{"id":2894,"date":"2021-08-01T12:02:00","date_gmt":"2021-08-01T16:02:00","guid":{"rendered":"https:\/\/coreclinicals.wpengine.com\/?p=2894"},"modified":"2023-04-12T08:01:14","modified_gmt":"2023-04-12T12:01:14","slug":"the-geographic-rounding-puzzle-issue-4","status":"publish","type":"post","link":"https:\/\/www.coreclinicalpartners.com\/the-geographic-rounding-puzzle-issue-4\/","title":{"rendered":"The Geographic Rounding Puzzle \u2014 Issue #4"},"content":{"rendered":"

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The Geographic Rounding Puzzle<\/h2>\n

Greetings from Atlanta!\u00a0<\/em><\/p>\n

I\u2019ve 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?\u00a0<\/em><\/p>\n

Earlier this year, our partner in Oklahoma City, INTEGRIS Baptist<\/a>, 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\u2019ll hear his part of the story from him directly below. But first, I want to talk about the big picture. Starting with goals.<\/p>\n

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What is the goal of geographic rounding, really?<\/h2>\n

Everyone expects geographic rounding to reduce length of stay. That\u2019s often a motivating factor for hospital leadership to get a geographic program up and running and sustain it over time. But let\u2019s step back for a moment and talk about the process for admissions to the hospitalist service.<\/p>\n

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\u2019s 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.<\/p>\n

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\u2019 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.<\/p>\n

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\u2019t attend\u00a0multidisciplinary rounds.<\/p>\n

What are multidisciplinary rounds?<\/strong><\/h3>\n

Multidisciplinary rounds, sometimes referred to as\u00a0interdisciplinary rounds\u00a0or 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\u2019s start making those calls. Or Mr. Jones in Room 2 is going to need home oxygen, so let\u2019s get a home health company involved.<\/p>\n

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\u2019s 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.<\/p>\n

But here\u2019s the thing about multidisciplinary rounding: you need the hospitalist at the meeting! If the hospitalist isn\u2019t 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\u2019t have time to participate in all the interdisciplinary meetings, no matter how streamlined each of them is.<\/p>\n

This is the problem geographic rounding is intended to solve. The real goal is to ensure that hospitalists can participate in multidisciplinary rounds.<\/p>\n

Main barriers to geographic rounding<\/strong><\/h3>\n

The barriers to the implementation of geographic rounding usually involve two main categories of objections:<\/p>\n

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  1. Concern that it will impact continuity of care<\/li>\n
  2. Concern that physicians won\u2019t be as in control of their time<\/li>\n<\/ol>\n

    First, let\u2019s 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\u2019t 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.<\/p>\n

    The second concern, that physicians won\u2019t 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\u2014and that\u2019s 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.<\/p>\n

    Some hospitalists initially push back on this change. Maybe they\u2019re used to retreating to the doctor\u2019s lounge to write up their notes, where no one will bother them. And while it\u2019s 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\u2019s goal of getting them the best care possible.<\/p>\n

    So, how do you really execute a geographic rounding model? Enter Mark Canada:<\/p>\n

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    The Team, Tools, and Elements of Success for Geographic Rounding<\/h2>\n

    By Mark Canada<\/em><\/p>\n

    When I first landed in Oklahoma City to implement INTEGRIS Baptist\u2019s geographic rounding program, my first conversation was with Dr. Robinson. It was Dr. Gary Riggs\u2019 first week as Medical Director at INTEGRIS and I was aware that geographic rounding had been on the hospital\u2019s radar for several years, but it had not been implemented to this point.<\/p>\n

    So what did Dr. Robinson tell me, in so many words? \u201cGet this done.\u201d<\/p>\n

    No pressure, of course.<\/p>\n

    Gathering the team<\/strong><\/h3>\n

    My first days on the ground I set meetings with the key stakeholders. I met with Wins Mathew, Core\u2019s 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\u2019s CNO Lewis Perkins and CEO Rex Van Meter, Luke Raczkowski, Senior Process Consultant, and finally Dr. Rachel Thompson, Core\u2019s SVP for Hospital Medicine who had been Core’s interim site medical director.<\/p>\n

    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.<\/p>\n

    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.<\/p>\n

    Bringing the tools<\/strong><\/h3>\n

    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\u2019t been able to expand that program or sustain the gains it made. The consultant brought some solid analysis and theory\u2014what Core brought were the tools, including:<\/p>\n