American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, December 16, 2013

Let's reduce the repetitiveness in frontline hospital workflow

Having worked as a hospital medicine doctor for several years, I still really enjoy my job and find it extremely interesting, challenging, and rewarding all at the same time. But there’s a question I find myself asking on an almost daily basis as I observe the intricacies of the daily hospital routine. Why is there so much repetitiveness in our hospital workflow?

I find this tends to fall into two main categories: First, different people asking the same questions over and over again to patients, often in the space of just a few minutes, and second, different people needing to gather and document the same data repeatedly during the course of the day. The issue of unnecessarily repeating tests and investigations is perhaps one of the most costly ailments afflicting our health care system, but that’s a whole other discussion topic, so I’m going to focus here on repetitiveness in our workflow patterns.

From when a patient is first seen in the emergency room to the point they are admitted to the medical floor, it’s highly likely that they would have been asked many of the exact the same questions by the ER triage, ER nurse, ER doctor, hospital medicine doctor, and the floor nurse! I can accept some repetition in the name of thoroughness and patient safety, but there’s way too much overlap. Teaching hospitals will typically be worse, because several members of the admitting team will be involved in the patient’s care (although this is probably a needed trade off in the name of educating interns and residents).

After the patient is admitted, the repetition will continue. On a typical morning, they will again be asked the same questions by several different people. What happened yesterday? How was your night? Any pain? Any new symptoms? First the nurse leaving the shift, then the new nurse coming onto the shift, then the members of the medical team. I am often very aware that by the time I enter the room to see the patient as a teaching attending, I’m going over the same thing for the umpteenth time. How annoying this must be for the patient when they’re already sick! I always feel very bad for them when this happens (and many are not shy on voicing their opinion about why in hospitals “we can’t just do everything at the same time!”). I typically start with an explanation like; “Sorry, but I’m going to ask you exactly the same questions again to see how you’re doing.”

The second major area of repetition in our daily workflow involves the data gathering process. A classic example would be collecting the patient’s vital signs. In many hospitals in the U.S., vital signs are still documented on paper charts, meaning that the chart will need to be located first in order to document the findings (and anyone who has ever worked in a hospital will tell you that these paper charts are not always easy to find). The process for documentation will go something like this: nursing tech, registered nurse, several doctors—all documenting the same thing. Even with computerized records, the physician may have to “locate” the vitals in one part of the chart, and somehow “pull” that information over to their record. The same process also plays out with documenting abnormal laboratory results and tests. Every physician will need to “pull” the same information, for use in their daily documentation. This lengthy workflow pattern simply shouldn’t be happening in today’s day and age.

Some authorities believe that it’s the medico-legal environment that makes us excessively document and repeat tasks. There’s also the billing issue, which means certain information has to be elicited and documented in order to be reimbursed. These factors may be very pertinent, but there’s also undoubtedly a fault with our working patterns and efficiency. So how best to optimize our workflow? Let’s talk about 5 areas where we can definitely get better:
1. communication between health care staff,
2. the way we traditionally “round” on our patients,
3. continuity of care and reduced “handoffs,”
4. better data capture and use of technology, and
5. a focus from hospital leadership on solving this

1. Communication between health care staff
A huge part of the problem unfortunately stems from a complete lack of communication between members of the care team. The nurse may never even talk to the doctor before they enter the patient’s room, and the doctor may not talk to the nurse after seeing the patient. Several doctors working with the same patient may also fail to communicate directly with one another. This moves nicely onto point number two.

2. Rounding model
One great way to improve the communication problem is to institute a full multidisciplinary rounding model, where the whole team rounds together, communicates directly with each other, and ideally also the patient. Although this sounds straightforward, it is actually a very complex process to initiate and get up and running. Speaking as someone who has worked in the United Kingdom’s National Health Service, it’s something that is done very well over there.

3. Continuity of care and reduced “handoffs”
Lack of continuity and excessive handoffs (when multiple physicians take care of the same patient) are another major concern. From the hospital medicine perspective, having the physician work in a stretch and take care of the same patients is crucial. A situation where 4 different doctors take care of the same patient in a week is highly detrimental to the patient and promotes repetition, not to mention that it’s not particularly good for provider satisfaction either.

4. Better data capture and use of technology
We have to ask ourselves how we can better capture relevant patient data and then put it all together into one area for everyone to easily access? Of course, every nurse or doctor will need to confirm the findings themselves (health care information is often very subjective), but it shouldn’t be a case of basic repetition. If you are the fourth doctor seeing the patient, then the baseline information should be readily available, so that you can stay completely focused on the most salient points. Imagine how much time would be saved, while also giving the impression to the patient that we are all on the same page. Whether the one “place” where we go for information is as simple as a whiteboard at the end of a patient’s bed, or more likely as IT develops, a “cloud” type software—there must be complete ease of access to this. As things currently stand, there are multiple places, including computerized notes, hand written notes in two or three different locations (typically there’s the “nurses” part of the chart and the “physicians” part). What’s lacking is a unified system.

5. Hospital leadership

Hospital leaders and administrators also need to recognize this problem and put resources into solving it. We need to develop hospital workgroups where we all sit down together, from different departments, and go over exactly where we can smooth out the system and make everything work more efficiently. Let’s decide who really needs to perform the task at hand. Does everyone involved in the chain now need to keep on repeating someone else’s work? Design charts and graphs that map out the doctors’ and nurses’ workflow, and optimize it appropriately to remove any unnecessary repetition. It often just comes down to basic common sense. Ironically, it’s often the patients who are the best people to ask, and will tell you what was excessively repetitive during their hospitalization!

In summary, there’s enormous potential for future improvement in this area. Doing so will not only be good for health care staff, but ultimately for patients, as we free up frontline clinicians for what they should be doing—spending time with them. But until we collaboratively figure this out, our patients may just have to keep putting up with hearing those same questions, and doctors and nurses will keep on doing the same task over and over again. It’s a work in progress.Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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