Background: There is a rising demand for hospitalist involvement in quality improvement (QI). Hospitalists now assume larger patient volumes and have become natural leaders in daily patient care, interdisciplinary rounding and patient safety. Despite a seemingly direct fit into QI, the majority of hospitalists have received minimal QI training in medical school, residency or beyond. Fundamental QI skills are likely gained from on-the-go experiential learning, which in combination with longitudinal QI education, could lead to valuable advances in our approach to QI in the hospital.
Purpose: In 2016, our large tertiary urban hospital piloted Gemba Lean as the primary QI tool on 2 medicine units. At that time, Gemba was driven by nurse leadership with little to no hospitalist involvement. The “Gemba walk” has been utilized by multiple industries and recently was adopted by hospital systems to bring together executives, managers and front line employees to identify actionable items to eliminate waste and enhance patient care and safety. In 2020, our primary goal was to educate our hospitalist leads from 8 geographic floors on QI fundamentals. Our secondary goal was to have our hospitalists act as unit leaders to design QI projects in a multidisciplinary approach involving housestaff, nursing and care coordinators.
Description: 2-part Gemba training was provided to our hospitalist leads by QI industrial engineers. The 1st part introduced QI essentials including PDSA cycles, 5 Whys Worksheets, and methods to identify work related waste. The 2nd part discussed application of these QI basics to identify a “key performance initiative (KPI)” that each hospitalist found relevant to his/her unit. Each KPI serves to improve unit metrics in one of the following areas: throughput efficiency, patient safety, patient experience or readmissions. Through a variety of exercises, hospitalists built an understanding of development of a KPI and maintenance of an auditing tool to ensure adherence to the KPI. Hospitalists then applied their QI knowledge to their individual units. Each hospitalist conducts meetings to review unit specific monthly metrics with all team members and to identify potential areas for a KPI. An example of a KPI is: “To discuss daily with 5 patients the side effects of new CHF medications in order to improve patient experience scores.” The KPI is displayed on the Gemba board in a central location where all members huddle daily to assess successes and downfalls of KPI goals. To ensure accountability, hospital executive leadership directs a weekly “Gemba virtual walk” where representatives from each unit, including hospitalists, present their KPIs. Concurrent feedback is given to the team and there is constant instructional guidance for hospitalists in the design of existing and new KPIs.
Conclusions: Hospitalists must be included in any discussion of hospital based QI. We hope to sustain this QI educational framework and strive to support hospitalist growth as QI leaders on their units and within the hospital. This experience has provided our hospitalists familiarity to the practice of QI as well as additional skills to enhance team building and communication. We anticipate that with hospitalist QI leaders, robust, multidisciplinary KPIs will be created with improvement in throughput, safety and patient satisfaction metrics in due time.