Corinne Haviley, RN, MS

Communication among hospital care providers is critically important to provide safe and effective care.15 Yet, studies in operating rooms, intensive care units (ICUs), and general medical units have revealed widely discrepant views on the quality of collaboration and communication between physicians and nurses.68 Although physicians consistently gave high ratings to the quality of collaboration with nurses, nurses rated the quality of collaboration with physicians relatively poorly.

A significant barrier to communication among providers on patient care units is the fluidity and geographic dispersion of team members.8 Physicians, nurses, and other hospital care providers have difficulty finding a way to discuss the care of their patients in person. Research has shown that nurses and physicians on patient care units do not communicate consistently and frequently are not in agreement about their patients' plans of care9, 10

Interdisciplinary Rounds (IDR) have been used as a means to assemble patient care unit team members and improve collaboration on the plan of care.1114 Prior research has demonstrated improved ratings of collaboration on the part of physicians,13, 14 but the effect of IDR on nurses' ratings of collaboration and teamwork has not been adequately assessed. One IDR study did not assess nurses' perceptions,13 while others used instruments not previously described and/or validated in the literature.12, 14 Regarding more concrete outcomes, research indicates variable effects of IDR on length of stay (LOS) and cost. Although 2 studies documented a reduction in LOS and cost with the use of IDR,12, 13 another study showed no effect.15 Furthermore, prior studies evaluated the use of IDR on resident‐covered teaching services. The effect IDR has on collaboration, LOS, and cost in a nonteaching hospitalist service setting is not known.

This study had 3 aims. The first was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. The second was to assess the feasibility and sustainability of the intervention. The third was to assess the impact of the intervention on hospital LOS and cost.

Methods

Results

Ratings of Teamwork and Perceptions of SIDR

As shown in Figure 1, a larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05).

Figure 1

Nurses' ratings of the teamwork and safety climate are summarized in Table 2. The median teamwork climate score was 85.7 (interquartile range [IQR], 75.092.9) for the intervention unit as compared to 61.6 (IQR, 48.283.9) for the control unit (P = 0.008). The median safety climate score was 75.0 (IQR, 70.581.3) for the intervention unit as compared to 61.1 (IQR, 30.281.3) for the control unit (P = 0.03).

Table 2.Nurses' Ratings of Teamwork and Patient Safety Climate by Unit

	Control Unit, n = 24	Intervention Unit, n = 25	P Value
Abbreviation: IQR, interquartile range.
Median Teamwork Climate Score (IQR)	75.0 (70.581.3)	61.6 (48.283.9)	0.008
Median Safety Climate Score (IQR)	85.7 (75.092.9)	61.1 (30.281.3)	0.03

Sixty‐five of 88 (74%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved the efficiency of their work day. Eighty of 88 (91%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved team collaboration. Seventy‐six of 88 (86%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved patient care. Sixty‐seven of 88 (76%) hospitalists and 22 of 25 (88%) nurses indicated that they wanted SIDR to continue indefinitely.

Discussion

We found that nurses working on a unit using SIDR rated the quality of communication and collaboration with hospitalists significantly higher as compared to a control unit. Notably, because hospitalists worked on both the intervention and control unit during their weeks on service, nurses on each unit were rating the quality of collaboration with the same hospitalists. Nurses also rated the teamwork and safety climate higher on the intervention unit. These findings are important because prior research has shown that nurses are often dissatisfied with the quality of collaboration and teamwork with physicians.68 Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6 Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.22, 23 SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.

Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.15 Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.2426 Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.

The majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their workday and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.11 Incorporating the input of frontline providers into the design of SIDR allowed us to create a sustainable intervention which fit into daily workflow.

Our bivariate analyses found significant patient case‐mix differences between the intervention and control unit, limiting our ability to perform direct comparisons in LOS and cost. Pre‐post analyses of LOS and cost may be affected by cyclical or secular trends. Because each approach has its own limitations, we felt that analyses using both an historic as well as a concurrent control would provide a more complete assessment of the effect of the intervention. We included case mix, among other variables, in out multivariable regression analyses and found no benefit to SIDR with regard to LOS and cost. Two prior studies have shown a reduction in LOS and cost with the use of IDR.12, 13 However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.12 The second study used a pre‐post study design which may not have accounted for unmeasured confounders affecting LOS and cost.13 A third, smaller study showed no effect on LOS and cost with the use of IDR.15 No prior study has evaluated the effect of IDR on LOS and cost in a nonteaching hospitalist service setting.

Our study has several limitations. First, our study reflects the experience of an intervention unit compared to a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizability of our findings. Second, we did not conduct preintervention provider surveys for comparison ratings of collaboration and teamwork. A prior study, conducted by our research group, found that nurses gave low ratings to the teamwork climate and the quality of collaboration with hospitalists.8 Because this baseline study showed consistently low nurse ratings of collaboration and teamwork across all medical units, and because the units in the current study were identical in size, structure, and staffing of nonphysician personnel, we did not repeat nurse surveys prior to the intervention. Third, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit.

In summary, SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a nonteaching hospitalist unit. Future research efforts should assess whether improved teamwork as a result of SIDR also translates into safer patient care.

Communication among hospital care providers is critically important to provide safe and effective care.15 Yet, studies in operating rooms, intensive care units (ICUs), and general medical units have revealed widely discrepant views on the quality of collaboration and communication between physicians and nurses.68 Although physicians consistently gave high ratings to the quality of collaboration with nurses, nurses rated the quality of collaboration with physicians relatively poorly.

A significant barrier to communication among providers on patient care units is the fluidity and geographic dispersion of team members.8 Physicians, nurses, and other hospital care providers have difficulty finding a way to discuss the care of their patients in person. Research has shown that nurses and physicians on patient care units do not communicate consistently and frequently are not in agreement about their patients' plans of care9, 10

Interdisciplinary Rounds (IDR) have been used as a means to assemble patient care unit team members and improve collaboration on the plan of care.1114 Prior research has demonstrated improved ratings of collaboration on the part of physicians,13, 14 but the effect of IDR on nurses' ratings of collaboration and teamwork has not been adequately assessed. One IDR study did not assess nurses' perceptions,13 while others used instruments not previously described and/or validated in the literature.12, 14 Regarding more concrete outcomes, research indicates variable effects of IDR on length of stay (LOS) and cost. Although 2 studies documented a reduction in LOS and cost with the use of IDR,12, 13 another study showed no effect.15 Furthermore, prior studies evaluated the use of IDR on resident‐covered teaching services. The effect IDR has on collaboration, LOS, and cost in a nonteaching hospitalist service setting is not known.

This study had 3 aims. The first was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. The second was to assess the feasibility and sustainability of the intervention. The third was to assess the impact of the intervention on hospital LOS and cost.

Methods

Results

Ratings of Teamwork and Perceptions of SIDR

As shown in Figure 1, a larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05).

Figure 1

Nurses' ratings of the teamwork and safety climate are summarized in Table 2. The median teamwork climate score was 85.7 (interquartile range [IQR], 75.092.9) for the intervention unit as compared to 61.6 (IQR, 48.283.9) for the control unit (P = 0.008). The median safety climate score was 75.0 (IQR, 70.581.3) for the intervention unit as compared to 61.1 (IQR, 30.281.3) for the control unit (P = 0.03).

Table 2.Nurses' Ratings of Teamwork and Patient Safety Climate by Unit

	Control Unit, n = 24	Intervention Unit, n = 25	P Value
Abbreviation: IQR, interquartile range.
Median Teamwork Climate Score (IQR)	75.0 (70.581.3)	61.6 (48.283.9)	0.008
Median Safety Climate Score (IQR)	85.7 (75.092.9)	61.1 (30.281.3)	0.03

Sixty‐five of 88 (74%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved the efficiency of their work day. Eighty of 88 (91%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved team collaboration. Seventy‐six of 88 (86%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved patient care. Sixty‐seven of 88 (76%) hospitalists and 22 of 25 (88%) nurses indicated that they wanted SIDR to continue indefinitely.

Discussion

We found that nurses working on a unit using SIDR rated the quality of communication and collaboration with hospitalists significantly higher as compared to a control unit. Notably, because hospitalists worked on both the intervention and control unit during their weeks on service, nurses on each unit were rating the quality of collaboration with the same hospitalists. Nurses also rated the teamwork and safety climate higher on the intervention unit. These findings are important because prior research has shown that nurses are often dissatisfied with the quality of collaboration and teamwork with physicians.68 Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6 Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.22, 23 SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.

Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.15 Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.2426 Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.

The majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their workday and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.11 Incorporating the input of frontline providers into the design of SIDR allowed us to create a sustainable intervention which fit into daily workflow.

Our bivariate analyses found significant patient case‐mix differences between the intervention and control unit, limiting our ability to perform direct comparisons in LOS and cost. Pre‐post analyses of LOS and cost may be affected by cyclical or secular trends. Because each approach has its own limitations, we felt that analyses using both an historic as well as a concurrent control would provide a more complete assessment of the effect of the intervention. We included case mix, among other variables, in out multivariable regression analyses and found no benefit to SIDR with regard to LOS and cost. Two prior studies have shown a reduction in LOS and cost with the use of IDR.12, 13 However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.12 The second study used a pre‐post study design which may not have accounted for unmeasured confounders affecting LOS and cost.13 A third, smaller study showed no effect on LOS and cost with the use of IDR.15 No prior study has evaluated the effect of IDR on LOS and cost in a nonteaching hospitalist service setting.

Our study has several limitations. First, our study reflects the experience of an intervention unit compared to a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizability of our findings. Second, we did not conduct preintervention provider surveys for comparison ratings of collaboration and teamwork. A prior study, conducted by our research group, found that nurses gave low ratings to the teamwork climate and the quality of collaboration with hospitalists.8 Because this baseline study showed consistently low nurse ratings of collaboration and teamwork across all medical units, and because the units in the current study were identical in size, structure, and staffing of nonphysician personnel, we did not repeat nurse surveys prior to the intervention. Third, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit.

In summary, SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a nonteaching hospitalist unit. Future research efforts should assess whether improved teamwork as a result of SIDR also translates into safer patient care.

Communication among hospital care providers is critically important to provide safe and effective care.15 Yet, studies in operating rooms, intensive care units (ICUs), and general medical units have revealed widely discrepant views on the quality of collaboration and communication between physicians and nurses.68 Although physicians consistently gave high ratings to the quality of collaboration with nurses, nurses rated the quality of collaboration with physicians relatively poorly.

A significant barrier to communication among providers on patient care units is the fluidity and geographic dispersion of team members.8 Physicians, nurses, and other hospital care providers have difficulty finding a way to discuss the care of their patients in person. Research has shown that nurses and physicians on patient care units do not communicate consistently and frequently are not in agreement about their patients' plans of care9, 10

Interdisciplinary Rounds (IDR) have been used as a means to assemble patient care unit team members and improve collaboration on the plan of care.1114 Prior research has demonstrated improved ratings of collaboration on the part of physicians,13, 14 but the effect of IDR on nurses' ratings of collaboration and teamwork has not been adequately assessed. One IDR study did not assess nurses' perceptions,13 while others used instruments not previously described and/or validated in the literature.12, 14 Regarding more concrete outcomes, research indicates variable effects of IDR on length of stay (LOS) and cost. Although 2 studies documented a reduction in LOS and cost with the use of IDR,12, 13 another study showed no effect.15 Furthermore, prior studies evaluated the use of IDR on resident‐covered teaching services. The effect IDR has on collaboration, LOS, and cost in a nonteaching hospitalist service setting is not known.

This study had 3 aims. The first was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. The second was to assess the feasibility and sustainability of the intervention. The third was to assess the impact of the intervention on hospital LOS and cost.

Methods

Results

Ratings of Teamwork and Perceptions of SIDR

As shown in Figure 1, a larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05).

Figure 1

Nurses' ratings of the teamwork and safety climate are summarized in Table 2. The median teamwork climate score was 85.7 (interquartile range [IQR], 75.092.9) for the intervention unit as compared to 61.6 (IQR, 48.283.9) for the control unit (P = 0.008). The median safety climate score was 75.0 (IQR, 70.581.3) for the intervention unit as compared to 61.1 (IQR, 30.281.3) for the control unit (P = 0.03).

Table 2.Nurses' Ratings of Teamwork and Patient Safety Climate by Unit

	Control Unit, n = 24	Intervention Unit, n = 25	P Value
Abbreviation: IQR, interquartile range.
Median Teamwork Climate Score (IQR)	75.0 (70.581.3)	61.6 (48.283.9)	0.008
Median Safety Climate Score (IQR)	85.7 (75.092.9)	61.1 (30.281.3)	0.03

Sixty‐five of 88 (74%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved the efficiency of their work day. Eighty of 88 (91%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved team collaboration. Seventy‐six of 88 (86%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved patient care. Sixty‐seven of 88 (76%) hospitalists and 22 of 25 (88%) nurses indicated that they wanted SIDR to continue indefinitely.

Discussion

We found that nurses working on a unit using SIDR rated the quality of communication and collaboration with hospitalists significantly higher as compared to a control unit. Notably, because hospitalists worked on both the intervention and control unit during their weeks on service, nurses on each unit were rating the quality of collaboration with the same hospitalists. Nurses also rated the teamwork and safety climate higher on the intervention unit. These findings are important because prior research has shown that nurses are often dissatisfied with the quality of collaboration and teamwork with physicians.68 Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6 Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.22, 23 SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.

Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.15 Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.2426 Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.

The majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their workday and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.11 Incorporating the input of frontline providers into the design of SIDR allowed us to create a sustainable intervention which fit into daily workflow.

Our bivariate analyses found significant patient case‐mix differences between the intervention and control unit, limiting our ability to perform direct comparisons in LOS and cost. Pre‐post analyses of LOS and cost may be affected by cyclical or secular trends. Because each approach has its own limitations, we felt that analyses using both an historic as well as a concurrent control would provide a more complete assessment of the effect of the intervention. We included case mix, among other variables, in out multivariable regression analyses and found no benefit to SIDR with regard to LOS and cost. Two prior studies have shown a reduction in LOS and cost with the use of IDR.12, 13 However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.12 The second study used a pre‐post study design which may not have accounted for unmeasured confounders affecting LOS and cost.13 A third, smaller study showed no effect on LOS and cost with the use of IDR.15 No prior study has evaluated the effect of IDR on LOS and cost in a nonteaching hospitalist service setting.

Our study has several limitations. First, our study reflects the experience of an intervention unit compared to a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizability of our findings. Second, we did not conduct preintervention provider surveys for comparison ratings of collaboration and teamwork. A prior study, conducted by our research group, found that nurses gave low ratings to the teamwork climate and the quality of collaboration with hospitalists.8 Because this baseline study showed consistently low nurse ratings of collaboration and teamwork across all medical units, and because the units in the current study were identical in size, structure, and staffing of nonphysician personnel, we did not repeat nurse surveys prior to the intervention. Third, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit.

In summary, SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a nonteaching hospitalist unit. Future research efforts should assess whether improved teamwork as a result of SIDR also translates into safer patient care.

Many hospitalists work with clinical coordinators and case managers.13 The descriptions of these roles often overlap4 and commonly include activities such as obtaining medical records, expediting tests and procedures, coordinating the plan of care with other health care providers, assessing postdischarge needs, completing discharge paperwork, and arranging follow‐up visits.2, 5, 6 Despite the potential to improve patient care and hospital efficiency, few studies have formally evaluated the impact of these roles. Moher et al. found that adding a clinical coordinator to a general medical team decreased length of stay (LOS) and improved patient satisfaction.5 However, this study was conducted at a time when the LOS was routinely longer than it is today. Forster et al. found that adding a clinical coordinator to a general medical team resulted in improved patient satisfaction but did not reduce length of stay or risk of adverse events occurring following hospital discharge.6 Both these studies evaluated the impact of adding a clinical coordinator to resident‐covered medical teams. Yet many hospitalists deliver care without residents, limiting the generalizability of the findings from these studies.

To date, no studies have evaluated the impact of clinical coordinators, case managers, or other nonphysician providers on the hospitalist work experience. This is surprising, as hospital medicine group leaders list daily workload and work hours among their top concerns.7 Clinical coordinators have the potential to improve patient care and hospital efficiency while simultaneously improving the experience of the hospitalists with whom they work. We conducted this study to evaluate the impact of a hospitalistcare coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

METHODS

RESULTS

There were 356 patients cared for by hospitalistHCC teams and 337 patients cared for by control hospitalists. Of the 60 weeks of hospitalist service of the study, hospitalistHCC teams accounted for 31 weeks (52%) and control hospitalists for 29 weeks (48%). Patients cared for by the hospitalistHCC teams were similar in age, sex, ethnicity, payer type, and DRG weight to those cared for by control hospitalists (see Table 2).

Sixty surveys were completed by hospitalists at the end of their week on service (response rate 100%). Of the 31 responses from hospitalists completing a hospitalistHCC team week, 28 (90%) reported that working with an HCC improved their efficiency and 28 (90%) that working with an HCC improved their job satisfaction. The hospitalists indicated that working with an HCC significantly improved the efficiency of most of their activities (see Table 3). Specifically, activities related to communication with nurses and patients and activities involving discharge planning and execution were improved with the use of an HCC. As would be expected, certain other activities did not improve. For example, there were no differences between the groups in the perceived efficiency of performing histories and physicals or placing admission orders. For activities that were significantly different, the Wilcoxon rank sum test and linear regression analysis adjusting for physician clustering showed identical results.

Seventy‐one of 196 eligible patients (36%) completed the discharge satisfaction interview. Of the 71 patients interviewed, 44 (62%) were cared for by hospitalistHCC teams and 27 (38%) were cared for by control hospitalists. Patient satisfaction with the clarity of the verbal and written discharge instructions and overall satisfaction with hospital discharge was similar between the 2 groups (see Table 4).

The unadjusted mean LOS for patients cared for by hospitalistHCC teams was 4.70 4.15 days compared with 5.07 3.99 days for patients cared for by control hospitalists (P = .005; see Table 5). The unadjusted mean cost for patients cared for by hospitalistHCC teams was $10,052.96 $11,708.73 compared with $11,703.19 $20,455.78 for patients cared for by control hospitalists (P = .008). In multivariate analysis using age, sex, ethnicity, payer type, and DRG weight as independent variables and adjusting for physician clustering, LOS remained lower for patients cared for by hospitalistHCC teams; however, this result was not statistically significant (0.28 days, P = .17). Similar multivariate regression analysis showed a trend toward lower cost for patients cared for by the hospitalistHCC teams (585.62, P = .15).

DISCUSSION

Our study found that hospitalists working in a team approach with an HCC rated the efficiency of their daily work and their job satisfaction significantly higher than did control hospitalists. Specific areas of improved efficiency included communication activities and activities related to hospital discharge. A prior study conducted by our group found that hospitalists spend a lot of time on indirect patient care activities such as communication and activities related to the discharge process, while spending relatively little time on direct patient care.8 Improving the efficiency of indirect patient care activities of hospitalists is likely to improve their job satisfaction. The importance of improving hospitalist workload and job satisfaction is underscored by the relatively high number of hospitalists at risk for burnout9 and the growing concern about daily workload among hospital medicine group leaders.7

Patient satisfaction was not significantly affected by the use of the hospitalistHCC team in our study. A priori, we postulated that patient satisfaction with the discharge process might improve with the use of the hospitalistHCC team. We therefore limited survey questions to assessing only satisfaction with hospital discharge rather than other aspects of patient hospital care. A recent study reported that patients rated the quality of discharge instructions significantly lower than they rated the overall quality of their hospital stay.10 However, the patients in our study gave high ratings to both discharge instructions and overall satisfaction with hospital discharge. This may explain why we were unable to detect a difference. Our study was limited by the relatively small number of patients we were able to contact to assess satisfaction. Previous studies evaluating the impact of care coordinators either did not assess patient satisfaction with discharge5 or found no difference in satisfaction with hospital discharge.6

Although our study did not find a difference in patient satisfaction with the discharge process, we believe the hospitalistHCC model has the potential to complement efforts to reduce the risk of adverse events as patients transition out of the hospital. It has been reported that 12% of patients have a preventable or ameliorable adverse event in the period immediately following hospital discharge.11, 12 Although Forster et al. did not find a reduction in the risk of adverse events with the addition of a clinical coordinator to a general medical team, they noted incongruence between the coordinator's role and the outcomes measured.6 Similarly, we would need to modify the role of the HCC from a position designed mainly to improve efficiency to one that complements efforts to improve the quality of the discharge process. Possible ways to enhance the HCC role in this regard include increasing the emphasis on and training in patient education skills. Several recently published articles have emphasized the need to redesign the discharge process in an effort to reduce the risk of adverse events following hospital discharge.1315 A modified HCC role might be an essential feature of a redesigned multidisciplinary discharge process.

We were unable to demonstrate improved efficiency for the hospital. Although LOS and cost were lower for patients cared for by the hospitalistHCC teams, the difference was not statistically significant. One possible explanation for why we did not observe a larger reduction in LOS is that our hospitalist service had a lower‐than‐average patient volume during the study period. The lower volume mirrored an unanticipated dip in hospital volume during the same period. Specifically, our service normally discharges an average of 338 patients per month, but during the study period we discharged an average of 235 patients per month. A potential LOS and cost benefit may have been attenuated by the relatively low volume, as hospitalists had ample time to dedicate to communication and coordination of discharge plans.

Our study had several limitations. It was conducted on a nonteaching hospitalist service at a single site. Hospitalist practices vary widely in their staffing and scheduling models. As previously mentioned, we were only able to perform patient satisfaction surveys during the second half of the study period. In addition, hospitalistHCC team patients made up a larger percentage of the patient survey responses (62%) than did control hospitalist patients (38%). This may have affected our ability to detect differences in satisfaction with the hospital discharge process. As also previously noted, our patient volume was lower than normal during the study period. We believe that a higher volume would have magnified differences in hospitalists' perceived efficiency and perhaps resulted in significant improvements in LOS and cost. Finally, the hospital provided funding for only a 12‐week study. This limited our sample size and the power of the study to detect important differences. It is possible that a larger sample size and/or longer study period may have been able to demonstrate a statistically significant improvement in LOS and cost.

Our findings are of particular importance in light of the persistent concerns about hospitalist workload and job satisfaction. Although many hospitalists work with clinical coordinators and case managers, we believe that having the formal structure of a hospitalistcare coordinator team was the key element to improving hospitalist efficiency and satisfaction. We hope that our study is a precursor to research evaluating models of delivering hospital care and their impact on hospitalist work experience, hospital efficiency, and patient outcomes.

Many hospitalists work with clinical coordinators and case managers.13 The descriptions of these roles often overlap4 and commonly include activities such as obtaining medical records, expediting tests and procedures, coordinating the plan of care with other health care providers, assessing postdischarge needs, completing discharge paperwork, and arranging follow‐up visits.2, 5, 6 Despite the potential to improve patient care and hospital efficiency, few studies have formally evaluated the impact of these roles. Moher et al. found that adding a clinical coordinator to a general medical team decreased length of stay (LOS) and improved patient satisfaction.5 However, this study was conducted at a time when the LOS was routinely longer than it is today. Forster et al. found that adding a clinical coordinator to a general medical team resulted in improved patient satisfaction but did not reduce length of stay or risk of adverse events occurring following hospital discharge.6 Both these studies evaluated the impact of adding a clinical coordinator to resident‐covered medical teams. Yet many hospitalists deliver care without residents, limiting the generalizability of the findings from these studies.

To date, no studies have evaluated the impact of clinical coordinators, case managers, or other nonphysician providers on the hospitalist work experience. This is surprising, as hospital medicine group leaders list daily workload and work hours among their top concerns.7 Clinical coordinators have the potential to improve patient care and hospital efficiency while simultaneously improving the experience of the hospitalists with whom they work. We conducted this study to evaluate the impact of a hospitalistcare coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

METHODS

RESULTS

There were 356 patients cared for by hospitalistHCC teams and 337 patients cared for by control hospitalists. Of the 60 weeks of hospitalist service of the study, hospitalistHCC teams accounted for 31 weeks (52%) and control hospitalists for 29 weeks (48%). Patients cared for by the hospitalistHCC teams were similar in age, sex, ethnicity, payer type, and DRG weight to those cared for by control hospitalists (see Table 2).

Sixty surveys were completed by hospitalists at the end of their week on service (response rate 100%). Of the 31 responses from hospitalists completing a hospitalistHCC team week, 28 (90%) reported that working with an HCC improved their efficiency and 28 (90%) that working with an HCC improved their job satisfaction. The hospitalists indicated that working with an HCC significantly improved the efficiency of most of their activities (see Table 3). Specifically, activities related to communication with nurses and patients and activities involving discharge planning and execution were improved with the use of an HCC. As would be expected, certain other activities did not improve. For example, there were no differences between the groups in the perceived efficiency of performing histories and physicals or placing admission orders. For activities that were significantly different, the Wilcoxon rank sum test and linear regression analysis adjusting for physician clustering showed identical results.

Seventy‐one of 196 eligible patients (36%) completed the discharge satisfaction interview. Of the 71 patients interviewed, 44 (62%) were cared for by hospitalistHCC teams and 27 (38%) were cared for by control hospitalists. Patient satisfaction with the clarity of the verbal and written discharge instructions and overall satisfaction with hospital discharge was similar between the 2 groups (see Table 4).

The unadjusted mean LOS for patients cared for by hospitalistHCC teams was 4.70 4.15 days compared with 5.07 3.99 days for patients cared for by control hospitalists (P = .005; see Table 5). The unadjusted mean cost for patients cared for by hospitalistHCC teams was $10,052.96 $11,708.73 compared with $11,703.19 $20,455.78 for patients cared for by control hospitalists (P = .008). In multivariate analysis using age, sex, ethnicity, payer type, and DRG weight as independent variables and adjusting for physician clustering, LOS remained lower for patients cared for by hospitalistHCC teams; however, this result was not statistically significant (0.28 days, P = .17). Similar multivariate regression analysis showed a trend toward lower cost for patients cared for by the hospitalistHCC teams (585.62, P = .15).

DISCUSSION

Our study found that hospitalists working in a team approach with an HCC rated the efficiency of their daily work and their job satisfaction significantly higher than did control hospitalists. Specific areas of improved efficiency included communication activities and activities related to hospital discharge. A prior study conducted by our group found that hospitalists spend a lot of time on indirect patient care activities such as communication and activities related to the discharge process, while spending relatively little time on direct patient care.8 Improving the efficiency of indirect patient care activities of hospitalists is likely to improve their job satisfaction. The importance of improving hospitalist workload and job satisfaction is underscored by the relatively high number of hospitalists at risk for burnout9 and the growing concern about daily workload among hospital medicine group leaders.7

Patient satisfaction was not significantly affected by the use of the hospitalistHCC team in our study. A priori, we postulated that patient satisfaction with the discharge process might improve with the use of the hospitalistHCC team. We therefore limited survey questions to assessing only satisfaction with hospital discharge rather than other aspects of patient hospital care. A recent study reported that patients rated the quality of discharge instructions significantly lower than they rated the overall quality of their hospital stay.10 However, the patients in our study gave high ratings to both discharge instructions and overall satisfaction with hospital discharge. This may explain why we were unable to detect a difference. Our study was limited by the relatively small number of patients we were able to contact to assess satisfaction. Previous studies evaluating the impact of care coordinators either did not assess patient satisfaction with discharge5 or found no difference in satisfaction with hospital discharge.6

Although our study did not find a difference in patient satisfaction with the discharge process, we believe the hospitalistHCC model has the potential to complement efforts to reduce the risk of adverse events as patients transition out of the hospital. It has been reported that 12% of patients have a preventable or ameliorable adverse event in the period immediately following hospital discharge.11, 12 Although Forster et al. did not find a reduction in the risk of adverse events with the addition of a clinical coordinator to a general medical team, they noted incongruence between the coordinator's role and the outcomes measured.6 Similarly, we would need to modify the role of the HCC from a position designed mainly to improve efficiency to one that complements efforts to improve the quality of the discharge process. Possible ways to enhance the HCC role in this regard include increasing the emphasis on and training in patient education skills. Several recently published articles have emphasized the need to redesign the discharge process in an effort to reduce the risk of adverse events following hospital discharge.1315 A modified HCC role might be an essential feature of a redesigned multidisciplinary discharge process.

We were unable to demonstrate improved efficiency for the hospital. Although LOS and cost were lower for patients cared for by the hospitalistHCC teams, the difference was not statistically significant. One possible explanation for why we did not observe a larger reduction in LOS is that our hospitalist service had a lower‐than‐average patient volume during the study period. The lower volume mirrored an unanticipated dip in hospital volume during the same period. Specifically, our service normally discharges an average of 338 patients per month, but during the study period we discharged an average of 235 patients per month. A potential LOS and cost benefit may have been attenuated by the relatively low volume, as hospitalists had ample time to dedicate to communication and coordination of discharge plans.

Our study had several limitations. It was conducted on a nonteaching hospitalist service at a single site. Hospitalist practices vary widely in their staffing and scheduling models. As previously mentioned, we were only able to perform patient satisfaction surveys during the second half of the study period. In addition, hospitalistHCC team patients made up a larger percentage of the patient survey responses (62%) than did control hospitalist patients (38%). This may have affected our ability to detect differences in satisfaction with the hospital discharge process. As also previously noted, our patient volume was lower than normal during the study period. We believe that a higher volume would have magnified differences in hospitalists' perceived efficiency and perhaps resulted in significant improvements in LOS and cost. Finally, the hospital provided funding for only a 12‐week study. This limited our sample size and the power of the study to detect important differences. It is possible that a larger sample size and/or longer study period may have been able to demonstrate a statistically significant improvement in LOS and cost.

Our findings are of particular importance in light of the persistent concerns about hospitalist workload and job satisfaction. Although many hospitalists work with clinical coordinators and case managers, we believe that having the formal structure of a hospitalistcare coordinator team was the key element to improving hospitalist efficiency and satisfaction. We hope that our study is a precursor to research evaluating models of delivering hospital care and their impact on hospitalist work experience, hospital efficiency, and patient outcomes.

Many hospitalists work with clinical coordinators and case managers.13 The descriptions of these roles often overlap4 and commonly include activities such as obtaining medical records, expediting tests and procedures, coordinating the plan of care with other health care providers, assessing postdischarge needs, completing discharge paperwork, and arranging follow‐up visits.2, 5, 6 Despite the potential to improve patient care and hospital efficiency, few studies have formally evaluated the impact of these roles. Moher et al. found that adding a clinical coordinator to a general medical team decreased length of stay (LOS) and improved patient satisfaction.5 However, this study was conducted at a time when the LOS was routinely longer than it is today. Forster et al. found that adding a clinical coordinator to a general medical team resulted in improved patient satisfaction but did not reduce length of stay or risk of adverse events occurring following hospital discharge.6 Both these studies evaluated the impact of adding a clinical coordinator to resident‐covered medical teams. Yet many hospitalists deliver care without residents, limiting the generalizability of the findings from these studies.

To date, no studies have evaluated the impact of clinical coordinators, case managers, or other nonphysician providers on the hospitalist work experience. This is surprising, as hospital medicine group leaders list daily workload and work hours among their top concerns.7 Clinical coordinators have the potential to improve patient care and hospital efficiency while simultaneously improving the experience of the hospitalists with whom they work. We conducted this study to evaluate the impact of a hospitalistcare coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

METHODS

RESULTS

There were 356 patients cared for by hospitalistHCC teams and 337 patients cared for by control hospitalists. Of the 60 weeks of hospitalist service of the study, hospitalistHCC teams accounted for 31 weeks (52%) and control hospitalists for 29 weeks (48%). Patients cared for by the hospitalistHCC teams were similar in age, sex, ethnicity, payer type, and DRG weight to those cared for by control hospitalists (see Table 2).

Sixty surveys were completed by hospitalists at the end of their week on service (response rate 100%). Of the 31 responses from hospitalists completing a hospitalistHCC team week, 28 (90%) reported that working with an HCC improved their efficiency and 28 (90%) that working with an HCC improved their job satisfaction. The hospitalists indicated that working with an HCC significantly improved the efficiency of most of their activities (see Table 3). Specifically, activities related to communication with nurses and patients and activities involving discharge planning and execution were improved with the use of an HCC. As would be expected, certain other activities did not improve. For example, there were no differences between the groups in the perceived efficiency of performing histories and physicals or placing admission orders. For activities that were significantly different, the Wilcoxon rank sum test and linear regression analysis adjusting for physician clustering showed identical results.

Seventy‐one of 196 eligible patients (36%) completed the discharge satisfaction interview. Of the 71 patients interviewed, 44 (62%) were cared for by hospitalistHCC teams and 27 (38%) were cared for by control hospitalists. Patient satisfaction with the clarity of the verbal and written discharge instructions and overall satisfaction with hospital discharge was similar between the 2 groups (see Table 4).

The unadjusted mean LOS for patients cared for by hospitalistHCC teams was 4.70 4.15 days compared with 5.07 3.99 days for patients cared for by control hospitalists (P = .005; see Table 5). The unadjusted mean cost for patients cared for by hospitalistHCC teams was $10,052.96 $11,708.73 compared with $11,703.19 $20,455.78 for patients cared for by control hospitalists (P = .008). In multivariate analysis using age, sex, ethnicity, payer type, and DRG weight as independent variables and adjusting for physician clustering, LOS remained lower for patients cared for by hospitalistHCC teams; however, this result was not statistically significant (0.28 days, P = .17). Similar multivariate regression analysis showed a trend toward lower cost for patients cared for by the hospitalistHCC teams (585.62, P = .15).

DISCUSSION

Our study found that hospitalists working in a team approach with an HCC rated the efficiency of their daily work and their job satisfaction significantly higher than did control hospitalists. Specific areas of improved efficiency included communication activities and activities related to hospital discharge. A prior study conducted by our group found that hospitalists spend a lot of time on indirect patient care activities such as communication and activities related to the discharge process, while spending relatively little time on direct patient care.8 Improving the efficiency of indirect patient care activities of hospitalists is likely to improve their job satisfaction. The importance of improving hospitalist workload and job satisfaction is underscored by the relatively high number of hospitalists at risk for burnout9 and the growing concern about daily workload among hospital medicine group leaders.7

Patient satisfaction was not significantly affected by the use of the hospitalistHCC team in our study. A priori, we postulated that patient satisfaction with the discharge process might improve with the use of the hospitalistHCC team. We therefore limited survey questions to assessing only satisfaction with hospital discharge rather than other aspects of patient hospital care. A recent study reported that patients rated the quality of discharge instructions significantly lower than they rated the overall quality of their hospital stay.10 However, the patients in our study gave high ratings to both discharge instructions and overall satisfaction with hospital discharge. This may explain why we were unable to detect a difference. Our study was limited by the relatively small number of patients we were able to contact to assess satisfaction. Previous studies evaluating the impact of care coordinators either did not assess patient satisfaction with discharge5 or found no difference in satisfaction with hospital discharge.6

Although our study did not find a difference in patient satisfaction with the discharge process, we believe the hospitalistHCC model has the potential to complement efforts to reduce the risk of adverse events as patients transition out of the hospital. It has been reported that 12% of patients have a preventable or ameliorable adverse event in the period immediately following hospital discharge.11, 12 Although Forster et al. did not find a reduction in the risk of adverse events with the addition of a clinical coordinator to a general medical team, they noted incongruence between the coordinator's role and the outcomes measured.6 Similarly, we would need to modify the role of the HCC from a position designed mainly to improve efficiency to one that complements efforts to improve the quality of the discharge process. Possible ways to enhance the HCC role in this regard include increasing the emphasis on and training in patient education skills. Several recently published articles have emphasized the need to redesign the discharge process in an effort to reduce the risk of adverse events following hospital discharge.1315 A modified HCC role might be an essential feature of a redesigned multidisciplinary discharge process.

We were unable to demonstrate improved efficiency for the hospital. Although LOS and cost were lower for patients cared for by the hospitalistHCC teams, the difference was not statistically significant. One possible explanation for why we did not observe a larger reduction in LOS is that our hospitalist service had a lower‐than‐average patient volume during the study period. The lower volume mirrored an unanticipated dip in hospital volume during the same period. Specifically, our service normally discharges an average of 338 patients per month, but during the study period we discharged an average of 235 patients per month. A potential LOS and cost benefit may have been attenuated by the relatively low volume, as hospitalists had ample time to dedicate to communication and coordination of discharge plans.

Our study had several limitations. It was conducted on a nonteaching hospitalist service at a single site. Hospitalist practices vary widely in their staffing and scheduling models. As previously mentioned, we were only able to perform patient satisfaction surveys during the second half of the study period. In addition, hospitalistHCC team patients made up a larger percentage of the patient survey responses (62%) than did control hospitalist patients (38%). This may have affected our ability to detect differences in satisfaction with the hospital discharge process. As also previously noted, our patient volume was lower than normal during the study period. We believe that a higher volume would have magnified differences in hospitalists' perceived efficiency and perhaps resulted in significant improvements in LOS and cost. Finally, the hospital provided funding for only a 12‐week study. This limited our sample size and the power of the study to detect important differences. It is possible that a larger sample size and/or longer study period may have been able to demonstrate a statistically significant improvement in LOS and cost.

Our findings are of particular importance in light of the persistent concerns about hospitalist workload and job satisfaction. Although many hospitalists work with clinical coordinators and case managers, we believe that having the formal structure of a hospitalistcare coordinator team was the key element to improving hospitalist efficiency and satisfaction. We hope that our study is a precursor to research evaluating models of delivering hospital care and their impact on hospitalist work experience, hospital efficiency, and patient outcomes.