Home Unit-Based Care Downstream effects of unit-based care

Downstream effects of unit-based care

October 2013
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Published in the October 2013 issue of Today’s Hospitalist

Editor’s note: This is the fourth in a series of articles on how one hospitalist program successfully launched unit-based care. The full series covers four themes:

1) Getting started with unit-based care
2) Passing hurdles of politics and finance
3) Saving money and making converts
4) Downstream effects – transformative impact

THIS IS THE LAST ARTICLE IN MY SERIES on how and why our hospitalist group implemented unit-based care with multidisciplinary rounding. Since we started this initiative three years ago, we have gained a great many insights into how this systematic process of care evolves to meet hospitals’ financial and quality pressures.

I know the word “transformative” is too easily used by medical leaders and administrators, but I believe what we have accomplished has truly transformed how we practice inpatient medicine and our hospital’s culture. Here’s a look at some changes that caught me by surprise.

A new community
When unit-based care with multidisciplinary rounds was first implemented, it was humbling to realize how many nurses felt that hospitalists were an impediment to good care!

Why? The physicians, who didn’t know the nurses’ names without looking at name tags, came off as remote authority figures. And because nurses had no forum to be heard, they felt completely disenfranchised.

As for the hospitalists, they didn’t really trust the quality of nursing care. Patients would have been shocked to realize that their care was provided by clinicians who didn’t communicate and who often went out of their way to avoid each other. Unfortunately, I think this is what happens in most hospitals.

Multidisciplinary rounds gave us “for the first time “a way to standardize communication, so we could start talking to one another. We gave everyone involved “physicians, nurses, care managers, physical therapists and pharmacists “a simple script to follow, which automatically standardized communication.

Fast forward three years, and that ability to communicate has become the foundation for true professional relationships and a sense of community on each unit.

It would be hard to scientifically quantify how our interactions have changed. But hospitalists are now included in birthday parties held for staff on unit-based floors, and when one of our original unit-based hospitalists left to work in Hawaii, the floor nurses threw an incredible farewell party.

That may sound frivolous in comparison to controlled social scientific observation. But to an attending physician who has observed more than two decades’ worth of nurse-physician interactions, it is an incredible indicator of unit cohesiveness.

Open to more innovation
It also begs the question: How can any quality initiative be successful when there is no standardized communication among frontline clinical staff? Through their participation in multidisciplinary rounds, nurses, care managers and even unit secretaries are now all partners in care. Many of their ideas on how to improve rounds have been incorporated into the unit-based model.

And with that model in place, our physicians became much more receptive to new quality initiatives. They realized we would approach any innovation in a systematic way with the right resources and that we could build on the foundation of unit-based care. They still mistrust anything new “but their attitude now is a lot less malignant.

We have rolled out several quality initiatives on top of the unit-based model. We worked with the pharmacy department, for instance, to hire and use pharmacy technicians to accurately complete our medication reconciliation sheets. That initiative was piloted on our first unit base, then extended to all unit-based floors.

We’re also now on a completely different footing with administration. We used to be consistently in the administration’s doghouse, the department that always overran its budget, used locums heavily and provided poor service.

Now? Administration turns to us to help solve any number of hospital and inpatient issues. That’s allowed us to flex our political muscle, including asking for appropriate resources, and improved group morale.

Quality is not free! Because of the financial success of unit-based care, we’ve been able to add FTEs and increase the number of rounding and admitting shifts. That’s enabled our group to provide better service to our ED and surgical subspecialists, and to take responsibility for regional transfers to our institution.

It’s not about productivity
An innovation like unit-based care would be very hard to implement in most hospitalist groups where throughput and patient flow are secondary to individual physician productivity. One big transformation was that our program now looks at individual physicians’ average length of stay (aLOS) and variable cost per case, not individual wRVUs.

When other programs are happy with a high census that boosts wRVUs, I worry about how a high census may reduce our discharge and throughput efficiencies “and ultimately cost the hospital system money. Instead, we’ve increased throughput and reduced our cost per discharge as a unit-based cost.

That puts our group way ahead of the curve in a major paradigm shift I see coming to hospital medicine. With ACOs, value-based purchasing, and reduced Medicare and Medicaid reimbursement, hospitals will move from being profit centers to cost centers.

In such an environment, individual productivity and wRVUs will become almost moot points. Instead, the focus will shift to reducing variable cost per case and aLOS, which is often a proxy for the cost to the hospital of an admission. That’s going to be a challenge for hospitalist groups tied to wRVUs for reimbursement. But our program is already there.

Standardize, standardize, standardize
A final thought: We were incredibly fortunate that Presbyterian Hospital continues to have just one hospitalist group for the entire 453-bed hospital. We leveraged that by standardizing everything that was not specifically diagnostic.

I think that institutions with multiple hospitalist groups have trouble implementing quality initiatives because it becomes that much harder to put standardization in place, which I see as the key to improving quality and eliminating waste. No hospital has multiple ED groups, because that would make standardization impossible. Yet it is still acceptable for one hospital to have two, three, sometimes four different hospitalist groups, all performing admissions, subsequent visits and discharges slightly differently.

I believe that creates barriers to quality improvement. It’s particularly difficult when multiple groups in a hospital are all incentivized on productivity.

That doesn’t mean that implementing unit-based care, even with only one program, was easy. It is hard work that requires coordinating multiple disciplines that often mistrust one another. It also takes courage and a strong understanding of hospital operations to realize how clinical practice affects the bottom line.

But the results are essential for surviving the financial and quality challenges that most hospital systems face. Within a decade, I believe that most hospitals will have some variation of unit-based care with multidisciplinary rounds. As I see it, that’s the natural evolution of the hospitalist movement.

David J. Yu, MD, MBA, is the medical director of adult inpatient medicine services with Presbyterian Medical Group at Presbyterian Hospital in Albuquerque, N.M. Send him questions about starting or maintaining unit-based interdisciplinary rounds at dyu3@phs.org.