SUNY Upstate Medical University, Syracuse, NY
The authors report no relevant financial relationships. The authors wish to thank Megan Greenman for collaborating with us in the patient satisfaction surveys. We would also like to thank Andrea Kite and Sherria Sparks, who were instrumental in implementing our pilot on their floors.
J Clin Pathways. 2017;3(4):37-46. Received January 28, 2017; accepted April 17, 2017
Dr Amit S Dhamoon
SUNY Upstate Medical University
750 East Adams Street
Syracuse, NY 13210
Phone: (315) 464-4484
Abstract: Effective coordination of care has been associated with improved performance on patient-centered measures of care quality. A standardized protocol for conducting multidisciplinary rounds (MDR) can improve communication within the health care team in order to deliver safer and more effective care. The authors designed and implemented a pilot study to introduce a care coordination model using a structured MDR protocol at an academic medical center. Patient surveys were used to evaluate patients’ assessments of their quality of care, and health care provider surveys were used to evaluate improvements in communication, team work, and other quality measures before and after the implementation of the MDR protocol. Length of stay (LOS) among hospitalized patients was also measured. Scores on patient-centered measures of quality improved after the intervention. Physician survey responses improved in 9 out of 11 measures, and nurse survey responses improved in 12 out of 14 measures, which related to communication, patient safety, and workflow. Mean LOS decreased from 4 hospital days to 3.6 hospital days, representing a 10% relative reduction. The study findings indicate that implementation of a standardized MDR protocol can improve care coordination, patient assessments of care quality, and patient LOS.
Citation: Journal of Clinical Pathways. 2017;3(4):37-46.
Received January 28, 2017; Accepted April 17, 2017
With the passage of the Patient Protection and Affordable Care Act (ACA)1 in 2010, hospital reimbursement through Centers for Medicare and Medicaid Services (CMS) is now directly linked to performance measures evaluating the patient experience as well as the quality of care.2 For example, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey is sent to a random sample of patients who are discharged from a hospital. The scores from these surveys are recorded, publicly available, and directly affect reimbursement from CMS.2,3 Therefore, patients’ satisfaction with their care has become an important quality measure for hospitals and can affect their reimbursement.
Coordination of care is an important aspect of achieving a high performance on such quality measures. Multiple health care providers (eg, nursing, case management, physicians, social workers, and physical and occupational therapists) are often involved in the care of a single patient. In an academic medical center, patient care is further complicated by different levels of expertise in the medical team, which include medical students, interns, senior residents, and attending physicians. Furthermore, the amount of time directly spent with a patient indirectly correlates with the level of expertise of a member on a medical team. The attending physicians usually holds a teaching and supervisory role, while the intern and medical student are more directly involved in the hour-to-hour patient care.
Prior studies have highlighted the significance of effective communication between physicians and nurses in reducing medical errors.4,5 According to the Joint Commission, ineffective communication has consistently been identified as one of the top three causes of sentinel events from 2010 to 2012.6 Successful coordination of care through teamwork and communication among health care providers can reduce clinical errors, ensure the delivery of safer patient care,7,8 and enhance the patient experience, potentially improving the results of patient satisfaction surveys.9-11
Structured coordinated care meetings such as daily multidisciplinary rounds (MDR) are utilized in hospitals to facilitate communication between multiple specialized health care providers, but there is little research into the effect of MDR on patient-centered outcomes, such as satisfaction with care. Several studies have examined the effect of MDR on communication improvement, reduction of medical errors, and decreased length of stay (LOS), but results have been surprisingly variable; whereas MDR has consistently shown improved communication and decreased medical errors,3,12-16 the effect of MDR on LOS has been mixed.17-23
This pilot study was designed to create a novel model for the implementation of an MDR protocol in a large university-based academic hospital on acute general medicine wards that encompassed the entire health care team, including bedside nurses and medical trainees. We hypothesized that daily MDR, with implementation of a novel patient communication tool, would enhance teamwork and communication, decrease LOS, and improve staff satisfaction and patient-centered outcomes.
This clinical study was reviewed and approved (#364972) by the Institutional Review Board at SUNY Upstate Medical University (Syracuse, NY). Written informed consent was obtained from all survey participants.
The pilot study was conducted from February 2013 to February 2014 on three general medicine units at SUNY Upstate Medical University, a 409-bed tertiary care teaching hospital. The study included three general medicine telemetry units; two 24-bed units; and one 16-bed unit. Teaching medical teams consist of one attending physician, one senior resident, two interns, and one or two medical students. Each teaching medical service is generally assigned to a single general medicine unit.
Implementation of the MDR Protocol
The house staff and floor staff were educated on the MDR protocol prior to the intervention date in October 2013, and our study investigators randomly observed the MDR in practice to ensure standardization throughout the intervention period.
The MDR protocol required that the MDR team meet daily at a standard time in the morning, based on the medical team’s preference, for approximately 30 minutes (Figure 1). The MDR team included the unit case manager, charge nurse, medical team, pharmacist, and social worker, as well as physical and occupational therapists. Our MDR was unique in that the bedside nurse for each patient also participated in the roundtable discussion. The charge nurse would coordinate nursing staff to rotate in and out of the MDR. The bedside nurse would present the patient for discussion, and a checklist was followed by the medical senior resident for each patient, pertinent to discharge planning (Figure 2).
To facilitate the coordination of care during MDR, patient information forms were completed daily by the medical team (Figure 3), and these forms were used as a communication tool to update the patient of their clinical status, barriers to discharge, and upcoming tests. All members of the MDR team utilized the patient form as a communication tool. The medical team completed the patient information sheet during MDR as a result of communication brought from all members. This was directly delivered and communicated to the patient at bedside by the medical team after MDR.
Patients were eligible for a standard survey on discharge as long as they were on the study unit for the majority of their hospital admission and did not have any psychiatric diagnoses that would preclude them from completing the survey. Patients were also excluded if they were not a medical patient for more than 24 hours or if they were leaving against medical advice.
The patient survey included three questions regarding patient perceptions of the quality of the communication they received regarding their care; the level of team work exhibited by their health care providers; and the overall quality of the care they received (Figure 4). These questions were modeled after the national HCAHPS Survey.3 Responses were measured on a 5-point Likert response scale, with a score of 1 indicating worst and a score of 5 indicating best, that was tailored similar to the HCAHP surveys. The patient survey was collected by a nursing clerk, who would then record the patient’s LOS on the envelope containing the completed survey.
Patients were surveyed between February 2013 and May 2013, prior to implementation of the MDR protocol. Surveys were halted from June 2013 to October 2013 to allow an adjustment period for the new incoming house staff, as well as to educate both house staff and floor staff on the MDR protocol. After implementation of the MDR protocol, patient surveys resumed from October 2013 to February 2014.
Nurse and physician surveys were similarly designed to reflect the questions on the HCAHPS Survey to assess communication, teamwork, satisfaction, and patient safety.3 Responses were measured on a 5-point Likert response scale, with a score of 1 indicating strongly disagree and a score of 5 indicating strongly agree. Nurses and physicians were surveyed before and after the intervention on their respective units during the period from February 2013 through May 2013, and again from October 2013 through February 2014.
We conducted a power analysis to determine the sample size for a power of 80% to detect a 25% elevation in the cumulative patient satisfaction score. Using Cronbach’s alpha, we calculated a coefficient of variance and determined the sample size of 50 patient surveys before and after the intervention.
All surveys utilized a 5-point Likert-like response scale. The cumulative and individual survey scores from the pre-intervention and postintervention periods were compared using t tests for interval data and chi-square tests for nominal data where appropriate. All statistical analyses were conducted using Microsoft Excel with the help of a statistician.
Our primary outcome measures were improvements in postintervention scores vs pre-intervention scores on patient satisfaction and perceptions of teamwork and communication. Secondary endpoints included postintervention scores on nurse and physician perceptions of teamwork, communication, patient safety, and the overall process of discharge planning.
We also evaluated differences in pre- and post-intervention average LOS, with patient stays in the hospital longer than 14 days being excluded from analysis.
Patient Survey Responses
A total of 96 completed patient surveys were collected in the pre-intervention phase, and 89 completed patient surveys were collected postintervention.
The mean scores on all three questions on the patient surveys increased after implementation of MDR. Individually, there was a 5% to 8% relative improvement in each question after the intervention. Additionally, the cumulative score on all three questions increased from 13.43 to 13.64 (Table 1). The number of individual affirmative responses (scores of 4 or 5, indicating “good” or “best”) increased after the intervention vs pre-intervention.
Physician and Nurse Survey Responses
A total of 65 physician surveys were collected prior to the intervention, and 44 physician surveys were collected after the intervention. We saw expected increases in mean scores on 9 of 11 measures related to communication, patient safety, and workflow (Table 2). Unexpectedly, we saw decreases in the mean scores relating to medication review with the patient as well as perception of communication with physical and occupational therapy.
A total of 39 surveys were collected from the nursing staff from the study floors prior to the intervention, and 27 surveys were collected after the intervention. In the nurse survey, we saw expected increases in mean scores on 12 of 14 measures related to communication, patient safety, and workflow satisfaction (Table 3). We again had an unexpected decrease in the mean score relating to medication review with the patient, as well as perception of communication with nursing and case management.
Physician and nursing staff perception of communication both increased after intervention with MDR (Tables 2 and 3). Comparatively, physicians perceived more effective communication before and after our intervention than nursing staff.
LOS data were available in 92 of the 96 patients for the pre-intervention period. Two were removed from calculating the mean LOS because their LOS exceeded 14 days. In the postintervention period, 87 out of 89 patients had usable LOS data, of which six were removed because their LOS exceeded 14 days.
The mean LOS decreased from 4 to 3.6 hospital days after implementing MDR, although this was not significant (P = .40). This represented a 10% relative reduction in hospital LOS.
To our knowledge, this is the first published study in a tertiary care teaching hospital in the United States to pilot the concept that implementation of a comprehensive MDR protocol to standardize the coordination of care among multidisciplinary team members. Our findings demonstrated that this type of intervention can improve patient assessments of their quality of care.
In a previous study, O’Leary and colleagues examined the effects of a communication skills training program with physician and nonphysician personnel and showed improvement in patient satisfaction scores, although their findings did not show statistical significance.22 Their study was similar to ours in that we utilized the HCAHPS Surveys as a measurement tool for the patient surveys. Our study was also unique in utilizing a patient-focused information sheet, as well as a checklist to facilitate communication within MDR as well as to the patient. Daily checklists have been used previously in many intensive care unit settings, but not frequently in general medical wards.5
We found a positive association between implementation of the MDR protocol and patient-centered outcome measures. However, because of our small sample size, these results lacked statistical significance. The mean cumulative scores from our pre-intervention patient surveys were higher than we anticipated during our power analysis. Cronbach’s alpha and our target sample size was calculated assuming a mean score of 9 with an anticipated 25% improvement to 12. In hindsight, a target improvement of 10%, as well as taking into account a higher pre-intervention satisfaction score, could help to determine a better powered study. This was also noted by O’Leary and colleagues, who surmised that they would require over 3000 patient surveys to achieve statistical significance to detect an absolute 4% improvement in their hospital rating.22 Previous studies on MDR have also had difficulty establishing statistical significance despite showing an improvement with patient satisfaction scores.23 Similarly, Simmons and colleagues were also able to show increased patient comprehension of care and satisfaction after initiating a communication tool in emergency department patients, but again, the results did not achieve statistical significance.24
Another limitation was that our MDR occurred only during regular weekdays. MDR did not occur during holidays or weekends, but collection of patient surveys continued during the specified period. It is possible that some of the surveys collected may have occurred without daily MDR.
Our study was also limited due to the lack of patient localization within a specific unit. Although we conducted our study specific to a unit and specified medical team, there were patients in the same unit who were taken care of by a different service or provider. During our study, this was estimated to be less than 20%. However, previous studies have found an increase in quantity and quality of physician and nurse communication with patient localization.25,26
Nonetheless, the relative improvement in patient satisfaction may still significantly influence CMS measures. O’Leary and colleagues also found that a 3% improvement from 76% to 79% in the doctor communication ratings would translate into an improvement from the 25th to 50th percentile.22 Thus, even small improvements in communication and teamwork can lead to large improvements in patient satisfaction ratings as well as hospital reimbursement.
We compared our patient surveys during the same study period to the hospital-collected HCAHPS scores, and our results mirrored those third-party collection scores. For confidentiality purposes, we were unable to publish those data.
Our study suggested improved perception of physician and nursing communication. Interestingly, our results mirror previous studies that showed discrepant views between physicians and nursing regarding communication.4,5 In these prior studies, such differences were attributed to differences in gender, authority, and the role in patient care.4
We were able to show that with improved communication, health care providers’ perceptions of patient safety also improved. Nursing staff are frequently expected to communicate the plan of care with patients since they are the first staff member to encounter patients and their families. Although our results suggested improved perception of patient care, this study was not designed to measure adverse outcomes. Previous studies have showed improved communication leading to reduction of adverse outcomes.12 This would be a worthwhile area to study with regards to our unique MDR model.
Our study associated a decrease in LOS of 10% with implementation of the MDR protocol. Despite the lack of statistical significance, there is a large clinical and financial impact associated with this difference. Most studies have been able to show a decrease in LOS with interventions to improve communication through interdisciplinary meetings. In the few studies that have not shown this (or found increased LOS), those studies have either had low patient acuity, low frequency of interdisciplinary meetings, or small sample sizes.20,21,27 Wild and colleagues20 hypothesized that their patients were clinically more stable, and thus it was more difficult to significantly decrease their LOS. In addition, they powered their study to target a decrease of 1.5 days, and in the end also agreed that perhaps that was too lofty, as most other studies have been able to decrease LOS around 0.5 days.20
With the passage of the ACA and the increasing importance of quality of care and patient satisfaction, teamwork and communication are paramount to the delivery of quality hospital care. Our pilot study suggests that a comprehensive care coordination model involving the implementation of a standardized MDR protocol could improve communication among the health care team and possibly reduce LOS. Communication of the outcomes of MDR using a novel patient communication tool was also associated with improvements in patient assessments of their quality of care. This pilot study serves as a base model for further quality assurance studies. A future study will need to be larger in scope for statistical significance, and should also look to investigate adverse outcomes.
Our experience and the results of our study revealed the importance of and the barriers associated with incorporating a successful permanent model of MDR. We found that short-term practice of a standardized model quickly transitioned to long-term habits with improved efficiency. In the current atmosphere of hospital-based medicine, transitioning to full geographical units, as well as utilizing a standardized communication tool, is important to run effective MDR and ultimately improve communication and patient care.
1. Patient Protection and Affordable Care Act. US Government Publishing Office website. https://www.gpo.gov/fdsys/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf. Accessed April 19, 2017.
2. Centers for Medicare and Medicaid Services. Hospital Value-Based Purchasing. Centers for Medicare and Medicaid Services website. cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/index.html?redirect=/hospital-value-based-purchasing. Accessed April 19, 2017.
3. HCAHPs: Patient’s Perspectives of Care Survey. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Accessed April 19, 2017.
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