. However, overall care and education can be negatively impacted when rounds extend past late morning. Optimal teaching rounds involve balancing the three domains of patient care, education, and operational efficiency. We developed an interdisciplinary workgroup, including residents, attendings, and nurses, to develop and refine strategies to optimize this balance at our institution.
Purpose: We report our experience implementing a Lean Rounds initiative to end rounds by 11am, while preserving optimal patient care and maximizing education for resident teaching services in general medicine and cardiology.
Description: The Lean Rounds initiative began in 7/2021 in response to new residency guidelines to end rounds by 11:00am. A workgroup formed over the next 4 months and developed consensus guidelines and educational materials between 11/2021-1/2022. The development phase began in 1/2022 with didactic trainings for faculty, interactive sessions with residents during teaching conferences, and dissemination of written guides. Between 1/2022 and 8/2022, uptake and satisfaction were assessed via weekly surveys to residents and attendings, augmented by in-person discussion at resident conferences. We received 37 surveys from attendings and 26 from residents (10% overall response rate). Seventy-one percent (45/63) of respondents reported using Lean Rounds practices “most of the time” or “all of the time” and were defined as high utilizers; 29% (18/63) reported using these practices “somewhat”, “very little” or “not at all” and were defined as low utilizers. There were higher rates of satisfaction (defined as “happy” or “very happy”) among high utilizers than among low utilizers regarding perceived quality of patient care (96% vs. 89%), patient- and interdisciplinary team communication (96% vs 83%), efficiency (84% vs 39%) and rounds end time (80% vs 33%), but slightly lower rates of satisfaction with educational content of rounds (84% vs 89%). Among high utilizers, there was a higher proportion of rounds ending before 11:00am (29% vs 0%) or 11:30am (74% vs 50%), but still not meeting our goal of most teams ending by 11:00am. Overall, these differences were promising and led to iterative changes; statistical significance was not calculated due to small sample size. Identified barriers to implementation with associated solutions are described in Table 1. The Lean Rounds implementation phase began in 2/2023 and is ongoing. As of 11/17/23, we have received 67 surveys from residents (36% response rate), with 21% (14/67) reporting rounds ended by 11 am and 58% (39/67) by 11:30 am. Residents who finished rounds before 11:30am had higher rates of satisfaction than residents who finished rounds after 11:30am regarding both patient care (90% vs 57%) and education (79% vs 64%), suggesting that the increase in efficiency has likely fostered (and not hindered) patient care or education.
Conclusions: Implementation and refinement of Lean Rounds strategies was associated with shorter rounds, which in turn was associated with increased satisfaction with patient care and education. Challenges included ensuring consistent implementation and collecting feedback. Next steps include monitoring implementation, intensifying efforts in target areas, and working to ensure rounds end at 11:00am in most cases.
