Jeffrey Chi, MD

^“Am I supposed to have such a hard time feeling the kidneys?” “I think I’m doing it wrong,” echoed another classmate. The frustration of these first-year students, who were already overwhelmed by the three pages of physical exam techniques that they were responsible for, became increasingly visible as they palpated the abdomens of their standardized patients. Then, they asked the dreaded question: “How often do you do this on real patients?”

When we teach first-year medical students the physical exam, these students are already aware that they have never observed physicians perform these maneuvers in their own medical care. “How come I’ve never seen my doctor do this before?” is a common question that we are often asked. We as faculty struggle with demonstrating and defending techniques that we hardly ever use given their variable utility in daily clinical practice. However, students are told that they must be familiar with the various “tools” in the repertoire, and they are led to believe that these skills will be a fundamental part of their future practice as physicians. Of course, when they begin their clerkships, the truth is revealed: the currency on the wards revolves around the computer. The experienced and passionate clinicians who may astonish them with the bedside exam are the exception and are hardly the rule.

In this issue of Journal of Hospital Medicine, Bergl et al.¹ found that when medical students rotated on their internal medicine clerkship, patients were rarely examined during attending rounds and were even examined less often when these rounds were not at the bedside. Although the students themselves consistently incorporated the physical exam into patient assessments and presentations, neither their findings nor those of the residents were ever validated by the attending physician or by others. Notably, the physical exam did not influence clinical decision making as much as one might expect.

These findings should not come as a surprise. The current generation of residents and junior attendings today are more accustomed to emphasizing labs, imaging studies, pathology reports, and other data within the electronic health record (EHR) and with formulating initial plans before having met the patient.² Physicians become uneasy when asked to decide without the reassurance of daily lab results, as if the information in the EHR is highly fundamental to patient care. Caring for the “iPatient” often trumps revisiting and reexamining the real patient.³ Medical teams are also bombarded with increasing demands for their attention and time and are pushed to expedite patient discharges while constantly responding to documentation queries in the EHR. Emphasis on patient throughput, quality metrics, and multidisciplinary communication is essential to provide effective patient care but often feels at odds with opportunities for bedside teaching.

Although discussions on these obstacles have increased in recent years, time-motion studies spanning decades and even preceding the duty-hours era have consistently shown that physicians reserve little time for physical examination and direct patient care.⁴ In other words, the challenges in bringing physicians to the bedside might have less to do with environmental barriers than we think.

Much of what we teach about physical diagnosis is imperfect,⁵ and the routine annual exam might well be eliminated given its low yield.⁶ Nevertheless, we cannot discount the importance of the physical exam in fostering the bond between the patient and the healthcare provider, particularly in patients with acute illnesses, and in making the interaction meaningful to the practitioner.

Many of us can easily recall embarrassing examples of obvious physical exam findings that were critical and overlooked with consequences – the missed incarcerated hernia in a patient labeled with gastritis and vomiting, or the patient with chest pain who had to undergo catheterization because the shingles rash was missed. The confidence in normal findings that might save a patient from unnecessary lab tests, imaging, or consultation is often not discussed. The burden is on us to retire maneuvers that have outlived their usefulness and to demonstrate to students the hazards and consequences of poor examination skills. We must also further what we know and understand about the physical exam as Osler, Laennec, and others before us once did. Point-of-care ultrasound is only one example of how innovation can bring trainees to the bedside, excite learners, engage patients, and affect care in a meaningful way while enhancing the nonultrasound-based skills of practitioners.⁷

It is promising that the students in this study consistently examined their patients each day. As future physicians, they can be very enthusiastic learners eager to apply the physical exam skills they have recently acquired during their early years of training. However, this excitement can taper off if not actively encouraged and reinforced, especially if role models are unintentionally sending the message that the physical exam does not matter or emphasizing exam maneuvers that do not serve a meaningful purpose. New technology will hopefully help us develop novel exam skills. If we can advance what we can diagnose at the bedside, students will remain motivated to improve and learn exam skills that truly affect patient-care decisions. After all, one day, they too will serve as role models for the next generation of physicians and hopefully will be the ones taking care of us at the bedside.

Disclosures 

The authors declare no conflicts of interest.

^“Am I supposed to have such a hard time feeling the kidneys?” “I think I’m doing it wrong,” echoed another classmate. The frustration of these first-year students, who were already overwhelmed by the three pages of physical exam techniques that they were responsible for, became increasingly visible as they palpated the abdomens of their standardized patients. Then, they asked the dreaded question: “How often do you do this on real patients?”

When we teach first-year medical students the physical exam, these students are already aware that they have never observed physicians perform these maneuvers in their own medical care. “How come I’ve never seen my doctor do this before?” is a common question that we are often asked. We as faculty struggle with demonstrating and defending techniques that we hardly ever use given their variable utility in daily clinical practice. However, students are told that they must be familiar with the various “tools” in the repertoire, and they are led to believe that these skills will be a fundamental part of their future practice as physicians. Of course, when they begin their clerkships, the truth is revealed: the currency on the wards revolves around the computer. The experienced and passionate clinicians who may astonish them with the bedside exam are the exception and are hardly the rule.

In this issue of Journal of Hospital Medicine, Bergl et al.¹ found that when medical students rotated on their internal medicine clerkship, patients were rarely examined during attending rounds and were even examined less often when these rounds were not at the bedside. Although the students themselves consistently incorporated the physical exam into patient assessments and presentations, neither their findings nor those of the residents were ever validated by the attending physician or by others. Notably, the physical exam did not influence clinical decision making as much as one might expect.

These findings should not come as a surprise. The current generation of residents and junior attendings today are more accustomed to emphasizing labs, imaging studies, pathology reports, and other data within the electronic health record (EHR) and with formulating initial plans before having met the patient.² Physicians become uneasy when asked to decide without the reassurance of daily lab results, as if the information in the EHR is highly fundamental to patient care. Caring for the “iPatient” often trumps revisiting and reexamining the real patient.³ Medical teams are also bombarded with increasing demands for their attention and time and are pushed to expedite patient discharges while constantly responding to documentation queries in the EHR. Emphasis on patient throughput, quality metrics, and multidisciplinary communication is essential to provide effective patient care but often feels at odds with opportunities for bedside teaching.

Although discussions on these obstacles have increased in recent years, time-motion studies spanning decades and even preceding the duty-hours era have consistently shown that physicians reserve little time for physical examination and direct patient care.⁴ In other words, the challenges in bringing physicians to the bedside might have less to do with environmental barriers than we think.

Much of what we teach about physical diagnosis is imperfect,⁵ and the routine annual exam might well be eliminated given its low yield.⁶ Nevertheless, we cannot discount the importance of the physical exam in fostering the bond between the patient and the healthcare provider, particularly in patients with acute illnesses, and in making the interaction meaningful to the practitioner.

Many of us can easily recall embarrassing examples of obvious physical exam findings that were critical and overlooked with consequences – the missed incarcerated hernia in a patient labeled with gastritis and vomiting, or the patient with chest pain who had to undergo catheterization because the shingles rash was missed. The confidence in normal findings that might save a patient from unnecessary lab tests, imaging, or consultation is often not discussed. The burden is on us to retire maneuvers that have outlived their usefulness and to demonstrate to students the hazards and consequences of poor examination skills. We must also further what we know and understand about the physical exam as Osler, Laennec, and others before us once did. Point-of-care ultrasound is only one example of how innovation can bring trainees to the bedside, excite learners, engage patients, and affect care in a meaningful way while enhancing the nonultrasound-based skills of practitioners.⁷

It is promising that the students in this study consistently examined their patients each day. As future physicians, they can be very enthusiastic learners eager to apply the physical exam skills they have recently acquired during their early years of training. However, this excitement can taper off if not actively encouraged and reinforced, especially if role models are unintentionally sending the message that the physical exam does not matter or emphasizing exam maneuvers that do not serve a meaningful purpose. New technology will hopefully help us develop novel exam skills. If we can advance what we can diagnose at the bedside, students will remain motivated to improve and learn exam skills that truly affect patient-care decisions. After all, one day, they too will serve as role models for the next generation of physicians and hopefully will be the ones taking care of us at the bedside.

Disclosures 

The authors declare no conflicts of interest.

^“Am I supposed to have such a hard time feeling the kidneys?” “I think I’m doing it wrong,” echoed another classmate. The frustration of these first-year students, who were already overwhelmed by the three pages of physical exam techniques that they were responsible for, became increasingly visible as they palpated the abdomens of their standardized patients. Then, they asked the dreaded question: “How often do you do this on real patients?”

When we teach first-year medical students the physical exam, these students are already aware that they have never observed physicians perform these maneuvers in their own medical care. “How come I’ve never seen my doctor do this before?” is a common question that we are often asked. We as faculty struggle with demonstrating and defending techniques that we hardly ever use given their variable utility in daily clinical practice. However, students are told that they must be familiar with the various “tools” in the repertoire, and they are led to believe that these skills will be a fundamental part of their future practice as physicians. Of course, when they begin their clerkships, the truth is revealed: the currency on the wards revolves around the computer. The experienced and passionate clinicians who may astonish them with the bedside exam are the exception and are hardly the rule.

In this issue of Journal of Hospital Medicine, Bergl et al.¹ found that when medical students rotated on their internal medicine clerkship, patients were rarely examined during attending rounds and were even examined less often when these rounds were not at the bedside. Although the students themselves consistently incorporated the physical exam into patient assessments and presentations, neither their findings nor those of the residents were ever validated by the attending physician or by others. Notably, the physical exam did not influence clinical decision making as much as one might expect.

These findings should not come as a surprise. The current generation of residents and junior attendings today are more accustomed to emphasizing labs, imaging studies, pathology reports, and other data within the electronic health record (EHR) and with formulating initial plans before having met the patient.² Physicians become uneasy when asked to decide without the reassurance of daily lab results, as if the information in the EHR is highly fundamental to patient care. Caring for the “iPatient” often trumps revisiting and reexamining the real patient.³ Medical teams are also bombarded with increasing demands for their attention and time and are pushed to expedite patient discharges while constantly responding to documentation queries in the EHR. Emphasis on patient throughput, quality metrics, and multidisciplinary communication is essential to provide effective patient care but often feels at odds with opportunities for bedside teaching.

Although discussions on these obstacles have increased in recent years, time-motion studies spanning decades and even preceding the duty-hours era have consistently shown that physicians reserve little time for physical examination and direct patient care.⁴ In other words, the challenges in bringing physicians to the bedside might have less to do with environmental barriers than we think.

Much of what we teach about physical diagnosis is imperfect,⁵ and the routine annual exam might well be eliminated given its low yield.⁶ Nevertheless, we cannot discount the importance of the physical exam in fostering the bond between the patient and the healthcare provider, particularly in patients with acute illnesses, and in making the interaction meaningful to the practitioner.

Many of us can easily recall embarrassing examples of obvious physical exam findings that were critical and overlooked with consequences – the missed incarcerated hernia in a patient labeled with gastritis and vomiting, or the patient with chest pain who had to undergo catheterization because the shingles rash was missed. The confidence in normal findings that might save a patient from unnecessary lab tests, imaging, or consultation is often not discussed. The burden is on us to retire maneuvers that have outlived their usefulness and to demonstrate to students the hazards and consequences of poor examination skills. We must also further what we know and understand about the physical exam as Osler, Laennec, and others before us once did. Point-of-care ultrasound is only one example of how innovation can bring trainees to the bedside, excite learners, engage patients, and affect care in a meaningful way while enhancing the nonultrasound-based skills of practitioners.⁷

It is promising that the students in this study consistently examined their patients each day. As future physicians, they can be very enthusiastic learners eager to apply the physical exam skills they have recently acquired during their early years of training. However, this excitement can taper off if not actively encouraged and reinforced, especially if role models are unintentionally sending the message that the physical exam does not matter or emphasizing exam maneuvers that do not serve a meaningful purpose. New technology will hopefully help us develop novel exam skills. If we can advance what we can diagnose at the bedside, students will remain motivated to improve and learn exam skills that truly affect patient-care decisions. After all, one day, they too will serve as role models for the next generation of physicians and hopefully will be the ones taking care of us at the bedside.

Disclosures 

The authors declare no conflicts of interest.

Given that multiple disciplines are often involved in caring for patients admitted to the hospital, timely communication, collaboration, and coordination amongst various disciplines is necessary for safe and effective patient care.¹ With the focus on improving patient satisfaction and throughput in hospitals, it is also important to make more accurate predictions of the discharge date and allow time for patients and their families to prepare for discharge.^2-4

Multidisciplinary rounds (MDR) are defined as structured daily communication amongst key members of the patient’s care team (eg, nurses, physicians, case managers, social workers, pharmacists, and rehabilitation services). MDR have shown to be a useful strategy for ensuring that all members of the care team are updated on the plan of care for the patient.⁵ During MDR, a brief “check-in” discussing the patient’s plan of care, pending needs, and barriers to discharge allows all team members, patients, and families to effectively coordinate care and plan and prepare for discharge.

Multiple studies have reported increased collaboration and improved communication between disciplines with the use of such multidisciplinary rounding.^2,5-7 Additionally, MDR have been shown to improve patient outcomes⁸ and reduce adverse events,⁹ length of stay (LOS),^6,8 cost of care,⁸ and readmissions.¹

We redesigned MDR on the general medicine wards at our institution in October 2014 by using Lean management techniques. Lean is defined as a set of philosophies and methods that aim to create transformation in thinking, behavior, and culture in each process, with the goal of maximizing the value for the patients and providers, adding efficiency, and reducing waste and waits.¹⁰

In this study, we evaluate whether this new model of MDR was associated with a decrease in the LOS. We also evaluate whether this new model of MDR was associated with an increase in discharges before noon, documentation of estimated discharge date (EDD) in our electronic health record (EHR), and patient satisfaction.

Setting, Design, and Patients

The study was conducted on the teaching general medicine service at our institution, an urban, 484-bed academic hospital. The general medicine service has patients on 4 inpatient units (total of 95 beds) and is managed by 5 teaching service teams.

We performed a pre-post study. The preperiod (in which the old model of MDR was followed) included 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) included 2085 patients discharged between October 23, 2014, and April 30, 2015. We excluded 139 patients that died in the hospital prior to discharge and patients on the nonteaching and/or private practice service.

All data were provided by our institution’s Digital Solutions Department. Our institutional review board issued a letter of determination exempting this study from further review because it was deemed to be a quality improvement initiative.

Use of Lean Management to Redesign our MDR

Our institution has incorporated the Lean management system to continually add value to services through the elimination of waste, thus simultaneously optimizing the quality of patient care, cost, and patient satisfaction.¹¹ Lean, derived from the Toyota Production System, has long been used in manufacturing and in recent decades has spread to healthcare.¹² We leveraged the following 3 key Lean techniques to redesign our MDR: (1) value stream management (VSM), (2) rapid process improvement workshops (RPIW), and (3) active daily management (ADM), as detailed in supplementary Appendix 1.

Interventions

Outcomes

The primary outcome was mean LOS. The secondary outcomes were (1) discharges before noon, (2) recording of the EDD in our EHR within 24 hours of admission (as time stamped on our EHR), and (3) patient satisfaction.

Data for patient satisfaction were obtained using the Press Ganey survey. We used data on patient satisfaction scores for the following 2 relevant questions on this survey: (1) extent to which the patient felt ready to be discharged and (2) how well staff worked together to care for the patient. Proportions of the “top-box” (“very good”) were used for the analysis. These survey data were available on 467 patients (11.7%) in the preperiod and 188 patients (9.0%) in the postperiod.

Data Analysis

A sensitivity analysis was conducted on a second cohort that included a subset of patients from the preperiod between November 1, 2013, and April 30, 2014, and a subset of patients from the postperiod between November 1, 2014, and April 1, 2015, to control for the calendar period (supplementary Appendix 2).

All analyses were conducted in R version 3.3.0, with the linear mixed-effects model lme4 statistical package.^13,14

Table 3 shows the differences in the outcomes between the pre- and postperiods. There was no change in the LOS or LOS adjusted for CMI. There was a 3.9% increase in discharges before noon in the postperiod compared with the preperiod (95% CI, 2.4% to 5.3%; P < .001). There was a 9.9% increase in the percentage of patients for whom the EDD was recorded in our EHR within 24 hours of admission (95% CI, 7.4% to 12.4%; P < .001). There was no change in the “top-box” patient satisfaction scores.

There were only marginal differences in the results between the entire cohort and a second subset cohort used for sensitivity analysis (supplementary Appendix 2).

In our study, there was no change in the mean LOS with the new model of MDR. There was an increase in discharges before noon and in recording of the EDD in our EHR within 24 hours of admission in the postperiod when the Lean-based new model of MDR was utilized. There was no change in patient satisfaction. With no change in staffing, we were able to accommodate the increase in the discharge volume in the postperiod.

We believe our results are attributable to several factors, including clearly defined roles and responsibilities for all participants of MDR, the inclusion of more experienced general medicine attending physician (compared with housestaff), Lean management techniques to identify gaps in the patient’s journey from emergency department to discharge using VSM, the development of appropriate workflows and standard work on how the multidisciplinary teams would work together at RPIWs, and ADM to ensure sustainability and engagement among frontline members and institutional leaders. In order to sustain this, we planned to continue monitoring data in daily, weekly, and monthly forums with senior physician and administrative leaders. Planning for additional interventions is underway, including moving MDR to the bedside, instituting an afternoon “check-in” that would enable more detailed action planning, and addressing barriers in a timely manner for patients ready to discharge the following day.

Our study has a few limitations. First, this is an observational study that cannot determine causation. Second, this is a single-center study conducted on patients only on the general medicine teaching service. Third, there were several concurrent interventions implemented at our institution to improve LOS, throughput, and patient satisfaction in addition to MDR, thus making it difficult to isolate the impact of our intervention. Fourth, in the new model of MDR, rounds took place only 5 days per week, thereby possibly limiting the potential impact on our outcomes. Fifth, while we showed improvements in the discharges before noon and recording of EDD in the post period, we were not able to achieve our target of 25% discharges before noon or 100% recording of EDD in this time period. We believe the limited amount of time between the pre- and postperiods to allow for adoption and learning of the processes might have contributed to the underestimation of the impact of the new model of MDR, thereby limiting our ability to achieve our targets. Sixth, the response rate on the Press Ganey survey was low, and we did not directly survey patients or families for their satisfaction with MDR.

Our study has several strengths. To our knowledge, this is the first study to embed Lean management techniques in the design of MDR in the inpatient setting. While several studies have demonstrated improvements in discharges before noon through the implementation of MDR, they have not incorporated Lean management techniques, which we believe are critical to ensure the sustainability of results.^1,3,5,6,8,15 Second, while it was not measured, there was a high level of provider engagement in the process in the new model of MDR. Third, because the MDR were conducted at the nurse’s station on each inpatient unit in the new model instead of in a conference room, it was well attended by all members of the multidisciplinary team. Fourth, the presence of a visibility board allowed for all team members to have easy access to visual feedback throughout the day, even if they were not present at the MDR. Fifth, we believe that there was also more accurate estimation of the date and time of discharge in the new model of MDR because the discussion was facilitated by the case manager, who is experienced in identifying barriers to discharge (compared with the housestaff in the old model of MDR), and included the more experienced attending physician. Finally, the consistent presence of a multidisciplinary team at MDR allowed for the incorporation of everyone’s concerns at one time, thereby limiting the need for paging multiple disciplines throughout the day, which led to quicker resolution of issues and assignment of pending tasks.

In conclusion, our study shows no change in the mean LOS when the Lean-based model of MDR was utilized. Our study demonstrates an increase in discharges before noon and in recording of EDD on our EHR within 24 hours of admission in the post period when the Lean-based model of MDR was utilized. There was no change in patient satisfaction. While this study was conducted at an academic medical center on the general medicine wards, we believe our new model of MDR, which leveraged Lean management techniques, may successfully impact patient flow in all inpatient clinical services and nonteaching hospitals.

Disclosure

The authors report no financial conflicts of interest and have nothing to disclose.

Given that multiple disciplines are often involved in caring for patients admitted to the hospital, timely communication, collaboration, and coordination amongst various disciplines is necessary for safe and effective patient care.¹ With the focus on improving patient satisfaction and throughput in hospitals, it is also important to make more accurate predictions of the discharge date and allow time for patients and their families to prepare for discharge.^2-4

Multidisciplinary rounds (MDR) are defined as structured daily communication amongst key members of the patient’s care team (eg, nurses, physicians, case managers, social workers, pharmacists, and rehabilitation services). MDR have shown to be a useful strategy for ensuring that all members of the care team are updated on the plan of care for the patient.⁵ During MDR, a brief “check-in” discussing the patient’s plan of care, pending needs, and barriers to discharge allows all team members, patients, and families to effectively coordinate care and plan and prepare for discharge.

Multiple studies have reported increased collaboration and improved communication between disciplines with the use of such multidisciplinary rounding.^2,5-7 Additionally, MDR have been shown to improve patient outcomes⁸ and reduce adverse events,⁹ length of stay (LOS),^6,8 cost of care,⁸ and readmissions.¹

We redesigned MDR on the general medicine wards at our institution in October 2014 by using Lean management techniques. Lean is defined as a set of philosophies and methods that aim to create transformation in thinking, behavior, and culture in each process, with the goal of maximizing the value for the patients and providers, adding efficiency, and reducing waste and waits.¹⁰

In this study, we evaluate whether this new model of MDR was associated with a decrease in the LOS. We also evaluate whether this new model of MDR was associated with an increase in discharges before noon, documentation of estimated discharge date (EDD) in our electronic health record (EHR), and patient satisfaction.

Setting, Design, and Patients

The study was conducted on the teaching general medicine service at our institution, an urban, 484-bed academic hospital. The general medicine service has patients on 4 inpatient units (total of 95 beds) and is managed by 5 teaching service teams.

We performed a pre-post study. The preperiod (in which the old model of MDR was followed) included 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) included 2085 patients discharged between October 23, 2014, and April 30, 2015. We excluded 139 patients that died in the hospital prior to discharge and patients on the nonteaching and/or private practice service.

All data were provided by our institution’s Digital Solutions Department. Our institutional review board issued a letter of determination exempting this study from further review because it was deemed to be a quality improvement initiative.

Use of Lean Management to Redesign our MDR

Our institution has incorporated the Lean management system to continually add value to services through the elimination of waste, thus simultaneously optimizing the quality of patient care, cost, and patient satisfaction.¹¹ Lean, derived from the Toyota Production System, has long been used in manufacturing and in recent decades has spread to healthcare.¹² We leveraged the following 3 key Lean techniques to redesign our MDR: (1) value stream management (VSM), (2) rapid process improvement workshops (RPIW), and (3) active daily management (ADM), as detailed in supplementary Appendix 1.

Interventions

Outcomes

The primary outcome was mean LOS. The secondary outcomes were (1) discharges before noon, (2) recording of the EDD in our EHR within 24 hours of admission (as time stamped on our EHR), and (3) patient satisfaction.

Data for patient satisfaction were obtained using the Press Ganey survey. We used data on patient satisfaction scores for the following 2 relevant questions on this survey: (1) extent to which the patient felt ready to be discharged and (2) how well staff worked together to care for the patient. Proportions of the “top-box” (“very good”) were used for the analysis. These survey data were available on 467 patients (11.7%) in the preperiod and 188 patients (9.0%) in the postperiod.

Data Analysis

A sensitivity analysis was conducted on a second cohort that included a subset of patients from the preperiod between November 1, 2013, and April 30, 2014, and a subset of patients from the postperiod between November 1, 2014, and April 1, 2015, to control for the calendar period (supplementary Appendix 2).

All analyses were conducted in R version 3.3.0, with the linear mixed-effects model lme4 statistical package.^13,14

Table 3 shows the differences in the outcomes between the pre- and postperiods. There was no change in the LOS or LOS adjusted for CMI. There was a 3.9% increase in discharges before noon in the postperiod compared with the preperiod (95% CI, 2.4% to 5.3%; P < .001). There was a 9.9% increase in the percentage of patients for whom the EDD was recorded in our EHR within 24 hours of admission (95% CI, 7.4% to 12.4%; P < .001). There was no change in the “top-box” patient satisfaction scores.

There were only marginal differences in the results between the entire cohort and a second subset cohort used for sensitivity analysis (supplementary Appendix 2).

In our study, there was no change in the mean LOS with the new model of MDR. There was an increase in discharges before noon and in recording of the EDD in our EHR within 24 hours of admission in the postperiod when the Lean-based new model of MDR was utilized. There was no change in patient satisfaction. With no change in staffing, we were able to accommodate the increase in the discharge volume in the postperiod.

We believe our results are attributable to several factors, including clearly defined roles and responsibilities for all participants of MDR, the inclusion of more experienced general medicine attending physician (compared with housestaff), Lean management techniques to identify gaps in the patient’s journey from emergency department to discharge using VSM, the development of appropriate workflows and standard work on how the multidisciplinary teams would work together at RPIWs, and ADM to ensure sustainability and engagement among frontline members and institutional leaders. In order to sustain this, we planned to continue monitoring data in daily, weekly, and monthly forums with senior physician and administrative leaders. Planning for additional interventions is underway, including moving MDR to the bedside, instituting an afternoon “check-in” that would enable more detailed action planning, and addressing barriers in a timely manner for patients ready to discharge the following day.

Our study has a few limitations. First, this is an observational study that cannot determine causation. Second, this is a single-center study conducted on patients only on the general medicine teaching service. Third, there were several concurrent interventions implemented at our institution to improve LOS, throughput, and patient satisfaction in addition to MDR, thus making it difficult to isolate the impact of our intervention. Fourth, in the new model of MDR, rounds took place only 5 days per week, thereby possibly limiting the potential impact on our outcomes. Fifth, while we showed improvements in the discharges before noon and recording of EDD in the post period, we were not able to achieve our target of 25% discharges before noon or 100% recording of EDD in this time period. We believe the limited amount of time between the pre- and postperiods to allow for adoption and learning of the processes might have contributed to the underestimation of the impact of the new model of MDR, thereby limiting our ability to achieve our targets. Sixth, the response rate on the Press Ganey survey was low, and we did not directly survey patients or families for their satisfaction with MDR.

Our study has several strengths. To our knowledge, this is the first study to embed Lean management techniques in the design of MDR in the inpatient setting. While several studies have demonstrated improvements in discharges before noon through the implementation of MDR, they have not incorporated Lean management techniques, which we believe are critical to ensure the sustainability of results.^1,3,5,6,8,15 Second, while it was not measured, there was a high level of provider engagement in the process in the new model of MDR. Third, because the MDR were conducted at the nurse’s station on each inpatient unit in the new model instead of in a conference room, it was well attended by all members of the multidisciplinary team. Fourth, the presence of a visibility board allowed for all team members to have easy access to visual feedback throughout the day, even if they were not present at the MDR. Fifth, we believe that there was also more accurate estimation of the date and time of discharge in the new model of MDR because the discussion was facilitated by the case manager, who is experienced in identifying barriers to discharge (compared with the housestaff in the old model of MDR), and included the more experienced attending physician. Finally, the consistent presence of a multidisciplinary team at MDR allowed for the incorporation of everyone’s concerns at one time, thereby limiting the need for paging multiple disciplines throughout the day, which led to quicker resolution of issues and assignment of pending tasks.

In conclusion, our study shows no change in the mean LOS when the Lean-based model of MDR was utilized. Our study demonstrates an increase in discharges before noon and in recording of EDD on our EHR within 24 hours of admission in the post period when the Lean-based model of MDR was utilized. There was no change in patient satisfaction. While this study was conducted at an academic medical center on the general medicine wards, we believe our new model of MDR, which leveraged Lean management techniques, may successfully impact patient flow in all inpatient clinical services and nonteaching hospitals.

Disclosure

The authors report no financial conflicts of interest and have nothing to disclose.

Given that multiple disciplines are often involved in caring for patients admitted to the hospital, timely communication, collaboration, and coordination amongst various disciplines is necessary for safe and effective patient care.¹ With the focus on improving patient satisfaction and throughput in hospitals, it is also important to make more accurate predictions of the discharge date and allow time for patients and their families to prepare for discharge.^2-4

Multidisciplinary rounds (MDR) are defined as structured daily communication amongst key members of the patient’s care team (eg, nurses, physicians, case managers, social workers, pharmacists, and rehabilitation services). MDR have shown to be a useful strategy for ensuring that all members of the care team are updated on the plan of care for the patient.⁵ During MDR, a brief “check-in” discussing the patient’s plan of care, pending needs, and barriers to discharge allows all team members, patients, and families to effectively coordinate care and plan and prepare for discharge.

Multiple studies have reported increased collaboration and improved communication between disciplines with the use of such multidisciplinary rounding.^2,5-7 Additionally, MDR have been shown to improve patient outcomes⁸ and reduce adverse events,⁹ length of stay (LOS),^6,8 cost of care,⁸ and readmissions.¹

We redesigned MDR on the general medicine wards at our institution in October 2014 by using Lean management techniques. Lean is defined as a set of philosophies and methods that aim to create transformation in thinking, behavior, and culture in each process, with the goal of maximizing the value for the patients and providers, adding efficiency, and reducing waste and waits.¹⁰

In this study, we evaluate whether this new model of MDR was associated with a decrease in the LOS. We also evaluate whether this new model of MDR was associated with an increase in discharges before noon, documentation of estimated discharge date (EDD) in our electronic health record (EHR), and patient satisfaction.

Setting, Design, and Patients

The study was conducted on the teaching general medicine service at our institution, an urban, 484-bed academic hospital. The general medicine service has patients on 4 inpatient units (total of 95 beds) and is managed by 5 teaching service teams.

We performed a pre-post study. The preperiod (in which the old model of MDR was followed) included 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) included 2085 patients discharged between October 23, 2014, and April 30, 2015. We excluded 139 patients that died in the hospital prior to discharge and patients on the nonteaching and/or private practice service.

All data were provided by our institution’s Digital Solutions Department. Our institutional review board issued a letter of determination exempting this study from further review because it was deemed to be a quality improvement initiative.

Use of Lean Management to Redesign our MDR

Our institution has incorporated the Lean management system to continually add value to services through the elimination of waste, thus simultaneously optimizing the quality of patient care, cost, and patient satisfaction.¹¹ Lean, derived from the Toyota Production System, has long been used in manufacturing and in recent decades has spread to healthcare.¹² We leveraged the following 3 key Lean techniques to redesign our MDR: (1) value stream management (VSM), (2) rapid process improvement workshops (RPIW), and (3) active daily management (ADM), as detailed in supplementary Appendix 1.

Interventions

Outcomes

The primary outcome was mean LOS. The secondary outcomes were (1) discharges before noon, (2) recording of the EDD in our EHR within 24 hours of admission (as time stamped on our EHR), and (3) patient satisfaction.

Data for patient satisfaction were obtained using the Press Ganey survey. We used data on patient satisfaction scores for the following 2 relevant questions on this survey: (1) extent to which the patient felt ready to be discharged and (2) how well staff worked together to care for the patient. Proportions of the “top-box” (“very good”) were used for the analysis. These survey data were available on 467 patients (11.7%) in the preperiod and 188 patients (9.0%) in the postperiod.

Data Analysis

A sensitivity analysis was conducted on a second cohort that included a subset of patients from the preperiod between November 1, 2013, and April 30, 2014, and a subset of patients from the postperiod between November 1, 2014, and April 1, 2015, to control for the calendar period (supplementary Appendix 2).

All analyses were conducted in R version 3.3.0, with the linear mixed-effects model lme4 statistical package.^13,14

Table 3 shows the differences in the outcomes between the pre- and postperiods. There was no change in the LOS or LOS adjusted for CMI. There was a 3.9% increase in discharges before noon in the postperiod compared with the preperiod (95% CI, 2.4% to 5.3%; P < .001). There was a 9.9% increase in the percentage of patients for whom the EDD was recorded in our EHR within 24 hours of admission (95% CI, 7.4% to 12.4%; P < .001). There was no change in the “top-box” patient satisfaction scores.

There were only marginal differences in the results between the entire cohort and a second subset cohort used for sensitivity analysis (supplementary Appendix 2).

In our study, there was no change in the mean LOS with the new model of MDR. There was an increase in discharges before noon and in recording of the EDD in our EHR within 24 hours of admission in the postperiod when the Lean-based new model of MDR was utilized. There was no change in patient satisfaction. With no change in staffing, we were able to accommodate the increase in the discharge volume in the postperiod.

We believe our results are attributable to several factors, including clearly defined roles and responsibilities for all participants of MDR, the inclusion of more experienced general medicine attending physician (compared with housestaff), Lean management techniques to identify gaps in the patient’s journey from emergency department to discharge using VSM, the development of appropriate workflows and standard work on how the multidisciplinary teams would work together at RPIWs, and ADM to ensure sustainability and engagement among frontline members and institutional leaders. In order to sustain this, we planned to continue monitoring data in daily, weekly, and monthly forums with senior physician and administrative leaders. Planning for additional interventions is underway, including moving MDR to the bedside, instituting an afternoon “check-in” that would enable more detailed action planning, and addressing barriers in a timely manner for patients ready to discharge the following day.

Our study has a few limitations. First, this is an observational study that cannot determine causation. Second, this is a single-center study conducted on patients only on the general medicine teaching service. Third, there were several concurrent interventions implemented at our institution to improve LOS, throughput, and patient satisfaction in addition to MDR, thus making it difficult to isolate the impact of our intervention. Fourth, in the new model of MDR, rounds took place only 5 days per week, thereby possibly limiting the potential impact on our outcomes. Fifth, while we showed improvements in the discharges before noon and recording of EDD in the post period, we were not able to achieve our target of 25% discharges before noon or 100% recording of EDD in this time period. We believe the limited amount of time between the pre- and postperiods to allow for adoption and learning of the processes might have contributed to the underestimation of the impact of the new model of MDR, thereby limiting our ability to achieve our targets. Sixth, the response rate on the Press Ganey survey was low, and we did not directly survey patients or families for their satisfaction with MDR.

Our study has several strengths. To our knowledge, this is the first study to embed Lean management techniques in the design of MDR in the inpatient setting. While several studies have demonstrated improvements in discharges before noon through the implementation of MDR, they have not incorporated Lean management techniques, which we believe are critical to ensure the sustainability of results.^1,3,5,6,8,15 Second, while it was not measured, there was a high level of provider engagement in the process in the new model of MDR. Third, because the MDR were conducted at the nurse’s station on each inpatient unit in the new model instead of in a conference room, it was well attended by all members of the multidisciplinary team. Fourth, the presence of a visibility board allowed for all team members to have easy access to visual feedback throughout the day, even if they were not present at the MDR. Fifth, we believe that there was also more accurate estimation of the date and time of discharge in the new model of MDR because the discussion was facilitated by the case manager, who is experienced in identifying barriers to discharge (compared with the housestaff in the old model of MDR), and included the more experienced attending physician. Finally, the consistent presence of a multidisciplinary team at MDR allowed for the incorporation of everyone’s concerns at one time, thereby limiting the need for paging multiple disciplines throughout the day, which led to quicker resolution of issues and assignment of pending tasks.

In conclusion, our study shows no change in the mean LOS when the Lean-based model of MDR was utilized. Our study demonstrates an increase in discharges before noon and in recording of EDD on our EHR within 24 hours of admission in the post period when the Lean-based model of MDR was utilized. There was no change in patient satisfaction. While this study was conducted at an academic medical center on the general medicine wards, we believe our new model of MDR, which leveraged Lean management techniques, may successfully impact patient flow in all inpatient clinical services and nonteaching hospitals.

Disclosure

The authors report no financial conflicts of interest and have nothing to disclose.