The Geographic Rounding Puzzle
Greetings from Atlanta!
I’ve been writing a lot about emergency medicine in these first few issues, but this month I want to take on a subject central to our hospitalist medicine service: geographic rounding. What is the goal (really), why can it be so hard to implement and then sustain, and how do we approach it at Core?
Earlier this year, our partner in Oklahoma City, INTEGRIS Baptist, asked us to get their geographic rounding program off the ground. I sent Mark Canada, our VP of Clinical Operations, to Oklahoma City to make it happen. He was boots on the ground there multiple times, one time for nine days in a row. You’ll hear his part of the story from him directly below. But first, I want to talk about the big picture. Starting with goals.
What is the goal of geographic rounding, really?
Everyone expects geographic rounding to reduce length of stay. That’s often a motivating factor for hospital leadership to get a geographic program up and running and sustain it over time. But let’s step back for a moment and talk about the process for admissions to the hospitalist service.
A traditional way to do hospital admissions is in a round-robin. Doctor A gets the first patient, Doctor B gets the second patient, and so on. If you are a hospitalist and it’s your turn, you get a patient. But that patient could be going to any floor of the hospital, depending on a range of factors, from their particular disease process to bed availability to ED flow.
The perceived benefit of this system is continuity of care. Once a patient is admitted, that hospitalist sees that patient through their entire length of stay, or as much of it as possible with a seven on, seven off schedule. The downside is that taking an elevator up and down to various floors is very inefficient for the hospitalists’ time. Another downside is that nursing never really knows where the doctor is. They have to page them and get a callback, and this ultimately leads to downstream effects on patient care and increased length of stay.
But the real problem with the round-robin model, the problem geographic rounding is intended to solve, is that a round-robin system means hospitalists typically can’t attend multidisciplinary rounds.
What are multidisciplinary rounds?
Multidisciplinary rounds, sometimes referred to as interdisciplinary rounds or transition of care plan (TCP) rounds, bring together all of the stakeholders involved in patient care to discuss, coordinate, and make joint decisions about patients one by one. Mrs. Smith in Room 1 needs to go to a skilled nursing facility, so let’s start making those calls. Or Mr. Jones in Room 2 is going to need home oxygen, so let’s get a home health company involved.
Multidisciplinary rounding is an important best practice for hospitals to implement and has numerous positive benefits. Most importantly, it gets patients into the right level of care faster, whether that’s in another facility, another floor, or getting discharged to go home. This leads to an overall reduction in length of stay and better care for the patients.
But here’s the thing about multidisciplinary rounding: you need the hospitalist at the meeting! If the hospitalist isn’t there, you are missing one of the key decision-makers for the patient’s care. But if you have a doctor with patients on ten floors, they simply don’t have time to participate in all the interdisciplinary meetings, no matter how streamlined each of them is.
This is the problem geographic rounding is intended to solve. The real goal is to ensure that hospitalists can participate in multidisciplinary rounds.
Main barriers to geographic rounding
The barriers to the implementation of geographic rounding usually involve two main categories of objections:
- Concern that it will impact continuity of care
- Concern that physicians won’t be as in control of their time
First, let’s talk about continuity of care. As I said, one reason the round-robin model of hospital admissions is so prevalent is because continuity of care is very important. You generally don’t want a patient to be admitted by one physician, taken care of by another for two days, then transferred somewhere else in the hospital, and so on. Something gets lost in patient care, and everyone usually agrees the fewer handoffs the better. Implementing geographic rounding is, to some extent, the process of finding that balance where you maintain continuity of care but also increase the efficiency with which physicians can perform interdisciplinary rounding. Mark will talk a little more about how we found that balance at INTEGRIS below.
The second concern, that physicians won’t have as much control over their time, often comes down to the fact that a geographic rounding model makes the hospitalist more accessible to other members of the care team, including nursing—and that’s a good thing! If the hospitalist is always assigned to patients on one floor, or in one wing, that means they really can show up for the interdisciplinary meeting, whenever that may be.
Some hospitalists initially push back on this change. Maybe they’re used to retreating to the doctor’s lounge to write up their notes, where no one will bother them. And while it’s true that being on the floor probably gets them more interruptions, those are good interruptions, the kinds that help the patients, and, ultimately, supports everyone’s goal of getting them the best care possible.
So, how do you really execute a geographic rounding model? Enter Mark Canada:
The Team, Tools, and Elements of Success for Geographic Rounding
By Mark Canada
When I first landed in Oklahoma City to implement INTEGRIS Baptist’s geographic rounding program, my first conversation was with Dr. Robinson. It was Dr. Gary Riggs’ first week as Medical Director at INTEGRIS and I was aware that geographic rounding had been on the hospital’s radar for several years, but it had not been implemented to this point.
So what did Dr. Robinson tell me, in so many words? “Get this done.”
No pressure, of course.
Gathering the team
My first days on the ground I set meetings with the key stakeholders. I met with Wins Mathew, Core’s VP of Operations who lives in Oklahoma City and works in our Core office at the hospital. I met with Dr. Riggs, as well as the hospital’s CNO Lewis Perkins and CEO Rex Van Meter, Luke Raczkowski, Senior Process Consultant, and finally Dr. Rachel Thompson, Core’s SVP for Hospital Medicine who had been Core’s interim site medical director.
I wanted to understand what steps had been taken in the past, as well as understand the goals of the system, the physicians, and Core. The goal was to gather the working group which would then branch out and take these goals to the rest of the hospital staff and manage the key messages and processes we were there to implement.
It was a group discussion, all of us together, with the full support of hospital leadership. INTEGRIS is a 700-bed hospital and the hospitalist service takes care of approximately 200 patients a day. Getting geographic rounding in place would help them, and help INTEGRIS as well.
Bringing the tools
A previous consultant had done some initial work with solid results and a length-of-stay reduction for patients on one floor. But, they hadn’t been able to expand that program or sustain the gains it made. The consultant brought some solid analysis and theory—what Core brought were the tools, including:
- Lean A3 methodology
- Further data analysis and data capture
- Current state and future state process flow mapping
- Standard work documents
- Communication plan
We used Kotter’s change management principles to put in place the conditions where a new program has the best possible chance of success. The goal was to bake these tools into the culture of the hospital, to hardwire them so change can be sustained in the long run.
Balancing Continuity of Care
Our initial plan was to set the conditions in place for a July launch. However, hospital leaders asked us to move up the launch with a soft go-live in April. I was onsite and involved in daily huddles where I would ask each physician to give the program a Net Promoter Score. If it was anything less than a 10 out of 10, I would ask why. If they said their day had been an eight, I asked what would have made it a 10. This kind of open, immediate, and specific daily feedback was essential to surfacing initial areas for improvement.
For example, one of the barriers we identified during this soft golive was that not enough patients were making it into the hospitalists’ geographic areas. Originally, patients would be identified as going to a certain floor; however, their destination could change based on timing, bed availability, ED flow, or incoming transfers. All these would impact the daily flow of patients to rooms.
Our experience has found a best practice is to have an APP admission coordinator who works closely with the admitting physician and the nursing bed placement office on an almost hourly basis. This APP coordinator works with a physician to do the admission initially, then hands them off to the assigned hospitalist for that area. The APP coordinator is essential for making geographic rounding work.
Leading and lagging metrics
Our plan involved looking at metrics daily. We primarily measured two leading metrics:
- % of geographic rounders census assigned to geographic units
- % of total hospitalist census being covered by geographic units
Here, for example, is a chart on the percent of a physician’s census on assigned geographic units before and after we implemented an APP coordinator:
As for lagging indicators, the metrics we expect to see long-term improvement on are mainly:
- Length of stay
- Clinician satisfaction
- Patient satisfaction
Elements of success
Dr. Gary Riggs is a huge part of this program’s initial success on the ground. We are holding weekly meetings to review the data, go over our work plans, and look for opportunities for improvement to adjust as we move forward. At this point, about four months in, I am confident that we have hardwired a lot of those Lean principles into the process and culture.
Certainly, Core’s multidisciplinary approach, leadership, and process improvement teams deserve a lot of credit. What else has contributed to the program’s success so far? I think it is Core’s relentless drive and focus on the process. Getting geographic rounding off the ground wasn’t just one of 20 things we were doing; it was my main goal for weeks. We were all focused on driving success and putting the time in to make sure this worked.
That’s a huge part of what sets Core apart, and it’s a huge part of what we mean when we say that partnership is at the center of everything we do. We put in the time. And I thank Dr. Robinson and the entire team at INTEGRIS for working together to make this happen! Now, all eyes are on the program to see how it does and how it is sustained. I look forward to updating everyone in the future.