Home Cover Story The push is on for multidisciplinary rounds

The push is on for multidisciplinary rounds

July 2008

Published in the July 2008 issue of Today’s Hospitalist

For four hours “nearly half his work day “hospitalist James J. Jeffries II, MD, leads bedside multidisciplinary rounds (MDRs) on his patients. While he used to spend only between two and three hours on solo rounds, Dr. Jeffries says he jumped at the chance to take part in multidisciplinary rounds when Detroit’s Henry Ford Hospital piloted the program three years ago.

That doesn’t mean the model doesn’t have drawbacks. Spending 8 a.m. to 12 noon every day on team rounds, for instance, typically forces him to stay an extra hour beyond his nine-hour shift. But despite that extra time, he says the new model is more than worth it.

“I embraced bedside MDRs because I thought they would definitely facilitate care of the patient,” says Dr. Jeffries, one of 28 hospitalists at Henry Ford and a unit medical director.

“It’s difficult to coordinate this on a hospital-wide basis, but on a unit basis, it’s definitely possible.”

~ Amy Boutwell, MD, Newton Wellesley Hospital

Looking back, he feels he was right. Patients and families like seeing staff talking to each other at the bedside. Lengths of stay have dropped by a day or two, and his unit’s nursing staff is among the most satisfied at the 700-bed hospital.

And while Dr. Jeffries can’t say for sure that hospitalists’ new role as team leaders has enhanced their stature in the hospital, he points out that other units at Henry Ford are following suit.

Multidisciplinary rounds are gaining in popularity. In part, that’s because of growing pressure from accrediting groups like The Joint Commission and quality improvement organizations like the Institute for Healthcare Improvement (IHI). But perhaps just as importantly, this latest reinvention of the hospital medicine model is possible because many maturing hospitalist groups finally have enough physicians available during the day to organize and lead such teams.

“If a hospital has a hospitalist, there’s hardly an excuse not to do MDRs,” says Susan Hassmiller, PhD, RN, senior program officer and team leader at the Robert Wood Johnson Foundation (RWJF), which is working with the IHI to promote multidisciplinary rounds as part of a suite of safety initiatives. “An MDR takes a system that’s entirely fragmented and works as a team to lower the stakes of adverse events.”

But despite all the attention the concept is receiving, not everyone embraces the shifts in work style and mindset. “It’s been a challenge because we have to dictate to the hospitalist how to do daily rounds,” says Peter Watson, MD, chief of the hospitalist medicine division at Henry Ford. “That might not always go over well.”

How it works
Instead of the old rounding paradigm where the doctor does it all, writes notes and tries to talk to case managers and nurses on the fly, multidisciplinary rounds allow the entire process to happen at one time by pooling schedules and information.

Most agree that at a minimum, multidisciplinary rounds should include a hospitalist, a nursing supervisor who can relay messages to the patient’s nurse, and a case management supervisor. Others may join in as appropriate, including the primary care physician, intensivist, clinical nurse specialist, social worker, pharmacist, nutritionist, occupational therapist, physical therapist, speech therapist, specialists, housestaff and others.

Not all facilities devote four hours to rounds. “You can do multidisciplinary rounding from three minutes at the bedside to three hours in a conference room and anywhere in between,” Dr. Hassmiller says. Some facilities run teams every day, while others do so only on weekdays because case managers are not available on weekends. Still others round as a team just three days a week to save time.

There’s also variability as to where and how to conduct multidisciplinary rounds, particularly if bedside planning is too time-consuming. While Albert Caccavale, DO, does bedside rounds with a nurse at the 160-bed Yavapai Regional Medical Center in Prescott, Ariz., he says they talk outside the patient’s room on “crazy” days.

And when she led multidisciplinary rounds at the 100-bed Willamette Falls Hospital in Oregon City, Ore., Cornelia C. Taylor, MD, would meet at the end of the hallway for 30 minutes after rounds with her team. Initially, that raised some eyebrows, especially from a vice president of operations.

“He would see us all huddled together and think, ‘What’s up with these people shooting the breeze? Shouldn’t they be doing something more productive?’ ” But once he saw the results, Dr. Taylor says, he became much more supportive.

A daily game plan
Hospitalists typically lead multidisciplinary teams, although there are instances “in hospitals without hospitalists, for example, or when a hospitalist just starting out defers to a nurse leader “where it makes sense for nurses or case managers to take the lead. The consensus is that mornings, either before or after new admissions have been processed, seem to work best. That way, discharges can be handled after rounds.

During rounds, team members usually review vital signs, do checks such as making sure that a diabetic’s blood sugar is under control, and make plans for the day, writing orders on the spot. A pharmacist may talk about medications ordered that weren’t on the formulary, suggest alternatives, or talk to a patient who needs to go home on an injectable anticoagulant.

Social workers and case managers may note a patient’s ongoing insurance problems. Hospitalists say that the on-the-spot availability results in fewer mistakes and redundancies, better patient care and workflow, better communication between physicians and nurses, and fewer pages and other interruptions later on.

It also gives team members a game plan for the rest of their day. “Everyone walks out with a list of what they need to accomplish that’s organized to improve quality and throughput,” says David J. Rosenberg, MD, MPH, head of hospital medicine at North Shore University Hospital in Manhasset, N.Y. His job description now includes running MDRs “a major undertaking, because North Shore is one of only a few hospitals in the country that have implemented multidisciplinary rounds for every patient in the hospital.

More face time with nurses
As an example of how teams increase efficiency, Dr. Taylor mentions an elderly patient at Willamette Falls who had a leg clot. By taking five minutes to discuss the case during rounds “prescribing medication, instructing the patient on how to use it, working with discharge planning for a follow-up appointment with the primary care physician and labs for later that week, and arranging transportation home and home health care “Dr. Taylor was able to discharge the patient by 11 a.m. Without multidisciplinary rounds, she says, the patient would have been discharged several days later.

And because such rounds ensure that nurses get face-to-face time with physicians, Dr. Taylor says, the result is fewer chart-reading snafus, better overall patient safety and improved nursing satisfaction.

“It was the perfect way to get immediate communication at the beginning of the day,” Dr. Taylor says. “All I needed to do was visit the patient and do my dictation and the job was taken care of.”

Team challenges
While they offer many benefits, however, multidisciplinary rounds aren’t all smooth sailing. Consistently getting team members together, for instance, requires constant coordination.

“It’s challenging to change the workflow in the morning when everybody has so many different patients, often on different rounds,” says Amy Boutwell, MD, a hospitalist at Newton Wellesley Hospital in Newton, Mass., who has worked on the concept of multidisciplinary rounds for the IHI. Because of logistical challenges, “it’s difficult to coordinate this on a hospital-wide basis, but on a unit basis, it’s definitely possible.”

It’s particularly critical to rotate nurses so that one joins the rounds to discuss her or his patients, then leaves as another nurse comes in. And hospitalists who don’t work on a geographic basis with hospitalist-only units also need to rotate in and out, making it critical to be at the meeting place on time.

Some hospitals have moved toward geographic units for hospitalists to make multidisciplinary rounds easier. Yavapai Regional, for example, has tried (with limited success) to put most hospitalist patients on one pod so hospitalists can run team rounds without being spread too thin. It’s also looking at other patient-placement options to reduce the number of nurses that hospitalists have to interact with during rounds.

Even with good planning, putting such rounds into practice requires flexibility. At Yavapai Regional, Dr. Caccavale calls the floor the day before or early in the morning to pin down exactly when rounds will begin, usually between 9 a.m. and 9:30 a.m.

Before then, nurses are busy with checkouts. “I’d like to say there’s an easy way to do it,” Dr. Caccavale says, “but there isn’t.”

Ironing out the kinks
To make multidisciplinary rounds work, hospitalists say one must-have tool is some type of worksheet filled out at the bedside that can later be used during handoffs.

“It’s like an airplane pilot going through a checklist before taking off. ‘Is glycemic control an issue? No? Next,’ ” says Henry Ford’s Dr. Watson. He adds that having a discharge checklist is also a good idea.

Not surprisingly, technology plays a role in most teams. Dr. Jeffries from Henry Ford uses a wireless computer on wheels with a large screen that allows patients and families to see labs and X-rays. Likewise, doctors and nurses at Hackensack University Medical Center in Hackensack, N.J., have computers on wheels that they use to look up lab data, X-rays and echos. Louis Evan Teichholz, MD, Hackensack’s chief of cardiology and medical director of cardiac services, says that the teams can access those images even if the reports aren’t back.

And everyone agrees it’s best to test the process on one unit to work out the kinks. For example, Yavapai Regional first used multidisciplinary rounds in one wing, expanded to a floor, then to all medical floors. Henry Ford began on a teaching floor for a four-month trial, and only later rolled the rounds out to the rest of the teaching and nonteaching floors.

Support from the top
It may also help to find a physician champion. At Henry Ford, that was initially the chief of the general internal medicine division, with acceptance for multidisciplinary rounds trickling down from the top.

At Willamette, Dr. Taylor told administrators she met during her interview that she wanted to set up the program because she had seen its advantages in a previous position. The hospital, she says, was enthusiastic.

“A physician is looked upon as a leader,” she says, “so it makes it more natural to have the hospitalist make the initial effort to get it going.”

Expect the process to be rough at first and perhaps indefinitely, possibly requiring some management decisions, like consolidating floors where therapists are working.

At Henry Ford, the nurses or case managers are sometimes too busy to participate, which grinds discharge planning to a halt. Other times, emergencies or a rash of new admissions means that team rounds may run into the afternoon and not be quite as organized.

Another challenge is buy-in. Some hospitalists may have a hard time breaking solo habits that were forged in medical school or residency and may choose not to participate. As time goes on, however, resistance is expected to evaporate as more physicians are hired based on whether they have experience with the model. Henry Ford, for example, has been training internal medicine residents to work in multidisciplinary teams, a move that is paying off. Dr. Watson says the hospital just recruited eight of its own residents for the hospitalist program, who already have three years of MDR experience.

Refining the model
Already, some hospitals are taking the lessons learned from multidisciplinary rounds and creating more targeted teams. For example, North Shore is spinning off a group from its MDRs to review patients who have been in the hospital more than 20 days.

Henry Ford hopes to use the model to improve the transition to the outpatient setting. The hospital is also setting a new goal of increasing before-noon discharges, a challenge because the mornings are booked with rounds. The hospital recently began piloting multidisciplinary rounds in units where hospitalists co-manage patients, such as the orthopedic unit and certain surgery areas.

And some hospitals have embraced creative tactics to gain acceptance from not only physicians, but patients. For example, Hackensack provides its own taxi voucher or car service to make sure its goal of discharging two patients on each floor before 10 a.m. happens even if the family can’t come, Dr. Teichholz says.

Some facilities are just now starting to collect data about the effects of multidisciplinary rounds on length of stay, throughput and readmission rates. Others say it may be impossible to tease out these savings from MDRs and other
safety efforts.

Hospitalist groups looking to get started need to keep in mind that it’s not a one-size-fits-all model, Dr. Teichholz cautions. “People have to figure out what works in their specific institution,” he says. “The important thing is buying into the concept that medicine is more of a team approach.”

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

Do hospitalists need a new skill set for team rounds?

WANTED: OUTGOING HOSPITALIST with friendly attitude to lead multidisciplinary rounds. Must have leadership skills. Comfortable having abilities questioned.

Out of your comfort zone? As a physician used to getting things done, you may actually have more of the skills needed to lead and manage a multidisciplinary team than you think.

While it would certainly help to have more formal training in collaboration and communication, most physicians who came up through internal medicine are good listeners, have good delegation skills “especially if they participate in training “and have leadership skills just by being steeped in the independence fostered in medical school, insists David J. Rosenberg, MD, MPH, head of hospital medicine at North Shore University Hospital in Manhasset, N.Y.

“The greatest issue in running a MDR is overcoming the fear of not having leadership skills,” he says. “But they’re innate in us. We just don’t have practice using them.”

While you may feel uncomfortable in some other areas, such as talking in front of a group, those skills can also be learned, according to James J. Jeffries II, MD, a hospitalist unit medical director at Henry Ford Hospital in Detroit. “This is a paradigm shift in communication, but it is certainly teachable,” he says.

Even if you balk at social interactions, a little effort “and charm “can accomplish a lot, says Cornelia C. Taylor, MD, who formerly led multidisciplinary rounds at Willamette Falls Hospital in Oregon City, Ore. Thank and praise other MDR members daily for their help and let them know how you appreciate them, she suggests.

Make it genuine, says Peter Watson, MD, chief of the division of hospitalist medicine at Henry Ford Hospital. “We don’t want someone to go through the motions. We need hospitalists who are flexible, willing to conform to certain standardized practices, willing to be a collaborator on the team and not necessarily dictate how things work,” he said. “We all have to make individual sacrifices in practice style to work together in a patient-centered philosophy of practice.”

That includes sometimes being questioned at the bedside. “If you’ve engaged independent nurses who say, ‘I’m worried about doing that,’ the hospitalist has to be able to come back with, ‘Here’s why I feel we should go forward,’ ” Dr. Watson says. “When you’re part of a team, you’re centered on the patient, not on the physician, nurse or case manager. It’s not a blind lack of questioning authority.”

In the end, actions speak louder than words. Even Dr. Rosenberg, who coined the term “physician manager” to lend an air of authority when he began his team rounds program three years ago, says that he retired that designation. “I no longer need to use that title,” he says. “It’s part of the culture.”