Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service

Given that multiple disciplines are often involved in caring for patients admitted to the hospital, timely communication, collaboration, and coordination amongst various disciplines is necessary for safe and effective patient care.¹ With the focus on improving patient satisfaction and throughput in hospitals, it is also important to make more accurate predictions of the discharge date and allow time for patients and their families to prepare for discharge.^2-4

Multidisciplinary rounds (MDR) are defined as structured daily communication amongst key members of the patient’s care team (eg, nurses, physicians, case managers, social workers, pharmacists, and rehabilitation services). MDR have shown to be a useful strategy for ensuring that all members of the care team are updated on the plan of care for the patient.⁵ During MDR, a brief “check-in” discussing the patient’s plan of care, pending needs, and barriers to discharge allows all team members, patients, and families to effectively coordinate care and plan and prepare for discharge.

Multiple studies have reported increased collaboration and improved communication between disciplines with the use of such multidisciplinary rounding.^2,5-7 Additionally, MDR have been shown to improve patient outcomes⁸ and reduce adverse events,⁹ length of stay (LOS),^6,8 cost of care,⁸ and readmissions.¹

We redesigned MDR on the general medicine wards at our institution in October 2014 by using Lean management techniques. Lean is defined as a set of philosophies and methods that aim to create transformation in thinking, behavior, and culture in each process, with the goal of maximizing the value for the patients and providers, adding efficiency, and reducing waste and waits.¹⁰

In this study, we evaluate whether this new model of MDR was associated with a decrease in the LOS. We also evaluate whether this new model of MDR was associated with an increase in discharges before noon, documentation of estimated discharge date (EDD) in our electronic health record (EHR), and patient satisfaction.

Setting, Design, and Patients

The study was conducted on the teaching general medicine service at our institution, an urban, 484-bed academic hospital. The general medicine service has patients on 4 inpatient units (total of 95 beds) and is managed by 5 teaching service teams.

We performed a pre-post study. The preperiod (in which the old model of MDR was followed) included 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) included 2085 patients discharged between October 23, 2014, and April 30, 2015. We excluded 139 patients that died in the hospital prior to discharge and patients on the nonteaching and/or private practice service.

All data were provided by our institution’s Digital Solutions Department. Our institutional review board issued a letter of determination exempting this study from further review because it was deemed to be a quality improvement initiative.

Use of Lean Management to Redesign our MDR

Our institution has incorporated the Lean management system to continually add value to services through the elimination of waste, thus simultaneously optimizing the quality of patient care, cost, and patient satisfaction.¹¹ Lean, derived from the Toyota Production System, has long been used in manufacturing and in recent decades has spread to healthcare.¹² We leveraged the following 3 key Lean techniques to redesign our MDR: (1) value stream management (VSM), (2) rapid process improvement workshops (RPIW), and (3) active daily management (ADM), as detailed in supplementary Appendix 1.

Interventions

Outcomes

The primary outcome was mean LOS. The secondary outcomes were (1) discharges before noon, (2) recording of the EDD in our EHR within 24 hours of admission (as time stamped on our EHR), and (3) patient satisfaction.