Hospital Workflow Redesign Could Save Lives

On the outpatient side of primary care, attention recently has focused on the use of the medical home to provide ongoing, quality care. So what would happen if that concept were moved to an acute-care inpatient setting?

According to a study from Geisinger researchers, organizing multidiscipline teams of providers to deliver timely, coordinated, and even personalized care in a hospital—using this concept—could save thousands of patient lives a year.

In a large prospective study headed by Thanjavur Ravikumar, MD, Geisinger's director of surgical innovation, the team realized that the medical home model held answers for its continuum of care study conducted last year at the 242-bed Geisinger Wyoming Valley Medical Center in Wilkes-Barre, PA.

In essence, they say in this month's Annals of Surgery, their continuum of care study—which first looked at surgical patients and then at the medical/surgical population—borrowed tenets from the medical home model that could be used to provide patient-centered care in an inpatient setting:

• Continuity through different transition points in the hospital,
• Proactive interventions to prevent complications,
• Early recognition of patient deterioration to provide a "timely rescue",
• Multi-member team performance and quality-based rounding, and
• Use of electronic health records (EHRs) for real-time information sharing.

The pilot—which was building on earlier research obtained from two New York hospitals over the past decade—sought to "improve the efficiency of the hospital workflow," while reducing hospital mortality and keeping down costs, Ravikumar said.

To be clinically effective, the hospitals needed to find ways to take care of critically ill patients successfully outside the intensive care unit. "Rather than work harder and harder, we needed to work smarter. And, we needed to work smarter with the same resources," he said.

To meet these goals, the hospital looked at a process redesign. A 13-bed progressive care unit was created and staffed by hospitalists with experience in critical care. Hospitalists were reassigned to be floor-based and charged with coordinating care and ensuring quality for patients on their assigned floor--in addition to their own patient panel.

Then, hospitalist-led multidisciplinary rounds were conducted on each of the floors daily. Rounds included nurses, care managers, pharmacists, dieticians, and physical/occupational therapists. The goal was to "predict who would do poorly and then proactively [identify them] so they don't become candidates for rapid response [teams]," Ravikumar said.

To assist in this area, they used a "hawk" (high risk) and "dove" (low risk) system of stratification for patients they saw on their rounds. "This had to be simple," he says. Patients whose providers had to look after actively on an ongoing basis were designated as "hawks"—since staff would have to "watch them like a hawk." Patients doing well at the time of rounds were called doves--"which meant they [would likely] 'fly peaceably away' soon like doves," he said.

A multidisciplinary rounding tool was developed to standardize rounds—and keep track of the "hawks" and "doves"—using an EHR system. And, wireless communication devices were used for "real-time communications" between hospitalists and other stakeholders.

Based on the reduction in hospital mortality observed in this pilot and in the prior New York studies, Ravikumar estimates that an 18% to 25% reduction in hospital mortality could occur through these changes in the system. If this figure were stretched out nationally, this system redesign could have the potential to save up to 95,000 lives a year if adopted, he adds.

While small, incremental costs are involved in additional staffing, this is overshadowed by financial savings in length of stay reduction, optimization of resource utilization, and averting complications, Ravikumar says.

"The strength of this project is not just giving [hospitals] a cookie cutter approach, It's giving them principles," he said. "Each hospital has to use its own principles to adapt to its own micro-environment to do better every year."

This means that each hospital needs to look at its own mortality data to see where additional efforts are needed to protect patients, he says. For instance, one hospital may be good at managing morbidly obese patients while another may not: that latter hospital would need to find better ways to address the healthcare needs of those patients to keep mortality rates down.

"The basic principal is that...hospitals need to function in a safer zone than they do. Everyone wants to do it. Everyone wants to prove that. That's system redesign," said Ravikumar.