AUTHOR BIOGRAPHY
Julie M. Pearson, MPH, RN, Department of Medicine, Icahn School of Medicine at Mount Sinai
Julie M. Pearson (julie.pearson@mssm.edu) is the director of Performance Improvement and Analytics in the Department of Medicine at Mount Sinai. She is a registered nurse and is certified in obstetric and neonatal quality and safety. She also earned her Master of Public Health from the Columbia University Mailman School of Public Health.
*Corresponding author
Kim Keller, Mount Sinai Morningside
Kim Keller is a transformational leader and experienced coach to executives, directors, and managers in strategic planning, Lean leadership, and utilization of daily management. She has led process improvement events with multidisciplinary teams across multiple industries, as well as developed curriculum and taught introductory and intermediate courses on change management, leadership, and improvement.
Emily Veldboom, MBA, RN-BC, Mount Sinai Morningside
Emily Veldboom is a manager of patient care services at Mount Sinai Morningside hospital. She is a registered nurse who earned her Master of Science in nursing, along with her Master of Business Administration from Johns Hopkins University. She also completed the Academic-Practice Research Fellowship at Columbia University School of Nursing while working at NewYork-Presbyterian Hospital.
Haley Waite, MBS, Department of Gastroenterology, Icahn School of Medicine at Mount Sinai
Haley Waite is a former data analyst at The Mount Sinai Hospital. She earned her Master of Science in biomedical science from New York Medical College, as well as her Bachelor of Science in microbiology from the University of Wisconsin–Madison.
Faye Reiff-Pasarew, MD, Hospital Medicine, Icahn School of Medicine at Mount Sinai
Faye Reiff-Pasarew is the deputy chief medical officer and associate chief of Hospital Medicine at Mount Sinai Morningside, where she works as an academic hospitalist. She trained at the University of California San Francisco for medical school, The Mount Sinai Hospital for her internal medicine residency, and completed the Clinical Quality Fellowship Program in Quality Improvement and Patient Safety with the Greater New York Hospital Association and United Hospital Fund. Her areas of focus include quality improvement, hospital operations, and the medical humanities.
ABSTRACT
Background
Improving length of stay (LOS) is essential to decongesting hospitals and maintaining financial viability.
Local problem
The baseline LOS from March 2022 to February 2023 was 7.82 days with an observed to expected ratio (O/E) of 1.75 on a medicine unit at an urban academic hospital.
Methods
A Lean value-stream mapping exercise identified delays in advancing the inpatient plan due to delayed communication between physicians (MDs) and staff. Our Lean team held a Kaizen event where an interdisciplinary team developed care team rounds (CTRs), a new model of rounding, which integrated MD presentations with nurse input and fostered interdisciplinary staff discussion between the unit medical director (UMD), nurse manager (NM), charge nurse, case manager (CM), and social worker (SW).
Interventions
In the first Plan-Do-Study-Act (PDSA) cycle, all participants in CTRs walked the length of the unit together with a workstation on wheels and saw each patient at bedside unless contraindicated. However, due to negative feedback from the staff regarding inefficient use of time for CM and SW and disruption of the unit workflow due to the large group in the hallway, the second iteration took place at the nursing station, with CMs and SWs able to have a computer and phone during rounds. The aims were to reduce LOS, improve patient communication (determined by the Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] survey), and improve communication and workflow (qualitative analysis).
Results
The initial O/E ratio for LOS during the first PDSA cycle decreased from a baseline average of 1.75 (7.82 days) to 1.65 (7.88 days). Ultimately, the O/E for LOS reverted to 1.77, with a mean of 7.77 days for the intervention time period (March 2023 to Oct 2023); there was no significant decrease in LOS. There was also no trend in HCAHPS patient satisfaction scores, though low number of patient survey responses limited data.
Thirty-one percent of non-nursing staff reported an earlier initiation of the care plan, 58% reported improved communication with nursing, 63% wanted to discontinue CTRs, 23% wanted to continue with changes, and 11% wanted to continue without changes. The MDs primarily voiced concerns about insufficient time for education, whereas the CM and SW felt that too much time was devoted to education. Registered nurses felt the timing of CTRs interfered with morning tasks, though they did improve communication with CM and SW, but not providers.
Conclusions
Ultimately, lack of staff buy-in and insufficient evidence of improvement led to the suspension of CTRs. The inpatient medicine service presents a challenge in balancing the unique workflows of each team member while expediting communication between disciplines. Combining workflows expedites communication; however, it also leads to less efficient use of time. Future initiatives should use the lessons learned during this trial to strike the correct balance.
