Christopher S. Kim, MD, MBA

Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]

In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.

MODELS OF UNIT‐BASED LEADERSHIP

The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.

There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.

DISCUSSION

In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.

OTHER CONSIDERATIONS

Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.

The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.

Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.

CONCLUSION

The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.

Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]

In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.

MODELS OF UNIT‐BASED LEADERSHIP

The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.

There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.

DISCUSSION

In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.

OTHER CONSIDERATIONS

Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.

The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.

Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.

CONCLUSION

The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.

Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]

In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.

MODELS OF UNIT‐BASED LEADERSHIP

The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.

There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.

DISCUSSION

In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.

OTHER CONSIDERATIONS

Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.

The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.

Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.

CONCLUSION

The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.

In their seminal report Crossing the Quality Chasm, the Institute of Medicine outlined patient‐centered care as 1 of its 6 aims to improve the healthcare delivery system.[1] Patients who are more involved in their diagnosis and treatment plan are more likely to feel respected, be satisfied with their healthcare experience, and ultimately have better outcomes.[2, 3] In a study of hospitalized patients, only 42% were able to state their diagnosis at the time of discharge, suggesting that hospital providers could communicate better with patients about their hospital care.[4] Additionally, only 28% of hospitalized patients were able to list their medications, and only 37% were able to state the purpose of their medications. Although hospitals have taken great strides to improve the quality of patient care, publicly reported patient care surveys, such as the Hospital Consumer Assessment of Hospitals and Health Systems (HCAHPS), suggest that physician communication with patients could be further improved.[1, 5] Furthermore, a recent report by the Institute of Medicine stresses the need to get patients and families involved in their care.[6] Thus, hospital‐based providers should seek to enhance the quality of their communication with patients.

With greater emphasis placed on patient‐ and family‐centered care at many health systems, simple and easy‐to‐implement strategies to improve communication with patients need to be developed and tested.[7, 8] Patients who actively participate in their healthcare by asking questions of their doctor are able to control the focus of their interaction and adjust the amount of information provided.[9] Simply asking questions can have a critical impact, as 1 study found that the frequency with which patients asked questions was significantly related to the amount of information received about general and specific medical matters.[10] The notepad is a common tool for reminders and personal interactions that is used in everyday life, but has not been formalized in the hospital. We introduced Dear Doctor (DD) notes, a bedside notepad designed to prompt patient questions, with the goal of facilitating patient communication with their hospitalist physicians (Figure 1). As hospitalists provide direct and indirect care to a growing number of hospitalized patients, they are likely to be asked questions and opinions about the patients' diagnoses and plans. Furthermore, hospitalists are poised to lead institutional quality, safety, efficiency, and service improvement efforts in the inpatient setting. Becoming familiar with communication‐enhancing tools, such as the DD notes, may help hospitalists in their improvement team roles.

Figure 1

METHODS

RESULTS

Of the 440 patients surveyed in the intervention group (1 general medicine and 1 cardiology unit), 343 (78%) received the notepads in their rooms and 207 (47%) used them (Figure 2). Not every patient in the intervention group received DD notepads due to inconsistent placement of DD notepads upon every room turnover. Of the patients admitted to the control group (1 general medicine and 1 cardiology unit), 224 were surveyed. Fifty‐four percent of the 440 patients in the intervention group reported that they took notes related to their hospital care, compared to only 22% of the 224 patients in the control group (P < 0.001). Of the patients who took notes within the intervention group (n = 207), 91% of them utilized the DD notepads.

Figure 2

Patients in the intervention group who received and used the DD notes (n = 207) compared to patients in the control group (n = 224) were more likely to report that their questions were answered by their physicians (4.63 vs 4.45, P < 0.001). In an intention‐to‐treat analysis of all 440 patients in the intervention group, the overall satisfaction with physician communication was not significantly different between the intervention and control groups as measured on a 5‐point Likert scale (4.55 vs 4.55, P = 0.89). However, 89% of the patients in the intervention group who used the notepads felt that DD notepads either moderately or significantly improved their communication with their providers (Figure 3).

Figure 3

When the 207 patients who received DD notepads were asked how they used this tool, 99% of these patients used DD to write down questions, 82% to keep track of tests and procedures, and 54% indicated that their family and friends also used the notepads during the hospital stay (Table 1). Among these patients who utilized the DD notepads, 93% reported that they would use them again in the future.

Of the 97 patients in the intervention group who did not receive a DD notepad, we asked if they would use the DD notepad if they were made aware of such a tool. Of these patients, 77% agreed that they would use DD notes if they were made available in the future, 100% of them said that they would use DD to write down questions, 97% indicated that they would write notes about tests and procedures, and 88% of them believed that their families and friends would use DD notes.

DISCUSSION

As hospitals place greater emphasis and value on patient‐centered care as part of their clinical mission, it is important to develop tools to help facilitate the doctor‐patient relationship. We found that patients who were provided the Dear Doctor notepad were more satisfied that their doctors answered their questions and felt this tool enhanced their ability to communicate with their physicians. Employing the use of a familiar tool such as the notepad to remind patients about specific issues in their interactions with their providers can be a powerful intervention. Our study demonstrated that the DD notepad was widely accepted by patients, and that almost all of them would use this tool if it were made available to them in the future.

Other tools and methods to enhance the quality of communication between patients and their healthcare providers have included using whiteboards in the patients' rooms to relay the care plan to the patients, implementing bedside rounds by the healthcare team, and multidisciplinary huddling to coordinate information to the patient.[12, 13] Studies of these communication tools have shown potential to improve teamwork, interaction, and patient care. All of these have their own merit and value, and our DD notepad should be considered an adjunct to existing methods to enhance the patient care experience. A bedside tool that is familiar in form to most patients also needs to have the feature of easy access and use. Once this barrier has been removed for the patient and their family members, tools such as the DD notepad can impact the patient‐centeredness by fostering increased and better quality dialogue between the patients, their family members, and healthcare providers.

The DD notepad represents a means of communication that may have the potential to empower patients. It is possible that through question prompts, the DD notepad stimulates the patient to be an active partner with his or her healthcare team. This may enable patients to have some sense of control and accountability of their care in a setting where they would otherwise feel overwhelmed or powerless. The 3 general categories to help patients write down their questions included diagnosis, treatment plan, and medications. In the inpatient setting, where patient‐care activities can be fast paced, and patients are unable to recall some details when speaking to the healthcare team, these notes may remind the patient to write their thoughts down so that they may be remembered for a future time. In situations where patients may not know which questions to ask, the question prompts may be particularly helpful. We did not assess whether our particular question prompts were the key elements that resulted in their perceived value, or whether simply placing a blank notepad at the bedside would also have been successful. However, the specific questions were suggested by the focus groups. Enhanced communication, focusing on the patients' understanding of their condition, and the need to pursue certain diagnostic or therapeutic interventions, may help patients to be better prepared for the next course of plan. These topics of reasons for hospitalization, treatment plan, and medication changes are also important for patients to be active participants in their care, in particular as they transition from 1 site of care to the next, and their healthcare will be delivered by different providers.

There are several limitations to our study. First, this intervention was performed at a single hospital site with only 2 clinical services (general medicine, cardiology) represented in the study groups. Although we do not have any causal reasons to believe this tool would be looked upon differently by patients on other clinical services, it is possible that patients on a different clinical unit or service may view this tool as less or more useful. Second, as the patients were not randomized to intervention, but rather based on the units to which they were admitted, it is possible that other variables, such as the experience of the unit staff, the patient's condition, and housestaff‐based service versus hospitalist‐based service may have played a role in how the patients perceived the use of DD notes. Third, patients were only surveyed if they were able to verbally communicate in English. These notes may not be as useful in hospital settings to populations with language or literacy barriers. Fourth, the logistical implementation of DD notes limited our ability to deliver the DD notepads in every patient's rooms, where only 78% of the intervention group received the DD notepads. This may be the reason that we did not find that overall satisfaction with physician communication differed between intervention and control groups. Nonetheless, we performed an intention‐to‐treat analysis to minimize any biases in our analysis. Last, although our survey of patients asked about their satisfaction in using the DD note pads, we did not compare these results with those of Press‐Ganey or HCAHPS scores of patients on the intervention group versus the control group. Additionally, lack of data about type, quality, and quantity of questions asked by a control group to see if the notepads actually improved quality of questions asked is a limitation; however, we believe our outcomes of interest were most specifically evaluated through our survey questions.

DD notes show that the majority of patients who use this tool feel a modest to significant improvement in communication with their providers. Although the quality of medical care is undoubtedly the first priority, the patients' view of their care, which includes communication, is arguably just as important. An often‐forgotten goal of hospitals and clinics is to provide service excellence along with high‐quality care. Thus, it is imperative for hospitals and their care providers to not only focus on the quality and safety of the clinical care, but also be mindful of the patient's entire experience throughout their hospital stay. Many of the categories of questions asked in the HCAHPS address the patient's experience and perspectives of hospital care. Furthermore, the role of the HCAHPS survey in the Value‐Based Purchasing rules may enhance the importance of these notepads. As the results of HCAHPS are becoming more transparent and available to the public, the impact of such results will have a greater significance to the future of the hospital's clinical mission.

CONCLUSION

DD notepads are a simple, low‐cost, patient‐centered tool that can be an effective reminder for patients to ask their healthcare providers questions related to their hospital care. Utilizing a common tool such as the notepad, redesigned for the healthcare setting, can serve to help healthcare providers interact with their patients. Patient satisfaction may be higher in patients who use the DD notepad.

In their seminal report Crossing the Quality Chasm, the Institute of Medicine outlined patient‐centered care as 1 of its 6 aims to improve the healthcare delivery system.[1] Patients who are more involved in their diagnosis and treatment plan are more likely to feel respected, be satisfied with their healthcare experience, and ultimately have better outcomes.[2, 3] In a study of hospitalized patients, only 42% were able to state their diagnosis at the time of discharge, suggesting that hospital providers could communicate better with patients about their hospital care.[4] Additionally, only 28% of hospitalized patients were able to list their medications, and only 37% were able to state the purpose of their medications. Although hospitals have taken great strides to improve the quality of patient care, publicly reported patient care surveys, such as the Hospital Consumer Assessment of Hospitals and Health Systems (HCAHPS), suggest that physician communication with patients could be further improved.[1, 5] Furthermore, a recent report by the Institute of Medicine stresses the need to get patients and families involved in their care.[6] Thus, hospital‐based providers should seek to enhance the quality of their communication with patients.

With greater emphasis placed on patient‐ and family‐centered care at many health systems, simple and easy‐to‐implement strategies to improve communication with patients need to be developed and tested.[7, 8] Patients who actively participate in their healthcare by asking questions of their doctor are able to control the focus of their interaction and adjust the amount of information provided.[9] Simply asking questions can have a critical impact, as 1 study found that the frequency with which patients asked questions was significantly related to the amount of information received about general and specific medical matters.[10] The notepad is a common tool for reminders and personal interactions that is used in everyday life, but has not been formalized in the hospital. We introduced Dear Doctor (DD) notes, a bedside notepad designed to prompt patient questions, with the goal of facilitating patient communication with their hospitalist physicians (Figure 1). As hospitalists provide direct and indirect care to a growing number of hospitalized patients, they are likely to be asked questions and opinions about the patients' diagnoses and plans. Furthermore, hospitalists are poised to lead institutional quality, safety, efficiency, and service improvement efforts in the inpatient setting. Becoming familiar with communication‐enhancing tools, such as the DD notes, may help hospitalists in their improvement team roles.

Figure 1

METHODS

RESULTS

Of the 440 patients surveyed in the intervention group (1 general medicine and 1 cardiology unit), 343 (78%) received the notepads in their rooms and 207 (47%) used them (Figure 2). Not every patient in the intervention group received DD notepads due to inconsistent placement of DD notepads upon every room turnover. Of the patients admitted to the control group (1 general medicine and 1 cardiology unit), 224 were surveyed. Fifty‐four percent of the 440 patients in the intervention group reported that they took notes related to their hospital care, compared to only 22% of the 224 patients in the control group (P < 0.001). Of the patients who took notes within the intervention group (n = 207), 91% of them utilized the DD notepads.

Figure 2

Patients in the intervention group who received and used the DD notes (n = 207) compared to patients in the control group (n = 224) were more likely to report that their questions were answered by their physicians (4.63 vs 4.45, P < 0.001). In an intention‐to‐treat analysis of all 440 patients in the intervention group, the overall satisfaction with physician communication was not significantly different between the intervention and control groups as measured on a 5‐point Likert scale (4.55 vs 4.55, P = 0.89). However, 89% of the patients in the intervention group who used the notepads felt that DD notepads either moderately or significantly improved their communication with their providers (Figure 3).

Figure 3

When the 207 patients who received DD notepads were asked how they used this tool, 99% of these patients used DD to write down questions, 82% to keep track of tests and procedures, and 54% indicated that their family and friends also used the notepads during the hospital stay (Table 1). Among these patients who utilized the DD notepads, 93% reported that they would use them again in the future.

Of the 97 patients in the intervention group who did not receive a DD notepad, we asked if they would use the DD notepad if they were made aware of such a tool. Of these patients, 77% agreed that they would use DD notes if they were made available in the future, 100% of them said that they would use DD to write down questions, 97% indicated that they would write notes about tests and procedures, and 88% of them believed that their families and friends would use DD notes.

DISCUSSION

As hospitals place greater emphasis and value on patient‐centered care as part of their clinical mission, it is important to develop tools to help facilitate the doctor‐patient relationship. We found that patients who were provided the Dear Doctor notepad were more satisfied that their doctors answered their questions and felt this tool enhanced their ability to communicate with their physicians. Employing the use of a familiar tool such as the notepad to remind patients about specific issues in their interactions with their providers can be a powerful intervention. Our study demonstrated that the DD notepad was widely accepted by patients, and that almost all of them would use this tool if it were made available to them in the future.

Other tools and methods to enhance the quality of communication between patients and their healthcare providers have included using whiteboards in the patients' rooms to relay the care plan to the patients, implementing bedside rounds by the healthcare team, and multidisciplinary huddling to coordinate information to the patient.[12, 13] Studies of these communication tools have shown potential to improve teamwork, interaction, and patient care. All of these have their own merit and value, and our DD notepad should be considered an adjunct to existing methods to enhance the patient care experience. A bedside tool that is familiar in form to most patients also needs to have the feature of easy access and use. Once this barrier has been removed for the patient and their family members, tools such as the DD notepad can impact the patient‐centeredness by fostering increased and better quality dialogue between the patients, their family members, and healthcare providers.

The DD notepad represents a means of communication that may have the potential to empower patients. It is possible that through question prompts, the DD notepad stimulates the patient to be an active partner with his or her healthcare team. This may enable patients to have some sense of control and accountability of their care in a setting where they would otherwise feel overwhelmed or powerless. The 3 general categories to help patients write down their questions included diagnosis, treatment plan, and medications. In the inpatient setting, where patient‐care activities can be fast paced, and patients are unable to recall some details when speaking to the healthcare team, these notes may remind the patient to write their thoughts down so that they may be remembered for a future time. In situations where patients may not know which questions to ask, the question prompts may be particularly helpful. We did not assess whether our particular question prompts were the key elements that resulted in their perceived value, or whether simply placing a blank notepad at the bedside would also have been successful. However, the specific questions were suggested by the focus groups. Enhanced communication, focusing on the patients' understanding of their condition, and the need to pursue certain diagnostic or therapeutic interventions, may help patients to be better prepared for the next course of plan. These topics of reasons for hospitalization, treatment plan, and medication changes are also important for patients to be active participants in their care, in particular as they transition from 1 site of care to the next, and their healthcare will be delivered by different providers.

There are several limitations to our study. First, this intervention was performed at a single hospital site with only 2 clinical services (general medicine, cardiology) represented in the study groups. Although we do not have any causal reasons to believe this tool would be looked upon differently by patients on other clinical services, it is possible that patients on a different clinical unit or service may view this tool as less or more useful. Second, as the patients were not randomized to intervention, but rather based on the units to which they were admitted, it is possible that other variables, such as the experience of the unit staff, the patient's condition, and housestaff‐based service versus hospitalist‐based service may have played a role in how the patients perceived the use of DD notes. Third, patients were only surveyed if they were able to verbally communicate in English. These notes may not be as useful in hospital settings to populations with language or literacy barriers. Fourth, the logistical implementation of DD notes limited our ability to deliver the DD notepads in every patient's rooms, where only 78% of the intervention group received the DD notepads. This may be the reason that we did not find that overall satisfaction with physician communication differed between intervention and control groups. Nonetheless, we performed an intention‐to‐treat analysis to minimize any biases in our analysis. Last, although our survey of patients asked about their satisfaction in using the DD note pads, we did not compare these results with those of Press‐Ganey or HCAHPS scores of patients on the intervention group versus the control group. Additionally, lack of data about type, quality, and quantity of questions asked by a control group to see if the notepads actually improved quality of questions asked is a limitation; however, we believe our outcomes of interest were most specifically evaluated through our survey questions.

DD notes show that the majority of patients who use this tool feel a modest to significant improvement in communication with their providers. Although the quality of medical care is undoubtedly the first priority, the patients' view of their care, which includes communication, is arguably just as important. An often‐forgotten goal of hospitals and clinics is to provide service excellence along with high‐quality care. Thus, it is imperative for hospitals and their care providers to not only focus on the quality and safety of the clinical care, but also be mindful of the patient's entire experience throughout their hospital stay. Many of the categories of questions asked in the HCAHPS address the patient's experience and perspectives of hospital care. Furthermore, the role of the HCAHPS survey in the Value‐Based Purchasing rules may enhance the importance of these notepads. As the results of HCAHPS are becoming more transparent and available to the public, the impact of such results will have a greater significance to the future of the hospital's clinical mission.

CONCLUSION

DD notepads are a simple, low‐cost, patient‐centered tool that can be an effective reminder for patients to ask their healthcare providers questions related to their hospital care. Utilizing a common tool such as the notepad, redesigned for the healthcare setting, can serve to help healthcare providers interact with their patients. Patient satisfaction may be higher in patients who use the DD notepad.

In their seminal report Crossing the Quality Chasm, the Institute of Medicine outlined patient‐centered care as 1 of its 6 aims to improve the healthcare delivery system.[1] Patients who are more involved in their diagnosis and treatment plan are more likely to feel respected, be satisfied with their healthcare experience, and ultimately have better outcomes.[2, 3] In a study of hospitalized patients, only 42% were able to state their diagnosis at the time of discharge, suggesting that hospital providers could communicate better with patients about their hospital care.[4] Additionally, only 28% of hospitalized patients were able to list their medications, and only 37% were able to state the purpose of their medications. Although hospitals have taken great strides to improve the quality of patient care, publicly reported patient care surveys, such as the Hospital Consumer Assessment of Hospitals and Health Systems (HCAHPS), suggest that physician communication with patients could be further improved.[1, 5] Furthermore, a recent report by the Institute of Medicine stresses the need to get patients and families involved in their care.[6] Thus, hospital‐based providers should seek to enhance the quality of their communication with patients.

With greater emphasis placed on patient‐ and family‐centered care at many health systems, simple and easy‐to‐implement strategies to improve communication with patients need to be developed and tested.[7, 8] Patients who actively participate in their healthcare by asking questions of their doctor are able to control the focus of their interaction and adjust the amount of information provided.[9] Simply asking questions can have a critical impact, as 1 study found that the frequency with which patients asked questions was significantly related to the amount of information received about general and specific medical matters.[10] The notepad is a common tool for reminders and personal interactions that is used in everyday life, but has not been formalized in the hospital. We introduced Dear Doctor (DD) notes, a bedside notepad designed to prompt patient questions, with the goal of facilitating patient communication with their hospitalist physicians (Figure 1). As hospitalists provide direct and indirect care to a growing number of hospitalized patients, they are likely to be asked questions and opinions about the patients' diagnoses and plans. Furthermore, hospitalists are poised to lead institutional quality, safety, efficiency, and service improvement efforts in the inpatient setting. Becoming familiar with communication‐enhancing tools, such as the DD notes, may help hospitalists in their improvement team roles.

Figure 1

METHODS

RESULTS

Of the 440 patients surveyed in the intervention group (1 general medicine and 1 cardiology unit), 343 (78%) received the notepads in their rooms and 207 (47%) used them (Figure 2). Not every patient in the intervention group received DD notepads due to inconsistent placement of DD notepads upon every room turnover. Of the patients admitted to the control group (1 general medicine and 1 cardiology unit), 224 were surveyed. Fifty‐four percent of the 440 patients in the intervention group reported that they took notes related to their hospital care, compared to only 22% of the 224 patients in the control group (P < 0.001). Of the patients who took notes within the intervention group (n = 207), 91% of them utilized the DD notepads.

Figure 2

Patients in the intervention group who received and used the DD notes (n = 207) compared to patients in the control group (n = 224) were more likely to report that their questions were answered by their physicians (4.63 vs 4.45, P < 0.001). In an intention‐to‐treat analysis of all 440 patients in the intervention group, the overall satisfaction with physician communication was not significantly different between the intervention and control groups as measured on a 5‐point Likert scale (4.55 vs 4.55, P = 0.89). However, 89% of the patients in the intervention group who used the notepads felt that DD notepads either moderately or significantly improved their communication with their providers (Figure 3).

Figure 3

When the 207 patients who received DD notepads were asked how they used this tool, 99% of these patients used DD to write down questions, 82% to keep track of tests and procedures, and 54% indicated that their family and friends also used the notepads during the hospital stay (Table 1). Among these patients who utilized the DD notepads, 93% reported that they would use them again in the future.

Of the 97 patients in the intervention group who did not receive a DD notepad, we asked if they would use the DD notepad if they were made aware of such a tool. Of these patients, 77% agreed that they would use DD notes if they were made available in the future, 100% of them said that they would use DD to write down questions, 97% indicated that they would write notes about tests and procedures, and 88% of them believed that their families and friends would use DD notes.

DISCUSSION

As hospitals place greater emphasis and value on patient‐centered care as part of their clinical mission, it is important to develop tools to help facilitate the doctor‐patient relationship. We found that patients who were provided the Dear Doctor notepad were more satisfied that their doctors answered their questions and felt this tool enhanced their ability to communicate with their physicians. Employing the use of a familiar tool such as the notepad to remind patients about specific issues in their interactions with their providers can be a powerful intervention. Our study demonstrated that the DD notepad was widely accepted by patients, and that almost all of them would use this tool if it were made available to them in the future.

Other tools and methods to enhance the quality of communication between patients and their healthcare providers have included using whiteboards in the patients' rooms to relay the care plan to the patients, implementing bedside rounds by the healthcare team, and multidisciplinary huddling to coordinate information to the patient.[12, 13] Studies of these communication tools have shown potential to improve teamwork, interaction, and patient care. All of these have their own merit and value, and our DD notepad should be considered an adjunct to existing methods to enhance the patient care experience. A bedside tool that is familiar in form to most patients also needs to have the feature of easy access and use. Once this barrier has been removed for the patient and their family members, tools such as the DD notepad can impact the patient‐centeredness by fostering increased and better quality dialogue between the patients, their family members, and healthcare providers.

The DD notepad represents a means of communication that may have the potential to empower patients. It is possible that through question prompts, the DD notepad stimulates the patient to be an active partner with his or her healthcare team. This may enable patients to have some sense of control and accountability of their care in a setting where they would otherwise feel overwhelmed or powerless. The 3 general categories to help patients write down their questions included diagnosis, treatment plan, and medications. In the inpatient setting, where patient‐care activities can be fast paced, and patients are unable to recall some details when speaking to the healthcare team, these notes may remind the patient to write their thoughts down so that they may be remembered for a future time. In situations where patients may not know which questions to ask, the question prompts may be particularly helpful. We did not assess whether our particular question prompts were the key elements that resulted in their perceived value, or whether simply placing a blank notepad at the bedside would also have been successful. However, the specific questions were suggested by the focus groups. Enhanced communication, focusing on the patients' understanding of their condition, and the need to pursue certain diagnostic or therapeutic interventions, may help patients to be better prepared for the next course of plan. These topics of reasons for hospitalization, treatment plan, and medication changes are also important for patients to be active participants in their care, in particular as they transition from 1 site of care to the next, and their healthcare will be delivered by different providers.

There are several limitations to our study. First, this intervention was performed at a single hospital site with only 2 clinical services (general medicine, cardiology) represented in the study groups. Although we do not have any causal reasons to believe this tool would be looked upon differently by patients on other clinical services, it is possible that patients on a different clinical unit or service may view this tool as less or more useful. Second, as the patients were not randomized to intervention, but rather based on the units to which they were admitted, it is possible that other variables, such as the experience of the unit staff, the patient's condition, and housestaff‐based service versus hospitalist‐based service may have played a role in how the patients perceived the use of DD notes. Third, patients were only surveyed if they were able to verbally communicate in English. These notes may not be as useful in hospital settings to populations with language or literacy barriers. Fourth, the logistical implementation of DD notes limited our ability to deliver the DD notepads in every patient's rooms, where only 78% of the intervention group received the DD notepads. This may be the reason that we did not find that overall satisfaction with physician communication differed between intervention and control groups. Nonetheless, we performed an intention‐to‐treat analysis to minimize any biases in our analysis. Last, although our survey of patients asked about their satisfaction in using the DD note pads, we did not compare these results with those of Press‐Ganey or HCAHPS scores of patients on the intervention group versus the control group. Additionally, lack of data about type, quality, and quantity of questions asked by a control group to see if the notepads actually improved quality of questions asked is a limitation; however, we believe our outcomes of interest were most specifically evaluated through our survey questions.

DD notes show that the majority of patients who use this tool feel a modest to significant improvement in communication with their providers. Although the quality of medical care is undoubtedly the first priority, the patients' view of their care, which includes communication, is arguably just as important. An often‐forgotten goal of hospitals and clinics is to provide service excellence along with high‐quality care. Thus, it is imperative for hospitals and their care providers to not only focus on the quality and safety of the clinical care, but also be mindful of the patient's entire experience throughout their hospital stay. Many of the categories of questions asked in the HCAHPS address the patient's experience and perspectives of hospital care. Furthermore, the role of the HCAHPS survey in the Value‐Based Purchasing rules may enhance the importance of these notepads. As the results of HCAHPS are becoming more transparent and available to the public, the impact of such results will have a greater significance to the future of the hospital's clinical mission.

CONCLUSION

DD notepads are a simple, low‐cost, patient‐centered tool that can be an effective reminder for patients to ask their healthcare providers questions related to their hospital care. Utilizing a common tool such as the notepad, redesigned for the healthcare setting, can serve to help healthcare providers interact with their patients. Patient satisfaction may be higher in patients who use the DD notepad.

Many academic medical centers (AMCs) employ hospitalists to provide care for patients on resident services as supervising attendings,1, 2 as well as on nonresident services.3 The number of hospitalists working on nonresident services at AMCs has grown exponentially, as the Accreditation Council for Graduate Medical Education (ACGME) implemented duty‐hour standards for residents.3 According to the latest Society of Hospital Medicine (SHM) estimates, the number of practicing hospitalists is projected to grow to 30,000 by 2010.4 As astonishing as this growth may sound, it is anticipated that more hospitalists will be needed to meet the demand for these physicians.5 Further, as financial realities require AMCs to be increasingly efficient without compromising patient care, and hospitalists provide a greater range of clinical services, it is important to better understand how hospitalists spend their time in the hospital. Understanding the daily work flow of hospitalists can identify how these physicians can be better supported. A previous report by O'Leary et al.6 highlighted how hospitalists spent their time during their usual day shifts at an AMC. It is important to validate their study to determine broadly applicable findings. We performed a time‐motion study where we followed the admitting hospitalists during the day and night shifts. We felt it was important to focus on hospitalists who are admitting patients, as this has potential patient safety and quality implications related to multitasking, triaging, and helping patients navigate through a complex admission process involving multiple clinical services. Our goal was to better understand how the flow of patients impacted these physicians, and determine how our hospitalists spent their time providing direct and indirect patient care‐related activities. In addition, we looked for predictable variations in activities throughout the day that might be associated with the timely care of patients.

Materials and Methods

Results

Overall, time spent on patient care activities comprised the bulk of hospitalists' shifts (82%) (Figure 1). Patient care activities were further categorized as direct patient caredefined as face‐to‐face patient or family time; and indirect patient caredefined as activities related to patient care, but without patient or family contact. Direct and indirect patient care accounted for 15% and 67% of the hospitalists' time, respectively. The other 18% of the hospitalists' time spent in the hospital were broadly categorized into: professional development, education, personal, downtime, and travel. Professional development included activities such as looking up information (eg, literature search); education included times that hospitalists spent with residents or medical students; personal time included only restroom and food breaks; and travel included time spent moving from 1 area to the next during their shift.

Figure 1

The majority of the hospitalists' direct patient care time was spent on evaluating new patients (79%). Significantly smaller amounts of time were spent on other direct care activities: cross‐covering other patients (8%), follow‐up visits (7%), family meetings (4%), and discharge instructions (2%) (Figure 2).

Figure 2

Indirect patient care activities included, 41% of time used to communicate with other healthcare providers, 26% on medical documentation, 20% reviewing medical records and results, and 13% of time writing orders (Figure 3). Communication accounted for a large proportion of a hospitalists' work, and included telephone conversations with Emergency Department (ED) or other admitting providers, handoffs, paging, face‐to‐face conversations with consultants and other support staff, and e‐mail.

Figure 3

Figure 4 shows the hourly distribution of time spent on direct and indirect patient care by a hospitalist throughout the day. The day‐time hospitalists pick up their signout from the nocturnists at 7 _AM to begin their shift. The swing hospitalists arrive at 2 _PM during the weekdays, and their primary duty is to triage and admit patients until 7 _PM. The nocturnists start their shift at 7 _PM, at which time the daytime and swing‐shift hospitalists all sign out for the night.

Figure 4

Discussion

Hospitalists on the nonresident service at our AMC utilize about 15% of their time on face‐to‐face patient care activities, 67% on indirect patient care activities, and 7% of time on moving from 1 part of the hospital to another. Hospitalists are valuable members of the physician work force who address the increasing patient care demands in the face of increasing limitations on residency work‐hours, a growing aging population, and existing inefficiencies in AMCs. The only other work‐flow study of hospitalists of which we are aware provided a single institution's perspective on time utilization by hospitalists. Our study in a different AMC setting revealed strong consistency with the O'Leary et al.6 study in the fraction of time hospitalists spent on direct patient care (15% and 18%, respectively), indirect patient care (67% and 69%); and within indirect patient care the time spent on documentation (26% and 37% of total time) and communications (41% and 35%). While travel in the O'Leary et al.6 study took up only 3% of hospitalists' time, the conclusions in that paper clearly suggest that the authors consider it an area of concern. Our study found that travel accounted for over 7% of hospitalists' time, confirming that intuition. The significant travel time may in part reflect the effects of a non‐geographically‐located hospitalist service. From these 2 studies we can be more confident that in large, tertiary care AMCs the time hospitalists spend on indirect patient care dominates that for direct patient care (by a factor of 4 in these studies), that within indirect patient care documentation and communication are dominant activities, and that travel can take a significant amount of time when patients are dispersed throughout the facility.

Both studies demonstrated that communication accounted for a significant proportion of a hospitalist's time. In our study communication accounted for 28% of their total time in the hospital, and 41% of the indirect patient care portion (Figure 3). A closer look within our communication category revealed that phone calls and handoffs accounted for two‐thirds of all communication time observed. As the hospitalists who carry the admitting pager, they receive the pages to take admission calls, but also take calls from consultants who have recommendations, as well as from nursing and other hospital staff. Depending on the nature of the conversation, the phone calls can last several minutes. While ensuring the communication between health care providers is complete and thorough, there may be opportunities to develop novel approaches to the way hospitalists communicate with other care providers. For example, at the UMHS, alternative communication methods with nursing staff have been proposed such as utilizing a website or a handheld device to help hospitalists prioritize their communications back to the nursing staff7; while standardizing the intake information from the ED or other admitting providers may help reduce the total time spent on phone calls. We will need to further explore the potential benefits of these ideas in future work.

Our data also reveal an interesting cyclicality of daily activities for the hospitalists, as shown in Figure 4. We identified batching behaviors throughout the day, which cause delays in seeing patients and can be deleterious to smooth workflows in support services. Spikes in indirect patient care, followed closely by spikes in direct patient care, occur regularly at shift changes (7 _AM, 2 _PM, and 7 _PM). Also, in the night shift, indirect patient care drops to its lowest levels (in % of time spent) throughout the day, and direct patient care reaches its highest levels. The day‐shift indirect care profile is counter‐cyclical with direct care, as the hospitalist shifts between direct care and indirect care depending on the time of the day. We discuss these phenomena in turn.

It is known that variability in any operation causes congestion and delay, as an unavoidable consequence of the physics of material and information flows.8 Indeed, an entire subindustry based on Lean manufacturing principles has evolved from the Toyota Production System based on the elimination of unnecessary variability in operations.9 Lean processes have been ongoing in manufacturing facilities for decades, and these efforts are just recently being embraced by the service sector in general, and health care specifically.10, 11 Batching is an extreme form of variability, where there is a lull in the amount of work being done and then a burst of work is done over a short period of time. This means that jobs pile up in the queue waiting for the next spike of activity. Our data indicate batching seems to be a common phenomenon for our hospitalists. The majority of the patients admitted to our hospitalist service are unscheduled admissions that arrive primarily through the ED. One potential result of the unscheduled admissions is that patients could be referred to our hospitalist service at a pace that is not well predictable on an hour‐to‐hour basis. This could lead to an unintended result of multiple patients admitted over a short period of time. This means that many patients wait for intake, delaying the onset of their care by the inpatient physician. Also, since an initial exam often results in orders for laboratory tests and studies, batching on the floor will translate into batching of orders going to nursing, pathology, radiology, and other hospital support services. This imposes the cost of variability on these other services in the hospital. From a systems perspective, efficiency will improve if these activities can be smoothed throughout the day. This may suggest opportunities to work with the ED, to help smooth the inflow of patients into the hospital system.

Within the hospital, all of the day‐shift hospitalists can be reached about the needs of their respective patients, however, the physician carrying the admission pager also fields calls for admissions, and acts as the default contact person for the hospitalist group. As this hospitalist receives information on new admissions, he/she is aware of patients ready for intake but cannot evaluate them at the rate they are being referred, so the queue builds. This continues into the swing shift, which also fields referrals faster than they can attend to them. The volatility in indirect care during the swing shift, 2 _PM to 7 _PM, reflects a significant amount of triaging and fielding general calls about hospitalist patients. These activities further reduce the swing shift's ability to clear the intake queue. The night shift finally gets to these patients and, eventually, clears the queue. There may be an opportunity to consider the use of multiple input pagers or other process changes that can smooth this flow and rationalize the recurring tasks of finding patients and the responsible physician.

Another concept in Lean thinking is that variability is costly when it represents a mismatch between demand for a service and the capacity to serve. With regards to admitted patients, when demand outpaces capacity, patients will wait. When capacity outpaces demand, there is excess capacity in the system. The ideal is to match demand and capacity at all times, so nobody waits and the system carries no costly excess capacity. As the intake providers for admitted patients, we can attack this problem from the capacity side. Here, 2 generic Lean tactics are to: (1) reallocate resources to a bottleneck that is holding up the entire system, and (2) relieve workers of time‐consuming but non‐value‐adding work so they have more capacity to devote to serving demand. In our study, carrying multiple input pagers is an example of tactic (1), and efficient communication technologies and practices that reduce indirect time is an example of (2). Systemwide improvements would require further investigation by working with the variability on the input side (eg, ED admissions).

Our study also found that a significant percent of the time observed was spent traveling (7.4%) from room to room between different floors in the hospital. Travel time, which is non‐value‐adding, is one of the major forms of waste Lean thinking.12 Our hospitalists can provide care to patients at any of the general medical‐surgical beds we have available at our health system. These beds are distributed across 14 units on 5 different floors, as well as in the ED if a bed is not available for an admitted patient. In hospitals routinely operating at high occupancy, such as our AMC, patients often get distributed throughout the facility for lack of beds on the appropriate service's ward. One cost for this is a potential mismatch between a patient's needs and floor nurses' training. Our study reveals another cost, and that is its contribution to the significant amount of time hospitalists spent on travel, which is largely driven by the need to see dispersed patients. Reducing this cost requires a systemic, rather than service‐specific, solution. Our AMC is adding observation‐status beds to relieve some of the pressure on licensed beds, and considering bed management (including parts of the admissions and discharge processes) changes designed to promote better collocation of patients with services. Further study on these and other collocation tactics is warranted.

The spike in indirect activities at 4 _PM represents, in part, an early signout by 1 or more of the hospitalists who are not scheduled to hold the admission pager, and have completed their work for the day. This handoff will be replicated at 7 _PM when the nocturnists arrive for their night shift. In addition to a significant indirect load on physicians, multiple handoffs have been associated with decreased quality of care.13 Again, it is worthwhile considering the feasibility of alternative shift schedules that can minimize handoffs.

Finally, our findings revealed that a low percentage of time was dedicated to providing discharge instructions (2.24% of direct patient care time, and 0.34% of total time). Because the task of discharging patients falls primarily on the day‐shift hospitalists, when combined with swing‐shift and night‐shift hospitalists' data, the low percentage measured on discharge instructions may have been diluted. Nonetheless, this may point to the need for further investigation on how hospitalists provide direct patient encounter time during this critical phase of transition out of the hospital.

Our study is not without limitations. The student observers shadowed a representative group of hospitalists, but they were not able to follow everyone in the group. More specifically, their observations were made on the hospitalist who was carrying the primary hospitalist service admitting pager. Although it was the intent of our study to focus on the hospitalists we felt would be the busiest, our results may not be generalizable to all hospitalists. Although our research supports the previous findings by O'Leary et al.,6 a second limitation to our study is that our analysis was done at a single hospitalist group in an AMC, and hence the results may not be generalizable to other hospitalist groups. Another limitation may be that we did not do an evaluation of the hours between 2 _AM to 7 _AM. This period of time is used to catch up on medical documentation and to be available for medical emergencies. As more hospitalist programs are employing the use of nocturnists, it may be informative to have this time period tracked for activities.

Conclusions

Our study supports the broad allocation of hospitalist time found in an earlier study at a different AMC,6 suggesting that these might be generally representative in other AMCs. We found that travel constitutes a significant claim in hospitalists' time, due in part to the inability to collocate hospitalist service patients. Remedies are not likely to be service‐specific, but will require systemwide analyses of admission and discharge processes. Communication takes a significant amount of hospitalist time, with pages and phone calls related to handoffs accounting for most of the total communication time. As hospitalists working at non‐AMC settings may experience different work flow issues, we would like to see time‐motion studies of hospitalists in other types of hospitals. Future studies should also seek to better understand the how hospitals at high occupancy may reduce batching and streamline both the discharge and admission process, determine the factors that account for the significant communication time and how these processes could be streamlined, and evaluate the potential benefits of geographical localization of hospitalists' patients.

Many academic medical centers (AMCs) employ hospitalists to provide care for patients on resident services as supervising attendings,1, 2 as well as on nonresident services.3 The number of hospitalists working on nonresident services at AMCs has grown exponentially, as the Accreditation Council for Graduate Medical Education (ACGME) implemented duty‐hour standards for residents.3 According to the latest Society of Hospital Medicine (SHM) estimates, the number of practicing hospitalists is projected to grow to 30,000 by 2010.4 As astonishing as this growth may sound, it is anticipated that more hospitalists will be needed to meet the demand for these physicians.5 Further, as financial realities require AMCs to be increasingly efficient without compromising patient care, and hospitalists provide a greater range of clinical services, it is important to better understand how hospitalists spend their time in the hospital. Understanding the daily work flow of hospitalists can identify how these physicians can be better supported. A previous report by O'Leary et al.6 highlighted how hospitalists spent their time during their usual day shifts at an AMC. It is important to validate their study to determine broadly applicable findings. We performed a time‐motion study where we followed the admitting hospitalists during the day and night shifts. We felt it was important to focus on hospitalists who are admitting patients, as this has potential patient safety and quality implications related to multitasking, triaging, and helping patients navigate through a complex admission process involving multiple clinical services. Our goal was to better understand how the flow of patients impacted these physicians, and determine how our hospitalists spent their time providing direct and indirect patient care‐related activities. In addition, we looked for predictable variations in activities throughout the day that might be associated with the timely care of patients.

Materials and Methods

Results

Overall, time spent on patient care activities comprised the bulk of hospitalists' shifts (82%) (Figure 1). Patient care activities were further categorized as direct patient caredefined as face‐to‐face patient or family time; and indirect patient caredefined as activities related to patient care, but without patient or family contact. Direct and indirect patient care accounted for 15% and 67% of the hospitalists' time, respectively. The other 18% of the hospitalists' time spent in the hospital were broadly categorized into: professional development, education, personal, downtime, and travel. Professional development included activities such as looking up information (eg, literature search); education included times that hospitalists spent with residents or medical students; personal time included only restroom and food breaks; and travel included time spent moving from 1 area to the next during their shift.

Figure 1

The majority of the hospitalists' direct patient care time was spent on evaluating new patients (79%). Significantly smaller amounts of time were spent on other direct care activities: cross‐covering other patients (8%), follow‐up visits (7%), family meetings (4%), and discharge instructions (2%) (Figure 2).

Figure 2

Indirect patient care activities included, 41% of time used to communicate with other healthcare providers, 26% on medical documentation, 20% reviewing medical records and results, and 13% of time writing orders (Figure 3). Communication accounted for a large proportion of a hospitalists' work, and included telephone conversations with Emergency Department (ED) or other admitting providers, handoffs, paging, face‐to‐face conversations with consultants and other support staff, and e‐mail.

Figure 3

Figure 4 shows the hourly distribution of time spent on direct and indirect patient care by a hospitalist throughout the day. The day‐time hospitalists pick up their signout from the nocturnists at 7 _AM to begin their shift. The swing hospitalists arrive at 2 _PM during the weekdays, and their primary duty is to triage and admit patients until 7 _PM. The nocturnists start their shift at 7 _PM, at which time the daytime and swing‐shift hospitalists all sign out for the night.

Figure 4

Discussion

Hospitalists on the nonresident service at our AMC utilize about 15% of their time on face‐to‐face patient care activities, 67% on indirect patient care activities, and 7% of time on moving from 1 part of the hospital to another. Hospitalists are valuable members of the physician work force who address the increasing patient care demands in the face of increasing limitations on residency work‐hours, a growing aging population, and existing inefficiencies in AMCs. The only other work‐flow study of hospitalists of which we are aware provided a single institution's perspective on time utilization by hospitalists. Our study in a different AMC setting revealed strong consistency with the O'Leary et al.6 study in the fraction of time hospitalists spent on direct patient care (15% and 18%, respectively), indirect patient care (67% and 69%); and within indirect patient care the time spent on documentation (26% and 37% of total time) and communications (41% and 35%). While travel in the O'Leary et al.6 study took up only 3% of hospitalists' time, the conclusions in that paper clearly suggest that the authors consider it an area of concern. Our study found that travel accounted for over 7% of hospitalists' time, confirming that intuition. The significant travel time may in part reflect the effects of a non‐geographically‐located hospitalist service. From these 2 studies we can be more confident that in large, tertiary care AMCs the time hospitalists spend on indirect patient care dominates that for direct patient care (by a factor of 4 in these studies), that within indirect patient care documentation and communication are dominant activities, and that travel can take a significant amount of time when patients are dispersed throughout the facility.

Both studies demonstrated that communication accounted for a significant proportion of a hospitalist's time. In our study communication accounted for 28% of their total time in the hospital, and 41% of the indirect patient care portion (Figure 3). A closer look within our communication category revealed that phone calls and handoffs accounted for two‐thirds of all communication time observed. As the hospitalists who carry the admitting pager, they receive the pages to take admission calls, but also take calls from consultants who have recommendations, as well as from nursing and other hospital staff. Depending on the nature of the conversation, the phone calls can last several minutes. While ensuring the communication between health care providers is complete and thorough, there may be opportunities to develop novel approaches to the way hospitalists communicate with other care providers. For example, at the UMHS, alternative communication methods with nursing staff have been proposed such as utilizing a website or a handheld device to help hospitalists prioritize their communications back to the nursing staff7; while standardizing the intake information from the ED or other admitting providers may help reduce the total time spent on phone calls. We will need to further explore the potential benefits of these ideas in future work.

Our data also reveal an interesting cyclicality of daily activities for the hospitalists, as shown in Figure 4. We identified batching behaviors throughout the day, which cause delays in seeing patients and can be deleterious to smooth workflows in support services. Spikes in indirect patient care, followed closely by spikes in direct patient care, occur regularly at shift changes (7 _AM, 2 _PM, and 7 _PM). Also, in the night shift, indirect patient care drops to its lowest levels (in % of time spent) throughout the day, and direct patient care reaches its highest levels. The day‐shift indirect care profile is counter‐cyclical with direct care, as the hospitalist shifts between direct care and indirect care depending on the time of the day. We discuss these phenomena in turn.

It is known that variability in any operation causes congestion and delay, as an unavoidable consequence of the physics of material and information flows.8 Indeed, an entire subindustry based on Lean manufacturing principles has evolved from the Toyota Production System based on the elimination of unnecessary variability in operations.9 Lean processes have been ongoing in manufacturing facilities for decades, and these efforts are just recently being embraced by the service sector in general, and health care specifically.10, 11 Batching is an extreme form of variability, where there is a lull in the amount of work being done and then a burst of work is done over a short period of time. This means that jobs pile up in the queue waiting for the next spike of activity. Our data indicate batching seems to be a common phenomenon for our hospitalists. The majority of the patients admitted to our hospitalist service are unscheduled admissions that arrive primarily through the ED. One potential result of the unscheduled admissions is that patients could be referred to our hospitalist service at a pace that is not well predictable on an hour‐to‐hour basis. This could lead to an unintended result of multiple patients admitted over a short period of time. This means that many patients wait for intake, delaying the onset of their care by the inpatient physician. Also, since an initial exam often results in orders for laboratory tests and studies, batching on the floor will translate into batching of orders going to nursing, pathology, radiology, and other hospital support services. This imposes the cost of variability on these other services in the hospital. From a systems perspective, efficiency will improve if these activities can be smoothed throughout the day. This may suggest opportunities to work with the ED, to help smooth the inflow of patients into the hospital system.

Within the hospital, all of the day‐shift hospitalists can be reached about the needs of their respective patients, however, the physician carrying the admission pager also fields calls for admissions, and acts as the default contact person for the hospitalist group. As this hospitalist receives information on new admissions, he/she is aware of patients ready for intake but cannot evaluate them at the rate they are being referred, so the queue builds. This continues into the swing shift, which also fields referrals faster than they can attend to them. The volatility in indirect care during the swing shift, 2 _PM to 7 _PM, reflects a significant amount of triaging and fielding general calls about hospitalist patients. These activities further reduce the swing shift's ability to clear the intake queue. The night shift finally gets to these patients and, eventually, clears the queue. There may be an opportunity to consider the use of multiple input pagers or other process changes that can smooth this flow and rationalize the recurring tasks of finding patients and the responsible physician.

Another concept in Lean thinking is that variability is costly when it represents a mismatch between demand for a service and the capacity to serve. With regards to admitted patients, when demand outpaces capacity, patients will wait. When capacity outpaces demand, there is excess capacity in the system. The ideal is to match demand and capacity at all times, so nobody waits and the system carries no costly excess capacity. As the intake providers for admitted patients, we can attack this problem from the capacity side. Here, 2 generic Lean tactics are to: (1) reallocate resources to a bottleneck that is holding up the entire system, and (2) relieve workers of time‐consuming but non‐value‐adding work so they have more capacity to devote to serving demand. In our study, carrying multiple input pagers is an example of tactic (1), and efficient communication technologies and practices that reduce indirect time is an example of (2). Systemwide improvements would require further investigation by working with the variability on the input side (eg, ED admissions).

Our study also found that a significant percent of the time observed was spent traveling (7.4%) from room to room between different floors in the hospital. Travel time, which is non‐value‐adding, is one of the major forms of waste Lean thinking.12 Our hospitalists can provide care to patients at any of the general medical‐surgical beds we have available at our health system. These beds are distributed across 14 units on 5 different floors, as well as in the ED if a bed is not available for an admitted patient. In hospitals routinely operating at high occupancy, such as our AMC, patients often get distributed throughout the facility for lack of beds on the appropriate service's ward. One cost for this is a potential mismatch between a patient's needs and floor nurses' training. Our study reveals another cost, and that is its contribution to the significant amount of time hospitalists spent on travel, which is largely driven by the need to see dispersed patients. Reducing this cost requires a systemic, rather than service‐specific, solution. Our AMC is adding observation‐status beds to relieve some of the pressure on licensed beds, and considering bed management (including parts of the admissions and discharge processes) changes designed to promote better collocation of patients with services. Further study on these and other collocation tactics is warranted.

The spike in indirect activities at 4 _PM represents, in part, an early signout by 1 or more of the hospitalists who are not scheduled to hold the admission pager, and have completed their work for the day. This handoff will be replicated at 7 _PM when the nocturnists arrive for their night shift. In addition to a significant indirect load on physicians, multiple handoffs have been associated with decreased quality of care.13 Again, it is worthwhile considering the feasibility of alternative shift schedules that can minimize handoffs.

Finally, our findings revealed that a low percentage of time was dedicated to providing discharge instructions (2.24% of direct patient care time, and 0.34% of total time). Because the task of discharging patients falls primarily on the day‐shift hospitalists, when combined with swing‐shift and night‐shift hospitalists' data, the low percentage measured on discharge instructions may have been diluted. Nonetheless, this may point to the need for further investigation on how hospitalists provide direct patient encounter time during this critical phase of transition out of the hospital.

Our study is not without limitations. The student observers shadowed a representative group of hospitalists, but they were not able to follow everyone in the group. More specifically, their observations were made on the hospitalist who was carrying the primary hospitalist service admitting pager. Although it was the intent of our study to focus on the hospitalists we felt would be the busiest, our results may not be generalizable to all hospitalists. Although our research supports the previous findings by O'Leary et al.,6 a second limitation to our study is that our analysis was done at a single hospitalist group in an AMC, and hence the results may not be generalizable to other hospitalist groups. Another limitation may be that we did not do an evaluation of the hours between 2 _AM to 7 _AM. This period of time is used to catch up on medical documentation and to be available for medical emergencies. As more hospitalist programs are employing the use of nocturnists, it may be informative to have this time period tracked for activities.

Conclusions

Our study supports the broad allocation of hospitalist time found in an earlier study at a different AMC,6 suggesting that these might be generally representative in other AMCs. We found that travel constitutes a significant claim in hospitalists' time, due in part to the inability to collocate hospitalist service patients. Remedies are not likely to be service‐specific, but will require systemwide analyses of admission and discharge processes. Communication takes a significant amount of hospitalist time, with pages and phone calls related to handoffs accounting for most of the total communication time. As hospitalists working at non‐AMC settings may experience different work flow issues, we would like to see time‐motion studies of hospitalists in other types of hospitals. Future studies should also seek to better understand the how hospitals at high occupancy may reduce batching and streamline both the discharge and admission process, determine the factors that account for the significant communication time and how these processes could be streamlined, and evaluate the potential benefits of geographical localization of hospitalists' patients.

Many academic medical centers (AMCs) employ hospitalists to provide care for patients on resident services as supervising attendings,1, 2 as well as on nonresident services.3 The number of hospitalists working on nonresident services at AMCs has grown exponentially, as the Accreditation Council for Graduate Medical Education (ACGME) implemented duty‐hour standards for residents.3 According to the latest Society of Hospital Medicine (SHM) estimates, the number of practicing hospitalists is projected to grow to 30,000 by 2010.4 As astonishing as this growth may sound, it is anticipated that more hospitalists will be needed to meet the demand for these physicians.5 Further, as financial realities require AMCs to be increasingly efficient without compromising patient care, and hospitalists provide a greater range of clinical services, it is important to better understand how hospitalists spend their time in the hospital. Understanding the daily work flow of hospitalists can identify how these physicians can be better supported. A previous report by O'Leary et al.6 highlighted how hospitalists spent their time during their usual day shifts at an AMC. It is important to validate their study to determine broadly applicable findings. We performed a time‐motion study where we followed the admitting hospitalists during the day and night shifts. We felt it was important to focus on hospitalists who are admitting patients, as this has potential patient safety and quality implications related to multitasking, triaging, and helping patients navigate through a complex admission process involving multiple clinical services. Our goal was to better understand how the flow of patients impacted these physicians, and determine how our hospitalists spent their time providing direct and indirect patient care‐related activities. In addition, we looked for predictable variations in activities throughout the day that might be associated with the timely care of patients.

Materials and Methods

Results

Overall, time spent on patient care activities comprised the bulk of hospitalists' shifts (82%) (Figure 1). Patient care activities were further categorized as direct patient caredefined as face‐to‐face patient or family time; and indirect patient caredefined as activities related to patient care, but without patient or family contact. Direct and indirect patient care accounted for 15% and 67% of the hospitalists' time, respectively. The other 18% of the hospitalists' time spent in the hospital were broadly categorized into: professional development, education, personal, downtime, and travel. Professional development included activities such as looking up information (eg, literature search); education included times that hospitalists spent with residents or medical students; personal time included only restroom and food breaks; and travel included time spent moving from 1 area to the next during their shift.

Figure 1

The majority of the hospitalists' direct patient care time was spent on evaluating new patients (79%). Significantly smaller amounts of time were spent on other direct care activities: cross‐covering other patients (8%), follow‐up visits (7%), family meetings (4%), and discharge instructions (2%) (Figure 2).

Figure 2

Indirect patient care activities included, 41% of time used to communicate with other healthcare providers, 26% on medical documentation, 20% reviewing medical records and results, and 13% of time writing orders (Figure 3). Communication accounted for a large proportion of a hospitalists' work, and included telephone conversations with Emergency Department (ED) or other admitting providers, handoffs, paging, face‐to‐face conversations with consultants and other support staff, and e‐mail.

Figure 3

Figure 4 shows the hourly distribution of time spent on direct and indirect patient care by a hospitalist throughout the day. The day‐time hospitalists pick up their signout from the nocturnists at 7 _AM to begin their shift. The swing hospitalists arrive at 2 _PM during the weekdays, and their primary duty is to triage and admit patients until 7 _PM. The nocturnists start their shift at 7 _PM, at which time the daytime and swing‐shift hospitalists all sign out for the night.

Figure 4

Discussion

Hospitalists on the nonresident service at our AMC utilize about 15% of their time on face‐to‐face patient care activities, 67% on indirect patient care activities, and 7% of time on moving from 1 part of the hospital to another. Hospitalists are valuable members of the physician work force who address the increasing patient care demands in the face of increasing limitations on residency work‐hours, a growing aging population, and existing inefficiencies in AMCs. The only other work‐flow study of hospitalists of which we are aware provided a single institution's perspective on time utilization by hospitalists. Our study in a different AMC setting revealed strong consistency with the O'Leary et al.6 study in the fraction of time hospitalists spent on direct patient care (15% and 18%, respectively), indirect patient care (67% and 69%); and within indirect patient care the time spent on documentation (26% and 37% of total time) and communications (41% and 35%). While travel in the O'Leary et al.6 study took up only 3% of hospitalists' time, the conclusions in that paper clearly suggest that the authors consider it an area of concern. Our study found that travel accounted for over 7% of hospitalists' time, confirming that intuition. The significant travel time may in part reflect the effects of a non‐geographically‐located hospitalist service. From these 2 studies we can be more confident that in large, tertiary care AMCs the time hospitalists spend on indirect patient care dominates that for direct patient care (by a factor of 4 in these studies), that within indirect patient care documentation and communication are dominant activities, and that travel can take a significant amount of time when patients are dispersed throughout the facility.

Both studies demonstrated that communication accounted for a significant proportion of a hospitalist's time. In our study communication accounted for 28% of their total time in the hospital, and 41% of the indirect patient care portion (Figure 3). A closer look within our communication category revealed that phone calls and handoffs accounted for two‐thirds of all communication time observed. As the hospitalists who carry the admitting pager, they receive the pages to take admission calls, but also take calls from consultants who have recommendations, as well as from nursing and other hospital staff. Depending on the nature of the conversation, the phone calls can last several minutes. While ensuring the communication between health care providers is complete and thorough, there may be opportunities to develop novel approaches to the way hospitalists communicate with other care providers. For example, at the UMHS, alternative communication methods with nursing staff have been proposed such as utilizing a website or a handheld device to help hospitalists prioritize their communications back to the nursing staff7; while standardizing the intake information from the ED or other admitting providers may help reduce the total time spent on phone calls. We will need to further explore the potential benefits of these ideas in future work.

Our data also reveal an interesting cyclicality of daily activities for the hospitalists, as shown in Figure 4. We identified batching behaviors throughout the day, which cause delays in seeing patients and can be deleterious to smooth workflows in support services. Spikes in indirect patient care, followed closely by spikes in direct patient care, occur regularly at shift changes (7 _AM, 2 _PM, and 7 _PM). Also, in the night shift, indirect patient care drops to its lowest levels (in % of time spent) throughout the day, and direct patient care reaches its highest levels. The day‐shift indirect care profile is counter‐cyclical with direct care, as the hospitalist shifts between direct care and indirect care depending on the time of the day. We discuss these phenomena in turn.

It is known that variability in any operation causes congestion and delay, as an unavoidable consequence of the physics of material and information flows.8 Indeed, an entire subindustry based on Lean manufacturing principles has evolved from the Toyota Production System based on the elimination of unnecessary variability in operations.9 Lean processes have been ongoing in manufacturing facilities for decades, and these efforts are just recently being embraced by the service sector in general, and health care specifically.10, 11 Batching is an extreme form of variability, where there is a lull in the amount of work being done and then a burst of work is done over a short period of time. This means that jobs pile up in the queue waiting for the next spike of activity. Our data indicate batching seems to be a common phenomenon for our hospitalists. The majority of the patients admitted to our hospitalist service are unscheduled admissions that arrive primarily through the ED. One potential result of the unscheduled admissions is that patients could be referred to our hospitalist service at a pace that is not well predictable on an hour‐to‐hour basis. This could lead to an unintended result of multiple patients admitted over a short period of time. This means that many patients wait for intake, delaying the onset of their care by the inpatient physician. Also, since an initial exam often results in orders for laboratory tests and studies, batching on the floor will translate into batching of orders going to nursing, pathology, radiology, and other hospital support services. This imposes the cost of variability on these other services in the hospital. From a systems perspective, efficiency will improve if these activities can be smoothed throughout the day. This may suggest opportunities to work with the ED, to help smooth the inflow of patients into the hospital system.

Within the hospital, all of the day‐shift hospitalists can be reached about the needs of their respective patients, however, the physician carrying the admission pager also fields calls for admissions, and acts as the default contact person for the hospitalist group. As this hospitalist receives information on new admissions, he/she is aware of patients ready for intake but cannot evaluate them at the rate they are being referred, so the queue builds. This continues into the swing shift, which also fields referrals faster than they can attend to them. The volatility in indirect care during the swing shift, 2 _PM to 7 _PM, reflects a significant amount of triaging and fielding general calls about hospitalist patients. These activities further reduce the swing shift's ability to clear the intake queue. The night shift finally gets to these patients and, eventually, clears the queue. There may be an opportunity to consider the use of multiple input pagers or other process changes that can smooth this flow and rationalize the recurring tasks of finding patients and the responsible physician.

Another concept in Lean thinking is that variability is costly when it represents a mismatch between demand for a service and the capacity to serve. With regards to admitted patients, when demand outpaces capacity, patients will wait. When capacity outpaces demand, there is excess capacity in the system. The ideal is to match demand and capacity at all times, so nobody waits and the system carries no costly excess capacity. As the intake providers for admitted patients, we can attack this problem from the capacity side. Here, 2 generic Lean tactics are to: (1) reallocate resources to a bottleneck that is holding up the entire system, and (2) relieve workers of time‐consuming but non‐value‐adding work so they have more capacity to devote to serving demand. In our study, carrying multiple input pagers is an example of tactic (1), and efficient communication technologies and practices that reduce indirect time is an example of (2). Systemwide improvements would require further investigation by working with the variability on the input side (eg, ED admissions).

Our study also found that a significant percent of the time observed was spent traveling (7.4%) from room to room between different floors in the hospital. Travel time, which is non‐value‐adding, is one of the major forms of waste Lean thinking.12 Our hospitalists can provide care to patients at any of the general medical‐surgical beds we have available at our health system. These beds are distributed across 14 units on 5 different floors, as well as in the ED if a bed is not available for an admitted patient. In hospitals routinely operating at high occupancy, such as our AMC, patients often get distributed throughout the facility for lack of beds on the appropriate service's ward. One cost for this is a potential mismatch between a patient's needs and floor nurses' training. Our study reveals another cost, and that is its contribution to the significant amount of time hospitalists spent on travel, which is largely driven by the need to see dispersed patients. Reducing this cost requires a systemic, rather than service‐specific, solution. Our AMC is adding observation‐status beds to relieve some of the pressure on licensed beds, and considering bed management (including parts of the admissions and discharge processes) changes designed to promote better collocation of patients with services. Further study on these and other collocation tactics is warranted.

The spike in indirect activities at 4 _PM represents, in part, an early signout by 1 or more of the hospitalists who are not scheduled to hold the admission pager, and have completed their work for the day. This handoff will be replicated at 7 _PM when the nocturnists arrive for their night shift. In addition to a significant indirect load on physicians, multiple handoffs have been associated with decreased quality of care.13 Again, it is worthwhile considering the feasibility of alternative shift schedules that can minimize handoffs.

Finally, our findings revealed that a low percentage of time was dedicated to providing discharge instructions (2.24% of direct patient care time, and 0.34% of total time). Because the task of discharging patients falls primarily on the day‐shift hospitalists, when combined with swing‐shift and night‐shift hospitalists' data, the low percentage measured on discharge instructions may have been diluted. Nonetheless, this may point to the need for further investigation on how hospitalists provide direct patient encounter time during this critical phase of transition out of the hospital.

Our study is not without limitations. The student observers shadowed a representative group of hospitalists, but they were not able to follow everyone in the group. More specifically, their observations were made on the hospitalist who was carrying the primary hospitalist service admitting pager. Although it was the intent of our study to focus on the hospitalists we felt would be the busiest, our results may not be generalizable to all hospitalists. Although our research supports the previous findings by O'Leary et al.,6 a second limitation to our study is that our analysis was done at a single hospitalist group in an AMC, and hence the results may not be generalizable to other hospitalist groups. Another limitation may be that we did not do an evaluation of the hours between 2 _AM to 7 _AM. This period of time is used to catch up on medical documentation and to be available for medical emergencies. As more hospitalist programs are employing the use of nocturnists, it may be informative to have this time period tracked for activities.

Conclusions

Our study supports the broad allocation of hospitalist time found in an earlier study at a different AMC,6 suggesting that these might be generally representative in other AMCs. We found that travel constitutes a significant claim in hospitalists' time, due in part to the inability to collocate hospitalist service patients. Remedies are not likely to be service‐specific, but will require systemwide analyses of admission and discharge processes. Communication takes a significant amount of hospitalist time, with pages and phone calls related to handoffs accounting for most of the total communication time. As hospitalists working at non‐AMC settings may experience different work flow issues, we would like to see time‐motion studies of hospitalists in other types of hospitals. Future studies should also seek to better understand the how hospitals at high occupancy may reduce batching and streamline both the discharge and admission process, determine the factors that account for the significant communication time and how these processes could be streamlined, and evaluate the potential benefits of geographical localization of hospitalists' patients.

The first observation units were implemented more than 40 years ago with the goal of reducing the number and duration of inpatient stays. Since then, observation units (OUs) have evolved as a safe alternative to hospitalization14 for the delivery of finite periods of care, typically less than 24 hours.58 Observation services allow for time to determine the need for hospitalization in cases that are unclear after their initial evaluation and treatment.9 Observation status is an administrative classification related to reimbursement that can be applied to patients whose diagnosis, treatment, stabilization, and discharge can reasonably be expected within 24 hours.10, 11 The site of care for observation is dependent in part upon existing facility structures; some institutions utilize virtual OUs within the emergency department (ED) or hospital ward, while others have dedicated, geographically distinct OUs, which may function as an extension of either the ED or inpatient settings.9

OUs have been instrumental in providing care to adult patients with chest pain, asthma, and acute infections.1218 Recently, there has been an increase in the number of publications from pediatric OUs in the United States and abroad. Observation may be a preferred model of care for select pediatric patients, as hospitalized children often experience brief stays.1921 Previous reviews on this model of care have combined adult and pediatric literature and have included research from countries with healthcare structures that differ considerably from the United States.2224 To date, no systematic review has summarized the pediatric OU literature with a focus on the US healthcare system.

As payers and hospitals seek cost‐effective alternatives to traditional inpatient care, geographically distinct OUs may become integral to the future of healthcare delivery for children. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. We also scrutinize the outcome measures presented in the included publications and propose future directions for research to improve both observation unit care, as well as the care delivered to patients under observation status within general inpatient or ED settings.

Methods

Results

A systematic search of the electronic databases identified 222 unique citations (Figure 1). A total of 107 abstracts were evaluated. We identified 48 articles for full‐text review, of which 18 met inclusion criteria. Hand search of references yielded 24 additional articles, of which 3 met inclusion criteria. Interrater agreement for selected articles was high at 98% (kappa = 0.85).

Figure 1

Discussion

In the 40 years since the first studies of pediatric OUs, several US health systems have extended observation services to children. This model of care may be expanding, as suggested by an increase in the number of publications in the past 10 years. However, the number of centers within the US reporting on their OU experience remains small. Our systematic review identified a recurrent theme related to OUsthe opportunity to improve operational processes of care compared with the traditional inpatient alternative. We have identified the need to standardize OU outcomes and propose measures for future OU research.

Conclusions

OUs have emerged to provide treatment at the intersection of outpatient and inpatient care during a time of dramatic change in both emergency and hospital medicine. As hospitalists expand their scope of practice to include observation care, opportunities will arise to collaborate with ED physicians and share their growing expertise in quality and efficiency of hospital care delivery to improve observation services for children. OUs have been established with laudable goalsto reduce inpatient admissions, increase patient safety, improve efficiency, and control costs. The current evidence is not adequate to determine if this model of healthcare delivery achieves these goals for children. Through synthesis of existing data, we have identified a need for standard reporting for OU outcomes and propose consistent measures for future observation care research. Only through prospective evaluation of comparable outcomes can we appraise the performance of pediatric OUs across institutions.

The first observation units were implemented more than 40 years ago with the goal of reducing the number and duration of inpatient stays. Since then, observation units (OUs) have evolved as a safe alternative to hospitalization14 for the delivery of finite periods of care, typically less than 24 hours.58 Observation services allow for time to determine the need for hospitalization in cases that are unclear after their initial evaluation and treatment.9 Observation status is an administrative classification related to reimbursement that can be applied to patients whose diagnosis, treatment, stabilization, and discharge can reasonably be expected within 24 hours.10, 11 The site of care for observation is dependent in part upon existing facility structures; some institutions utilize virtual OUs within the emergency department (ED) or hospital ward, while others have dedicated, geographically distinct OUs, which may function as an extension of either the ED or inpatient settings.9

OUs have been instrumental in providing care to adult patients with chest pain, asthma, and acute infections.1218 Recently, there has been an increase in the number of publications from pediatric OUs in the United States and abroad. Observation may be a preferred model of care for select pediatric patients, as hospitalized children often experience brief stays.1921 Previous reviews on this model of care have combined adult and pediatric literature and have included research from countries with healthcare structures that differ considerably from the United States.2224 To date, no systematic review has summarized the pediatric OU literature with a focus on the US healthcare system.

As payers and hospitals seek cost‐effective alternatives to traditional inpatient care, geographically distinct OUs may become integral to the future of healthcare delivery for children. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. We also scrutinize the outcome measures presented in the included publications and propose future directions for research to improve both observation unit care, as well as the care delivered to patients under observation status within general inpatient or ED settings.

Methods

Results

A systematic search of the electronic databases identified 222 unique citations (Figure 1). A total of 107 abstracts were evaluated. We identified 48 articles for full‐text review, of which 18 met inclusion criteria. Hand search of references yielded 24 additional articles, of which 3 met inclusion criteria. Interrater agreement for selected articles was high at 98% (kappa = 0.85).

Figure 1