Blog | 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.