Utilizing Lean Leadership Principles to Build an Academic Primary Care Practice of the Future.

This Perspective presents a case study of multidimensional clinical transformation in an academic general internal medicine practice. In the face of increasing internal and external pressures, health systems and individual medical practices have pursued multiple strategies to improve quality, patient experience, and efficiency, while reducing staff and provider stress and burnout. We describe a Lean-informed approach that emphasizes the importance of organizational alignment in goals, evidence-based problem solving, and leadership behaviors to support a culture of continuous improvement. Our aim in this Perspective is to provide a real-world example of a feasible process for the planning, preparation, and execution of effective transformation, and to present lessons that may be useful to other academic health center practices seeking to develop innovative models to achieve the quadruple aim.

Using a Systematic Framework of Interventions to Improve Early Discharges.

BACKGROUND: Late-afternoon hospital discharges can lead to admission bottlenecks and negatively affect the flow of patients needing hospital admission. Delays in discharge are a prevalent health care problem and have been linked to increased length of stay, lower patient satisfaction scores, and adverse outcomes. As a result, hospitals are placing a renewed emphasis on early discharge as a way to reduce admission delays and achieve optimal patient flow. This study shows that the Model for Improvement (MFI) is an effective approach for complex improvement efforts. METHODS: A needs assessment identified four common barriers to early discharge: (1) lack of communication between nurses, case managers, and teams about discharge planning; (2) obtaining home services, equipment, and oxygen early in the morning; (3) arranging transportation to facilities earlier in the day; and (4) communicating discharge expectations with patients and family members. Using the MFI, we tested and implemented interventions in three key areas: education, process changes, and audit and feedback. Key interventions included an educational campaign on the safety implications of reducing emergency department boarding time, an afternoon huddle with MDs and case managers, and a Web-based dashboard to provide real-time discharge by noon (DBN) audit and feedback. RESULTS: The DBN rate increased from a baseline of 10.4% to an average of 19.7% during a 24-month time frame, with significant improvements in average length of stay (5.88 to 5.60) and length of stay index (1.18 to 1.10) (p <0.05). CONCLUSION: Improving hospital throughput is becoming imperative, and a structured approach to improvement can lead to rapid and sustainable results.

Exploring Physician Perspectives of Residency Holdover Handoffs: A Qualitative Study to Understand an Increasingly Important Type of Handoff.

BACKGROUND: The term "holdover admissions" refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse. OBJECTIVE: To identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs. DESIGN: We undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis. PARTICIPANTS: IM residents, IM program directors, and hospitalists at a large academic medical center. MAIN MEASURES: A nine-question open-ended interview guide. KEY RESULTS: We identified 13 factors describing holdover handoffs. Five factors-physical space, standardization, task accountability, closed-loop verification, and resilience-were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education. CONCLUSIONS: The holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.