Restructured General Medicine Service to
Enhance Hospital Flow, Patient Safety, and Patient Satisfaction
When the patient census is high at BWH, expediting the
discharge process for patients who are ready to go home is one of the key
factors that can affect patient flow. If discharges are not efficient, the
Emergency Department can become crowded with patients who need to board there until
an inpatient bed becomes available.
One area of focus for improving overall patient flow is the General
Medicine Service (GMS). Often, discharges for general medicine patients are
slow or delayed because these patients are located on seven different units on
average and at times on up to thirteen different units. This makes it difficult
for patients' care teams to discharge them early in the day, despite being
ready, so that beds are open as new admissions begin to come from the ED. In
this inefficient system, teams are also unable to meaningfully respond
differently when the census in the hospital is high.
"Having a team's
patients spread throughout the hospital results in poor communication among the
care teams, especially between the physicians, nurses and care coordinators,"
said Robert Boxer, MD, PhD, associate director of the BWH Hospitalist Service.
"It's inefficient, and it doesn't promote the patient- and family-centered care
that we at the Brigham are committed to delivering."
To complicate things even further, GMS teams currently admit
on a four-day call cycle, meaning that teams do not admit new patients every
day. Another implication of this
traditional call cycle is that in the evenings and overnight, their patients
are cross-covered by another team.
Addressing the Issues
The combination of these factors led to the selection of GMS
as a care redesign initiative, sponsored by Chief Medical Officer Stan Ashley,
MD, and Senior Vice President of Patient Care Services and Chief Nursing
Officer Jackie Somerville, PhD, RN.
For months, multidisciplinary teams including GMS physicians,
nurses on med/surg floors, Admitting staff and ED staff have been working
together to restructure the GMS model, which will formally launch June 20.
"The new model will create truly integrated
inter-disciplinary teams as physician teams will be associated with a single
nursing unit," said Boxer, who is leading the GMS restructuring
initiative. "With these new teams, we believe we will see significant
improvements in multiple domains, including communication, efficiency, patient
safety, and the overall experience for patients and their families."
Regionalization will enhance communication among physicians
and nurses, and it will provide more consistency for patients and family
members. The physicians will have an opportunity to better get to know their
patients, as well as the nursing staff on the units, which include Tower 14AB,
14CD and 10BA.
"This is all about interprofessional collaboration," said Associate
Chief Nurse Nancy Hickey, MS, RN. "The team will round together on patients and
include the patient and family in a way that coordinates, refines and executes
the plan of care. Care will be more efficient, more collaborative and more
patient- and family-centered with this new model."
Regionalization will address some chronic issues, like late
or slow discharge and errors in care.
The restructuring calls for each team to admit patients
every day. Each pod will have a dedicated team of attendings and responding
clinicians for both day and evening shifts. New medical directors will be
assigned to each pod who will work closely with the nursing directors.
"Right now, patients are distributed across all floors
because we never have enough medicine beds," said Hickey. "The nursing and
medical directors will be charged with reducing length-of-stay and improving
the efficiency of discharges, and they will work closely with a pod-based care
coordinator on these goals."
The change in the admitting process is also a positive one."Having GMS teams admit every day will be a significant enhancement to our current process of assigning medical teams," said Sheila Harris, executive director of Patient Access Services. "With pod-based teams, we expect that we will have access to more timely and accurate information regarding discharges, which will have a positive impact on patient flow."
Added Boxer: "The change away from evening cross-coverage of
patients to dedicated evening teams on each pod will also allow us to better
care for patients and communicate with their family members who visit in the
These changes are expected to benefit the ED when patients
are boarding there while waiting for admission to GMS units.
"It's a challenge when patients and families in the ED
aren't able to go up to their rooms because there isn't a room available," said
Josh Kosowsky, MD, vice chair for
Clinical Affairs in Emergency Medicine. "Dr. Boxer and his team have
been excellent at understanding
the need to advance patient care and collaborating with us to achieve this."
Chief Medical Officer Stan Ashley, MD, said that the
restructuring of GMS is a step forward for BWH. "Achieving regionalization of
these patients will be challenging at times, but it's the right thing to do for
our patients, our caregivers and the hospital," he said. "These changes will
lead to improvements in efficiency, safety, quality, education and the
experience of patients and their families at BWH."