Regionalized Care and Adverse Events

Failures in communication among healthcare professionals are known threats to patient safety. These failures account for over 60% of root causes of sentinel events, the most serious events reported to The Joint Commission.[1] As such, identifying both patterns of effective communication as well as barriers to successful communication has been a focus of efforts aimed at improving patient safety. However, to date, the majority of this work has centered on improving communication in settings such as the operating room and intensive care unit,[2, 3, 4] or at times of care transitions.[5, 6, 7, 8]

Unique barriers exist for effective interdisciplinary communication in the hospital setting, particularly physiciannurse communication regarding shared hospitalized patients.[9] Traditionally, care of hospitalized patients is provided by physicians, nurses, and other team members working in varied workflow patterns, leading to dispersed team membership, where each team member cares for different groups of patients in different locations across the hospital. This dispersion is further heightened on teaching services, where residents' rotation schedules lead to frequent changes of care team membership, leaving inpatient care teams particularly vulnerable to ineffective communication. Evidence suggests that communication between nurses and physicians is currently suboptimal, leading to frequent disagreement regarding the patient's plan of care.[9, 10] This divergence between physician and nursing perceptions of patients' care plans may leave patients at greater risk of adverse events (AEs).

Several studies have examined the effects of regionalized inpatient care teams, where multidisciplinary team members care for the same patients on the same hospital unit, on communication and patient outcomes.[4, 11, 12, 13, 14] Results of these studies have been inconsistent, perhaps due to the particular characteristics of the care teams or to the study methodology. Thus, further rigorously done studies are required to better understand the impact of team regionalization on patient care. The goal of this study was to examine whether the implementation of regionalized inpatient care teams was associated with improvements in care team communication and preventable AEs.

METHODS

Intervention

On June 20, 2012, regionalized care was implemented on the GMS such that each of 3 GMS teams was localized to 1 of 3, 15‐bed nursing units. Prior to regionalization, the GMS physician care teams, each consisting of 1 hospitalist attending, 1 medical resident, and 2 medical interns, would care for patients on an average of 7 and up to 13 different nursing units on a given day.

Regionalized care consisted of a multifaceted intervention codeveloped by hospitalist, residency, nursing, emergency department, and hospital leadership and included: (1) regionalizing GMS teams as much as possible; (2) change in resident call structure from a traditional 4‐day call cycle to daily admitting; (3) collaborative efforts to enhance GMS patient discharges before noon to promote regionalized placement of patients without prolonging time in the emergency department (ED); (4) daily morning and postround multidisciplinary huddles to prioritize sicker patients and discharges; (5) encouragement of daily rounds at patients' bedsides with presence of physician team, nurse, and team pharmacist if available; (6) creation of unit‐ and team‐level performance reports; and (7) creation of unit‐based physician and nursing co‐leadership (Figure 1).[15]

Figure 1

RESULTS

The fidelity of the intervention in achieving its goal of regionalized care is discussed separately.[15] Briefly, the intervention was successful at achieving 85% regionalization by team (ie, average daily percentage of team's patients assigned to team's unit) and 87% regionalization by unit (ie, average daily percentage of unit's patients with assigned team) following implementation, compared to 20% regionalization by team and unit in the preintervention period. Importantly, the average daily census of physician care teams rose by 32%, from a mean of 10.8 patients/physician care team preregionalization to a mean of 14.3 patients/physician care team postregionalization.

DISCUSSION

In this study of general medicine patients at a large academic medical center, we found that regionalization of care teams on general medicine services was associated with improved recognition of care team members and agreement on estimated date of patient discharge, but was not associated with improvement in overall nurse and physician concordance of the patient care plan, or the odds of preventable AEs.

This intervention importantly addresses the barrier of dispersion of team membership, a well‐recognized barrier to interdisciplinary collaboration,[17, 18] particularly with resident physician teams due to frequently changing team membership. Localization of all team members, in addition to encouragement of daily collaborative bedside rounds as part of the regionalization initiative, likely contributed to our observed improvement in team member identification and discussion of daily care plans. Similarly, regionalization resulted in improved agreement in estimations of date of patient discharge. Focus on early patient discharges was an integral part of the implementation efforts; we therefore hypothesize that mutual focus on discharge planning by both nurses and responding clinicians may have explained this observed result.

On the other hand, regionalization did not appreciably improve the overall concordance of care plan between nurses and interns, despite a significant increase in team members agreeing that the plan had been discussed. Our findings support similar prior research demonstrating that regionalizing hospitalist attendings to single nursing units had limited impact on agreement of care plan between physicians and nurses.[13] Similarly, in settings where physicians and nurses are inherently regionalized, such as the intensive care unit[4] or the operating room,[3] communication between physicians and nurses remains difficult. Collectively, our findings suggest that colocalization of physicians and nurses alone is likely insufficient to improve measured communication between care team members. Existing literature suggests that more standardized approaches to improve communication, such as structured communication tools used during daily inpatient care[19, 20] or formalized team training,[21, 22, 23] lead to improvements in communication and collaboration. Despite these findings, it is important to highlight that this study did not assess other measures of workplace culture, such as teamwork and care team cohesiveness, which may have been positively affected by this intervention, even without measurable effect on concordance of care plan. Additionally, as noted, the average daily census on each team increased by almost a third postintervention, which may have impeded improvements in care team communication.

In addition, we found that our intervention had no significant impact on preventable AEs or severe preventable AEs. Although we cannot exclude the possibility that more subtle AEs were missed with our methodology, our results indicate that regionalized care alone may be inadequate to improve major patient safety outcomes. As discussed, the volume of patients did increase postintervention; thus, another way to state our results is that we were able to increase the daily volume of patients without any significant decreases in patient safety. Nevertheless, the results on patient safety were less than desired. A recent review of interdisciplinary team care interventions on general medical wards similarly demonstrated underwhelming improvements in patient safety outcomes, although the reviewed interventions did not specifically address preventable AEs, a gap in the literature commented on by the authors.[24] Other albeit limited literature has demonstrated improvement in patient safety outcomes via multifaceted efforts aimed at improving care team member communication. Notably, these efforts include colocalization of care team members to single units but also involve additional measures to improve communication and collaboration between care team members, such as structured communication during interdisciplinary rounds, and certification of key interdisciplinary teamwork skills.[11, 14] Although our regionalized care intervention included many similar features to these accountable care units (ACUs) including unit‐based care teams, unit‐level performance reporting, and unit‐based physician and nursing coleadership, significant differences existed. Notably, in addition to the above features, the ACU model also incorporated highly structured communication models for interdisciplinary rounding, and certification processes to ensure an appropriate communication skill base among care team members.[14] Thus, although creation of regionalized care teams is likely a necessary precursor to implementation of these additional measures, alone it may be insufficient to improve patient safety outcomes.

Importantly, in our study we identified that adverse drug events and manifestations of poor glycemic control occurred in high frequency both before and following implementation of regionalized care, supporting other literature that describes the prevalence of these AEs.[11, 25, 26, 27] These results suggest that targeted interventions to address these specific AEs are likely necessary. Notably, the intervention units in our study did not consistently employ clinical pharmacists assigned specifically to that unit's care team to allow for integration within the care team. As prior research has suggested that greater collaboration with clinical pharmacists results in reduction of adverse drug events,[28] next steps may include improved integration of team‐based pharmacists into the activities of the regionalized care teams. Inpatient management of diabetes also requires specific interventions,[29, 30, 31] only some of which may be addressable by having regionalized care and better interdisciplinary communication.

Our findings are subject to several limitations. First, this was a single‐site study and thus our findings may not be generalizable to other institutions. However, regionalized care is increasingly encouraged to optimize communication between care team members.[17, 18] Therefore, our null findings may be pertinent to other institutions looking to improve patient safety outcomes, demonstrating that additional initiatives will likely be required. Second, our modes of outcome measurement possess limitations. In measuring concordance of care plan, although previously used survey techniques were employed,[9] the concordance survey has not been formally validated, and we believe some of the questions may have led to ambiguity on the part of the responders that may have resulted in less accurate responses, thus biasing toward the null. Similarly, in measuring AEs, the screening tool relied on retrospective chart review looking for specific AE types[11] and thus may not have captured more subtle AEs. Additionally, our study may have been underpowered to demonstrate significant reduction in preventable AEs, although other studies of similar methodology demonstrated significant results with similar sample size.[11] This was due in part to our lower‐than‐expected baseline AE rate (6.6% compared with approximately 10.3% in previous studies).[11] Lastly, our study solely examined the association of regionalization with concordance of care plan and preventable AEs, but importantly excluded other clinically important outcomes that may have been positively (or negatively) impacted by these regionalization efforts, such as ED wait times, provider efficiency (eg, fewer pages, less time in transit, more time at the bedside), interdisciplinary teamwork, or patient or provider satisfaction.

CONCLUSION

In summary, our findings suggest that regionalized care teams alone may be insufficient to effectively promote communication between care team members regarding the care plan or to lead to improvements in patient safety, although we recognize that there may have been benefits (or unintended harms) not measured in this study but are nonetheless important for clinical care and workplace culture. This is an important lesson, as many hospitals move toward regionalized care in an effort to improve patient safety outcomes. However, strengthening the infrastructure by colocalizing care team members to maximize opportunity for communication is likely a necessary first step toward facilitating implementation of additional initiatives that may lead to more robust patient safety improvements, such as structured interdisciplinary bedside rounds (eg, facilitating and training all team members to fulfill specific roles), teamwork training, and certification of key interdisciplinary teamwork skills. Additionally, close examination of identified prevalent and preventable AEs can help to determine which additional initiatives are most likely to have greatest impact in improving patient safety.

Disclosures: This research was supported by funds provided by Brigham and Women's Hospital (BWH) and by funds provided by the Department of Medicine at BWH. All authors had full access to all of the data in the study and were integrally involved in the design, implementation, data collection, and analyses. The first author, Dr. Stephanie Mueller, takes responsibility for the integrity for the data and the accuracy of the data analysis. Dr. Schnipper reports grants from Sanofi Aventis, outside the submitted work.

Failures in communication among healthcare professionals are known threats to patient safety. These failures account for over 60% of root causes of sentinel events, the most serious events reported to The Joint Commission.[1] As such, identifying both patterns of effective communication as well as barriers to successful communication has been a focus of efforts aimed at improving patient safety. However, to date, the majority of this work has centered on improving communication in settings such as the operating room and intensive care unit,[2, 3, 4] or at times of care transitions.[5, 6, 7, 8]

Unique barriers exist for effective interdisciplinary communication in the hospital setting, particularly physiciannurse communication regarding shared hospitalized patients.[9] Traditionally, care of hospitalized patients is provided by physicians, nurses, and other team members working in varied workflow patterns, leading to dispersed team membership, where each team member cares for different groups of patients in different locations across the hospital. This dispersion is further heightened on teaching services, where residents' rotation schedules lead to frequent changes of care team membership, leaving inpatient care teams particularly vulnerable to ineffective communication. Evidence suggests that communication between nurses and physicians is currently suboptimal, leading to frequent disagreement regarding the patient's plan of care.[9, 10] This divergence between physician and nursing perceptions of patients' care plans may leave patients at greater risk of adverse events (AEs).

Several studies have examined the effects of regionalized inpatient care teams, where multidisciplinary team members care for the same patients on the same hospital unit, on communication and patient outcomes.[4, 11, 12, 13, 14] Results of these studies have been inconsistent, perhaps due to the particular characteristics of the care teams or to the study methodology. Thus, further rigorously done studies are required to better understand the impact of team regionalization on patient care. The goal of this study was to examine whether the implementation of regionalized inpatient care teams was associated with improvements in care team communication and preventable AEs.

METHODS

Intervention

On June 20, 2012, regionalized care was implemented on the GMS such that each of 3 GMS teams was localized to 1 of 3, 15‐bed nursing units. Prior to regionalization, the GMS physician care teams, each consisting of 1 hospitalist attending, 1 medical resident, and 2 medical interns, would care for patients on an average of 7 and up to 13 different nursing units on a given day.

Regionalized care consisted of a multifaceted intervention codeveloped by hospitalist, residency, nursing, emergency department, and hospital leadership and included: (1) regionalizing GMS teams as much as possible; (2) change in resident call structure from a traditional 4‐day call cycle to daily admitting; (3) collaborative efforts to enhance GMS patient discharges before noon to promote regionalized placement of patients without prolonging time in the emergency department (ED); (4) daily morning and postround multidisciplinary huddles to prioritize sicker patients and discharges; (5) encouragement of daily rounds at patients' bedsides with presence of physician team, nurse, and team pharmacist if available; (6) creation of unit‐ and team‐level performance reports; and (7) creation of unit‐based physician and nursing co‐leadership (Figure 1).[15]

Figure 1

RESULTS

The fidelity of the intervention in achieving its goal of regionalized care is discussed separately.[15] Briefly, the intervention was successful at achieving 85% regionalization by team (ie, average daily percentage of team's patients assigned to team's unit) and 87% regionalization by unit (ie, average daily percentage of unit's patients with assigned team) following implementation, compared to 20% regionalization by team and unit in the preintervention period. Importantly, the average daily census of physician care teams rose by 32%, from a mean of 10.8 patients/physician care team preregionalization to a mean of 14.3 patients/physician care team postregionalization.

DISCUSSION

In this study of general medicine patients at a large academic medical center, we found that regionalization of care teams on general medicine services was associated with improved recognition of care team members and agreement on estimated date of patient discharge, but was not associated with improvement in overall nurse and physician concordance of the patient care plan, or the odds of preventable AEs.

This intervention importantly addresses the barrier of dispersion of team membership, a well‐recognized barrier to interdisciplinary collaboration,[17, 18] particularly with resident physician teams due to frequently changing team membership. Localization of all team members, in addition to encouragement of daily collaborative bedside rounds as part of the regionalization initiative, likely contributed to our observed improvement in team member identification and discussion of daily care plans. Similarly, regionalization resulted in improved agreement in estimations of date of patient discharge. Focus on early patient discharges was an integral part of the implementation efforts; we therefore hypothesize that mutual focus on discharge planning by both nurses and responding clinicians may have explained this observed result.

On the other hand, regionalization did not appreciably improve the overall concordance of care plan between nurses and interns, despite a significant increase in team members agreeing that the plan had been discussed. Our findings support similar prior research demonstrating that regionalizing hospitalist attendings to single nursing units had limited impact on agreement of care plan between physicians and nurses.[13] Similarly, in settings where physicians and nurses are inherently regionalized, such as the intensive care unit[4] or the operating room,[3] communication between physicians and nurses remains difficult. Collectively, our findings suggest that colocalization of physicians and nurses alone is likely insufficient to improve measured communication between care team members. Existing literature suggests that more standardized approaches to improve communication, such as structured communication tools used during daily inpatient care[19, 20] or formalized team training,[21, 22, 23] lead to improvements in communication and collaboration. Despite these findings, it is important to highlight that this study did not assess other measures of workplace culture, such as teamwork and care team cohesiveness, which may have been positively affected by this intervention, even without measurable effect on concordance of care plan. Additionally, as noted, the average daily census on each team increased by almost a third postintervention, which may have impeded improvements in care team communication.

In addition, we found that our intervention had no significant impact on preventable AEs or severe preventable AEs. Although we cannot exclude the possibility that more subtle AEs were missed with our methodology, our results indicate that regionalized care alone may be inadequate to improve major patient safety outcomes. As discussed, the volume of patients did increase postintervention; thus, another way to state our results is that we were able to increase the daily volume of patients without any significant decreases in patient safety. Nevertheless, the results on patient safety were less than desired. A recent review of interdisciplinary team care interventions on general medical wards similarly demonstrated underwhelming improvements in patient safety outcomes, although the reviewed interventions did not specifically address preventable AEs, a gap in the literature commented on by the authors.[24] Other albeit limited literature has demonstrated improvement in patient safety outcomes via multifaceted efforts aimed at improving care team member communication. Notably, these efforts include colocalization of care team members to single units but also involve additional measures to improve communication and collaboration between care team members, such as structured communication during interdisciplinary rounds, and certification of key interdisciplinary teamwork skills.[11, 14] Although our regionalized care intervention included many similar features to these accountable care units (ACUs) including unit‐based care teams, unit‐level performance reporting, and unit‐based physician and nursing coleadership, significant differences existed. Notably, in addition to the above features, the ACU model also incorporated highly structured communication models for interdisciplinary rounding, and certification processes to ensure an appropriate communication skill base among care team members.[14] Thus, although creation of regionalized care teams is likely a necessary precursor to implementation of these additional measures, alone it may be insufficient to improve patient safety outcomes.

Importantly, in our study we identified that adverse drug events and manifestations of poor glycemic control occurred in high frequency both before and following implementation of regionalized care, supporting other literature that describes the prevalence of these AEs.[11, 25, 26, 27] These results suggest that targeted interventions to address these specific AEs are likely necessary. Notably, the intervention units in our study did not consistently employ clinical pharmacists assigned specifically to that unit's care team to allow for integration within the care team. As prior research has suggested that greater collaboration with clinical pharmacists results in reduction of adverse drug events,[28] next steps may include improved integration of team‐based pharmacists into the activities of the regionalized care teams. Inpatient management of diabetes also requires specific interventions,[29, 30, 31] only some of which may be addressable by having regionalized care and better interdisciplinary communication.

Our findings are subject to several limitations. First, this was a single‐site study and thus our findings may not be generalizable to other institutions. However, regionalized care is increasingly encouraged to optimize communication between care team members.[17, 18] Therefore, our null findings may be pertinent to other institutions looking to improve patient safety outcomes, demonstrating that additional initiatives will likely be required. Second, our modes of outcome measurement possess limitations. In measuring concordance of care plan, although previously used survey techniques were employed,[9] the concordance survey has not been formally validated, and we believe some of the questions may have led to ambiguity on the part of the responders that may have resulted in less accurate responses, thus biasing toward the null. Similarly, in measuring AEs, the screening tool relied on retrospective chart review looking for specific AE types[11] and thus may not have captured more subtle AEs. Additionally, our study may have been underpowered to demonstrate significant reduction in preventable AEs, although other studies of similar methodology demonstrated significant results with similar sample size.[11] This was due in part to our lower‐than‐expected baseline AE rate (6.6% compared with approximately 10.3% in previous studies).[11] Lastly, our study solely examined the association of regionalization with concordance of care plan and preventable AEs, but importantly excluded other clinically important outcomes that may have been positively (or negatively) impacted by these regionalization efforts, such as ED wait times, provider efficiency (eg, fewer pages, less time in transit, more time at the bedside), interdisciplinary teamwork, or patient or provider satisfaction.

CONCLUSION

In summary, our findings suggest that regionalized care teams alone may be insufficient to effectively promote communication between care team members regarding the care plan or to lead to improvements in patient safety, although we recognize that there may have been benefits (or unintended harms) not measured in this study but are nonetheless important for clinical care and workplace culture. This is an important lesson, as many hospitals move toward regionalized care in an effort to improve patient safety outcomes. However, strengthening the infrastructure by colocalizing care team members to maximize opportunity for communication is likely a necessary first step toward facilitating implementation of additional initiatives that may lead to more robust patient safety improvements, such as structured interdisciplinary bedside rounds (eg, facilitating and training all team members to fulfill specific roles), teamwork training, and certification of key interdisciplinary teamwork skills. Additionally, close examination of identified prevalent and preventable AEs can help to determine which additional initiatives are most likely to have greatest impact in improving patient safety.

Disclosures: This research was supported by funds provided by Brigham and Women's Hospital (BWH) and by funds provided by the Department of Medicine at BWH. All authors had full access to all of the data in the study and were integrally involved in the design, implementation, data collection, and analyses. The first author, Dr. Stephanie Mueller, takes responsibility for the integrity for the data and the accuracy of the data analysis. Dr. Schnipper reports grants from Sanofi Aventis, outside the submitted work.

Failures in communication among healthcare professionals are known threats to patient safety. These failures account for over 60% of root causes of sentinel events, the most serious events reported to The Joint Commission.[1] As such, identifying both patterns of effective communication as well as barriers to successful communication has been a focus of efforts aimed at improving patient safety. However, to date, the majority of this work has centered on improving communication in settings such as the operating room and intensive care unit,[2, 3, 4] or at times of care transitions.[5, 6, 7, 8]

Unique barriers exist for effective interdisciplinary communication in the hospital setting, particularly physiciannurse communication regarding shared hospitalized patients.[9] Traditionally, care of hospitalized patients is provided by physicians, nurses, and other team members working in varied workflow patterns, leading to dispersed team membership, where each team member cares for different groups of patients in different locations across the hospital. This dispersion is further heightened on teaching services, where residents' rotation schedules lead to frequent changes of care team membership, leaving inpatient care teams particularly vulnerable to ineffective communication. Evidence suggests that communication between nurses and physicians is currently suboptimal, leading to frequent disagreement regarding the patient's plan of care.[9, 10] This divergence between physician and nursing perceptions of patients' care plans may leave patients at greater risk of adverse events (AEs).

Several studies have examined the effects of regionalized inpatient care teams, where multidisciplinary team members care for the same patients on the same hospital unit, on communication and patient outcomes.[4, 11, 12, 13, 14] Results of these studies have been inconsistent, perhaps due to the particular characteristics of the care teams or to the study methodology. Thus, further rigorously done studies are required to better understand the impact of team regionalization on patient care. The goal of this study was to examine whether the implementation of regionalized inpatient care teams was associated with improvements in care team communication and preventable AEs.

METHODS

Intervention

On June 20, 2012, regionalized care was implemented on the GMS such that each of 3 GMS teams was localized to 1 of 3, 15‐bed nursing units. Prior to regionalization, the GMS physician care teams, each consisting of 1 hospitalist attending, 1 medical resident, and 2 medical interns, would care for patients on an average of 7 and up to 13 different nursing units on a given day.

Regionalized care consisted of a multifaceted intervention codeveloped by hospitalist, residency, nursing, emergency department, and hospital leadership and included: (1) regionalizing GMS teams as much as possible; (2) change in resident call structure from a traditional 4‐day call cycle to daily admitting; (3) collaborative efforts to enhance GMS patient discharges before noon to promote regionalized placement of patients without prolonging time in the emergency department (ED); (4) daily morning and postround multidisciplinary huddles to prioritize sicker patients and discharges; (5) encouragement of daily rounds at patients' bedsides with presence of physician team, nurse, and team pharmacist if available; (6) creation of unit‐ and team‐level performance reports; and (7) creation of unit‐based physician and nursing co‐leadership (Figure 1).[15]

Figure 1

RESULTS

The fidelity of the intervention in achieving its goal of regionalized care is discussed separately.[15] Briefly, the intervention was successful at achieving 85% regionalization by team (ie, average daily percentage of team's patients assigned to team's unit) and 87% regionalization by unit (ie, average daily percentage of unit's patients with assigned team) following implementation, compared to 20% regionalization by team and unit in the preintervention period. Importantly, the average daily census of physician care teams rose by 32%, from a mean of 10.8 patients/physician care team preregionalization to a mean of 14.3 patients/physician care team postregionalization.

DISCUSSION

In this study of general medicine patients at a large academic medical center, we found that regionalization of care teams on general medicine services was associated with improved recognition of care team members and agreement on estimated date of patient discharge, but was not associated with improvement in overall nurse and physician concordance of the patient care plan, or the odds of preventable AEs.

This intervention importantly addresses the barrier of dispersion of team membership, a well‐recognized barrier to interdisciplinary collaboration,[17, 18] particularly with resident physician teams due to frequently changing team membership. Localization of all team members, in addition to encouragement of daily collaborative bedside rounds as part of the regionalization initiative, likely contributed to our observed improvement in team member identification and discussion of daily care plans. Similarly, regionalization resulted in improved agreement in estimations of date of patient discharge. Focus on early patient discharges was an integral part of the implementation efforts; we therefore hypothesize that mutual focus on discharge planning by both nurses and responding clinicians may have explained this observed result.

On the other hand, regionalization did not appreciably improve the overall concordance of care plan between nurses and interns, despite a significant increase in team members agreeing that the plan had been discussed. Our findings support similar prior research demonstrating that regionalizing hospitalist attendings to single nursing units had limited impact on agreement of care plan between physicians and nurses.[13] Similarly, in settings where physicians and nurses are inherently regionalized, such as the intensive care unit[4] or the operating room,[3] communication between physicians and nurses remains difficult. Collectively, our findings suggest that colocalization of physicians and nurses alone is likely insufficient to improve measured communication between care team members. Existing literature suggests that more standardized approaches to improve communication, such as structured communication tools used during daily inpatient care[19, 20] or formalized team training,[21, 22, 23] lead to improvements in communication and collaboration. Despite these findings, it is important to highlight that this study did not assess other measures of workplace culture, such as teamwork and care team cohesiveness, which may have been positively affected by this intervention, even without measurable effect on concordance of care plan. Additionally, as noted, the average daily census on each team increased by almost a third postintervention, which may have impeded improvements in care team communication.

In addition, we found that our intervention had no significant impact on preventable AEs or severe preventable AEs. Although we cannot exclude the possibility that more subtle AEs were missed with our methodology, our results indicate that regionalized care alone may be inadequate to improve major patient safety outcomes. As discussed, the volume of patients did increase postintervention; thus, another way to state our results is that we were able to increase the daily volume of patients without any significant decreases in patient safety. Nevertheless, the results on patient safety were less than desired. A recent review of interdisciplinary team care interventions on general medical wards similarly demonstrated underwhelming improvements in patient safety outcomes, although the reviewed interventions did not specifically address preventable AEs, a gap in the literature commented on by the authors.[24] Other albeit limited literature has demonstrated improvement in patient safety outcomes via multifaceted efforts aimed at improving care team member communication. Notably, these efforts include colocalization of care team members to single units but also involve additional measures to improve communication and collaboration between care team members, such as structured communication during interdisciplinary rounds, and certification of key interdisciplinary teamwork skills.[11, 14] Although our regionalized care intervention included many similar features to these accountable care units (ACUs) including unit‐based care teams, unit‐level performance reporting, and unit‐based physician and nursing coleadership, significant differences existed. Notably, in addition to the above features, the ACU model also incorporated highly structured communication models for interdisciplinary rounding, and certification processes to ensure an appropriate communication skill base among care team members.[14] Thus, although creation of regionalized care teams is likely a necessary precursor to implementation of these additional measures, alone it may be insufficient to improve patient safety outcomes.

Importantly, in our study we identified that adverse drug events and manifestations of poor glycemic control occurred in high frequency both before and following implementation of regionalized care, supporting other literature that describes the prevalence of these AEs.[11, 25, 26, 27] These results suggest that targeted interventions to address these specific AEs are likely necessary. Notably, the intervention units in our study did not consistently employ clinical pharmacists assigned specifically to that unit's care team to allow for integration within the care team. As prior research has suggested that greater collaboration with clinical pharmacists results in reduction of adverse drug events,[28] next steps may include improved integration of team‐based pharmacists into the activities of the regionalized care teams. Inpatient management of diabetes also requires specific interventions,[29, 30, 31] only some of which may be addressable by having regionalized care and better interdisciplinary communication.

Our findings are subject to several limitations. First, this was a single‐site study and thus our findings may not be generalizable to other institutions. However, regionalized care is increasingly encouraged to optimize communication between care team members.[17, 18] Therefore, our null findings may be pertinent to other institutions looking to improve patient safety outcomes, demonstrating that additional initiatives will likely be required. Second, our modes of outcome measurement possess limitations. In measuring concordance of care plan, although previously used survey techniques were employed,[9] the concordance survey has not been formally validated, and we believe some of the questions may have led to ambiguity on the part of the responders that may have resulted in less accurate responses, thus biasing toward the null. Similarly, in measuring AEs, the screening tool relied on retrospective chart review looking for specific AE types[11] and thus may not have captured more subtle AEs. Additionally, our study may have been underpowered to demonstrate significant reduction in preventable AEs, although other studies of similar methodology demonstrated significant results with similar sample size.[11] This was due in part to our lower‐than‐expected baseline AE rate (6.6% compared with approximately 10.3% in previous studies).[11] Lastly, our study solely examined the association of regionalization with concordance of care plan and preventable AEs, but importantly excluded other clinically important outcomes that may have been positively (or negatively) impacted by these regionalization efforts, such as ED wait times, provider efficiency (eg, fewer pages, less time in transit, more time at the bedside), interdisciplinary teamwork, or patient or provider satisfaction.

CONCLUSION

In summary, our findings suggest that regionalized care teams alone may be insufficient to effectively promote communication between care team members regarding the care plan or to lead to improvements in patient safety, although we recognize that there may have been benefits (or unintended harms) not measured in this study but are nonetheless important for clinical care and workplace culture. This is an important lesson, as many hospitals move toward regionalized care in an effort to improve patient safety outcomes. However, strengthening the infrastructure by colocalizing care team members to maximize opportunity for communication is likely a necessary first step toward facilitating implementation of additional initiatives that may lead to more robust patient safety improvements, such as structured interdisciplinary bedside rounds (eg, facilitating and training all team members to fulfill specific roles), teamwork training, and certification of key interdisciplinary teamwork skills. Additionally, close examination of identified prevalent and preventable AEs can help to determine which additional initiatives are most likely to have greatest impact in improving patient safety.

Disclosures: This research was supported by funds provided by Brigham and Women's Hospital (BWH) and by funds provided by the Department of Medicine at BWH. All authors had full access to all of the data in the study and were integrally involved in the design, implementation, data collection, and analyses. The first author, Dr. Stephanie Mueller, takes responsibility for the integrity for the data and the accuracy of the data analysis. Dr. Schnipper reports grants from Sanofi Aventis, outside the submitted work.