Published in the April 2013 issue of Today’s Hospitalist
THE HOSPITALISTS at Seattle’s Virginia Mason Medical Center have been learning a new way to round. Instead of seeing all their patients in the morning and then spending the afternoons finishing up the work left undone at the bedside, they now try to complete all the work for one patient before moving to the next. That includes orders, consults, and all communications, documentation and billing.
It’s a Lean Process concept called “one-piece flow.” For the hospitalists, it’s resulted in earlier discharges, better communication with nurses, fewer dropped balls and, for many of them, a noticeably shorter work day.
“Take myself as an example,” says Michael Ingraham, MD, head of the 25-doctor hospitalist section at Virginia Mason. “With one-piece flow, I have cut an hour and a half off my work day.”
And while he doesn’t have data as proof, Dr. Ingraham believes he makes fewer mistakes. “I have a better chance of taking care of things in flow, rather than relying on my memory and my self-generated to-do checklist, which is invariably faulty.”
Implementation of the one-piece flow rounding production process at Virginia Mason started a year and a half ago, first with the nonteaching hospitalists and then the hospitalist-supported teaching teams. It is very much a work in progress with collaboration and leadership from across the hospital, and it has not been easy. But Dr. Ingraham says that the hospitalists remain committed to making a process developed for manufacturing work for inpatient care.
In the car industry, one-piece flow means building an entire Prius at one time rather than lining up 50 partially built ones and putting only the headlights on each. In hospital medicine, it means finding ways to avoid having to revisit work “and avoid touching a patient’s chart three or four times a day when once or twice will suffice.
Most hospitalists structure their daily workload according to what Dr. Ingraham calls “batching.” They first spend an hour looking at all their patient charts to get a sense of what needs to be done, “but not really doing anything concrete,” he points out. “Then they start rounding and ordering some services, but not everything for that patient while they are in the room.”
In the afternoon, they go back to each chart to complete orders, call consultants, write notes and “do what you put off doing in the patient’s room.” Some doctors may even circle back later to finish documentation and billing.
“You are duplicating or triplicating efforts,” says Dr. Ingraham. “In batching, you are trying to multitask all your patients, but the human brain is not meant to juggle 10 or 15 patients at one time.”
Under one-piece flow, the hospitalists spend only 10 or 15 minutes at the beginning of the day looking over their patient charts. That quick review is “a safety check” and triage, Dr. Ingraham says, to determine which patients need to be seen now and which can wait as long as six hours.
“Priority 1 patients are the one or two who look really sick and need to be seen quickly,” he explains. Priority 2 patients are those likely to be discharged that day. Priority 3 are active patients “in the thick of their hospitalization,” and Priority 4 are stable patients who can be safely saved until later in the day.
As the hospitalists see each patient, they spend as long as they need in talking to nurses (ideally, at the bedside), calling consultants, and doing all the orders, documentation and billing on a “computer on wheels” (COW) workstation. Only when they are done do they move onto the next patient.
“Cable guy hours”
One big challenge is becoming comfortable with not seeing some patients until late in the day. “I struggle with this,” Dr. Ingraham admits. “There is a certain amount of anxiety in not seeing a patient until the afternoon.”
It’s also tough to give patients, families and nurses a rough schedule “maybe as vague as “cable guy hours” ” to temper expectations. “If patients or nurses expect to be seen in the morning and I don’t show up,” he explains, “I start getting pages and patients get anxious.”
“I sometimes ask a nurse in the morning to tell patients that I won’t see them until 2:30,” he says. Nurses then let patients and families know what time to be available; they also let him know if there’s a problem that needs to be addressed sooner.
The hospitalists also have learned to be flexible, switching patients’ priority as conditions change. Interruptions are a problem because doctors have to drop what they are doing with one patient to deal with another who they may have planned to see later.
“We don’t have a solution to the challenge of interruptions yet,” Dr. Ingraham says. “If I do get interrupted with one-piece flow, I want to be able to go back to where I was and complete that work as soon as possible.”
To help with logistics, the group took a page from the out-
patient clinic and brought in medical assistants to act as “flow managers.”
“We realized that there are components of our work that don’t require the skills of an MD or a nurse,” Dr. Ingraham says. Flow managers do everything from summoning the nurse for the next patient to calling up a patient’s electronic record and screening out unnecessary interruptions.
“They can sign in, set up the notes, grab missing information and handle the checklist,” he explains. “They are out in the hallway primarily, maybe doing things left over from the hospitalist’s visit with the last patient.”
Two of Virginia Mason’s six hospitalist day teams work now with flow managers. The other four teams have housestaff doing much of the same work.
Initially, only one day team used a flow manager, Dr. Ingraham points out. But once the group realized that that team was completing 10% more discharges before 9 a.m., the group hired a second.
One challenge is how much time it takes to do discharge planning and complete discharge summaries. “If the patient has been here only a couple of days, I can get the discharge summary done,” says Dr. Ingraham. “But if I have to reconstruct two weeks, one of which I wasn’t involved in, then I need more time.”
It’s also been tough bringing one-piece flow thinking to the teaching teams. It’s led to attendings revising both how they supervise interns and the pace of rounds, and figuring out how to make sure trainees have enough autonomy.
“It can be difficult for some learners and teachers,” Dr. Ingraham points out. “We are learning how to vary the pace to accommodate different learners and more complicated patients.”
“We don’t want to graduate residents who think it’s OK to have a stack of charts on their desk to complete at 9 at night,” says Dr. Ingraham. “We don’t want to teach them that batching their work “so they are trying to document an exam 12 hours later and are tired “is right.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.