Introduction
The increasing scrutiny on both the quality and the cost of health care in the United States promotes value driven health care or the highest quality of care at the lowest cost. The perception that hospitalists provide high-value health care impels the continued growth in the field of Hospital Medicine. As the U.S health care system proceeds to reshape itself, hospitalists will continually be challenged to justify this perception by providing high-quality care in a cost-effective manner. The term cost-effective does not mean never spending any money or resources to diagnose, treat, and manage diseases. It does require being smart with decisions on how, when, and where to invest resources. The shotgun approach—ordering an entire battery of tests to rule out a multitude of diagnoses—does not generate cost-effective or even high-quality care. Ordering the right tests at the right time to safely diagnose conditions without needless waste entails not only critical thinking to ask the right questions to get the right information but also easily accessible decision-making support and multidisciplinary teamwork. Delivering cost-effective care in a complex hospital system with lots of moving parts starts with recognizing the relationship between the moving parts and identifying opportunities for improvement. This chapter will use examples to demonstrate how communication, multidisciplinary teamwork, and measurement can be incorporated into a hospitalist practice to deliver cost-effective care (Table 31-1).
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Communication
- “The single biggest problem in communication is the illusion that it has taken place.” (George Bernard Shaw, 20th-century Irish playwright)
Most clinicians rely on the pager as an essential communication tool. A telephone line open for the recipient to return the page and an assumed response time for answering the page before leaving the area if an unreasonable amount of time has passed rest on both spoken and unspoken rules. What is considered a reasonable amount of time is subject to interpretation and to the urgency of the situation. Despite the foibles of numeric paging, it remains a vital system of communication in the American health care system because of its reasonable cost and lack of acceptable alternatives. Unlike numeric paging, text paging allows providers to send text messages via the computer keyboard and telephone operators. The recipient can receive information not only about the call back number but also identification of the caller, the urgency of the call, the specific problem, and whether a response is required. This allows recipients to prioritize their calls and decide when to respond. Text paging can not only improve the communication experience but vastly improve the efficiency of communication. No system is perfect, however, unless the participants follow explicit rules or communication standards agreed upon by the service. Choosing to send numeric messages without indicating the nature or urgency of the call also does not offer advantages over numeric paging.
Essential health care delivery calls for effective communication. How hospitalists communicate with patients and families and other providers not only impacts their relationships with others, but also their ability to provide cost-effective care. One process, multidisciplinary rounds, facilitates communication with the primary goal to expedite care. Health care teams, composed of hospitalists, nurses, and case managers, at a minimum, should conduct rounds at least once daily each morning as early as possible after the nursing shift change and the hospitalist-to-hospitalist handoff. Some hospitals have found it useful to include nurses’ aides, pharmacists, physical and occupational therapists, social workers, and dieticians as well. During rounds, a hospitalist leads a brief discussion about the plan of care for each patient and solicits feedback from all participants. Discussions about each patient should last no longer than two to three minutes and are often shorter. For the occasional patient whose issues demand a longer discussion, that patient should be treated as an outlier and discussed at the end of rounds. Nonphysician providers should solicit physician orders during rounds. The team considers barriers to patient discharge with each discussion, identifies opportunities to improve care, and takes steps to overcome those barriers. Rounds conclude with the expectation that each participant has a clear understanding of each patient’s care plan for that day and for the hospital stay. At the completion of rounds hospitalists should be able to prioritize their work by seeing the sickest patients first, followed by potential early discharges, then the remainder of old patients, followed by new admissions.
Consumers and payers now view both patient satisfaction and 30-day hospital readmission rates as surrogate markers of quality. Multidisciplinary rounds may help health care teams score well on these quality measures because effective interdisciplinary communication promotes a shared understanding of the patient’s needs, expectations, and care plan that anticipates postdischarge needs. With sufficient forethought and discussion, providers are able to address these needs before the discharge day. This approach also minimizes sending mixed messages to the patient and family. The end result of effective interdisciplinary communication is not only more cost-effective care but also a more satisfied patient who is less likely to be readmitted to the hospital unnecessarily.
Multidisciplinary rounds beneficially provide everyone a forum for communication. A standardized process for focused interdisciplinary communication early in the day encourages participants to exchange essential information that will facilitate early patient discharges. The placement of multiple key stakeholders in the same room at the same time allows the team leader to communicate once rather than holding the same conversation with multiple providers, and minimizing interruptions throughout the day allows providers to provide more efficient care. All providers should make an effort to funnel communication toward rounds rather than stopping the doctor or nurse throughout day with questions and comments unless there is a critical update such as a cancelled discharge due to a new problem or unexpected test result. To optimize efficiency and to ensure that significant new information is incorporated into patient care plans, some hospitalist programs have found it useful to hold an additional brief huddle in the afternoon to review and possibly revise the plans which were discussed at morning rounds.
The act of holding rounds every morning is no panacea. In fact, if done incorrectly, multidisciplinary rounds can potentially lead to a paradoxical increase in costs. Such rounds require an investment of all providers’ time and energy. Any wise investment derives greater savings than the cost put into the investment. Longer rounds lower the return on investment and divert members from other competing responsibilities. Ineffective rounds fail to reduce the number of pages being sent between providers in the immediate period of time subsequent to rounds. It is important to set expectations early, be vigilant for any signs of trouble, and address issues before the rounds spiral out of control. Examples include (see also Table 31-2):
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Late arrivals. It is vitally important to set the expectation of prompt arrival. Otherwise, the start time for rounds will drift from day to day and waste time for those who do show up on time.
Lack of preparation. Participation at rounds requires that the current primary nurse and hospitalist have both received sufficient critical information from the overnight staff to effectively participate in rounds. Otherwise, participants will find themselves with nothing to say at rounds or worse, provide erroneous or useless information about each patient’s clinical status.
Exchange of extraneous information.
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