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A New Paradigm

With the patient at center stage, UCLA moves toward a broader, more integrated and purposeful approach to providing care.

Story by Dan Gordon.  Illustration by Sandra Dionisi

paradigmWHEN RONALD REAGAN UCLA MEDICAL CENTER opened in the spring of 2008, it was among the most sophisticated medical facilities of its kind, an architectural wonder heralded as the first in a new era of modern and technologically advanced teaching hospitals. But for all the change embodied in the move from the aging Center for the Health Sciences structure to the contemporary facility across the street, it’s the initiatives that have either begun or accelerated since the move that are fundamentally transforming the patient experience, both at Ronald Reagan UCLA Medical Center and at its sister facility, Santa Monica-UCLA Medical Center and Orthopaedic Hospital.

Driven by factors both external and internal – from the national imperative to deliver more cost-effective care and new restrictions on medical-resident work hours to a determination by the leadership of UCLA Health System to improve the patient experience – the hospitals have instituted changes designed to create a more integrated and purposeful system. A newly created department is devoted to ensuring clear care strategies, prompt discharges and appropriate post-discharge planning. Interdisciplinary rounds have dramatically improved communication across the healthcare teams and with patients. The increased use of hospitalists – physicians who specialize in inpatient care – has improved coordination and communication, reduced fragmentation of care and filled a void created by the lower number of hours residents can be on duty.

It is all adding up to a smoother system and a better experience for patients – a result that can be seen clearly in satisfaction rankings, which in only a few years have jumped from the 37th to the 98th percentile in an independent comparison of hospitals across the nation.

“We recognized that if we wanted to continue to thrive in today’s environment, we needed to improve the patient experience and use our resources as efficiently and effectively as possible,” says Tom Rosenthal, M.D., chief medical officer for UCLA Health System. “And to do that, we had to take a much more systematic approach to services within the hospital.”

> MEDICINE HAS, UNTIL RECENTLY, LARGELY RESEMBLED A COTTAGE INDUSTRY, with individual physicians responding to their patients’ needs and referring to specialists and subspecialists when a patient’s illness is beyond their expertise. “Even at a large hospital such as ours, most doctors worked fairly independently,” says Jan Tillisch, M.D., executive vice chair of the Department of Medicine in the David Geffen School of Medicine at UCLA. But particularly in the last decade, Dr. Tillisch notes, there has been a growing recognition that the patient’s system-wide needs should be addressed, and that a multidisciplinary team of individuals should implement their care.

“When you come to UCLA, whatever your illness, it should be addressed in a way that reduces duplication and competition among alternative forms of therapy, and gives the patient the best access in the most efficient way,” Dr. Tillisch says. “A system means you have a primary doctor who understands the priorities for that patient’s health but can also be educated by subspecialists as to what the patient needs, with strong communication and easily accessible information that everyone shares. We have begun to develop this type of integrated system, with more people involved and responsibilities distributed more widely.”

Under the banner of the UCLA Operating System, the hospitals have empowered performance-excellence teams, as well as outside consultants, to help implement process-improvement initiatives modeled after Toyota Lean production methods. The wideranging efforts aim to better organize the delivery of services and bolster communications across the healthcare team, as well as with patients. “Lean is a culture – it’s about engaging staff in eliminating waste and improving performance, so that everyone is looking at new and better ways of doing things,” says Douglas Gunderson, executive director of Operative Services and interim director of Performance Excellence.

Initiatives implemented by the performance-excellence group have included a “time out” before every procedure during which the healthcare team members validate that they are undertaking the right procedure with the right patient and know their role, and any questions or concerns can be raised and addressed. The group has analyzed how patients move from the emergency department to hospital beds to discharge, finding ways to improve the flow and ensure smooth transitions through better coordination. Closer scrutiny of supply needs has led to $10 million a year in cost savings without compromising care. A program called “C-I Care” trains all hospital staff in how to interact with patients in ways that show respect, ensure privacy and keep patients and their families informed of the care plan.

“We now have a comprehensive system that aligns our mission, vision and values to performance at the point of care,” says Gunderson. “We have metrics that allow us to track how we’re doing and see where we need to be more effective. Members of the staff are very open about opportunities to address problems, and are working together to improve performance. It’s been a very positive cultural change.”

> RARELY ARE THERE MANY EMPTY BEDS at Ronald Reagan UCLA Medical Center – and, with the facility operating at nearly 100 percent capacity, it is particularly important for processes to be in place that ensure patients receive services they need, and are prepared for discharge in a timely manner. “We want to optimize the number of people who can have access,” says Dr. Rosenthal, “and it doesn’t serve patients if they’re in the hospital longer than they have to be simply because the care wasn’t well organized.”

That imperative led to the building of a care-coordination department to support the physician and nurse teams around transitions of care both within the hospital and out of the hospital. The department’s nurse case managers and social workers work with the care team on each hospital service to establish and coordinate the target date and plan for discharge, identify any barriers, and help facilitate a plan of care to ensure that proper steps are taken to meet the goals. Social workers help families with decision-making and potential conflicts, and link them to community services. Last year, a consulting group, Stockamp, was brought in to work with both the Westwood and Santa Monica hospitals on the issue of patient progression – how to appropriately move patients through the system to avoid bottlenecks and ensure their stay isn’t any longer than necessary. The effort touched key hospital services such as transportation and patient placement (assigning patients to the right bed on the right service at the right time), as well as care coordination and the structure of patientcare rounds. The consulting group also introduced a new database system – metrics that the hospitals use to ensure proper patient progression.

“We have become much better at communicating with one another, identifying the status of any given patient and informing patients and families when we expect to discharge them, which is very important,” says Marcia Colone, Ph.D., director of care coordination for UCLA Health System. “With good communication we all have the same focus and priorities, which has a direct effect on both quality and satisfaction.”

> MAJOR CHANGES HAVE ALSO TAKEN PLACE in the structure of the rounds on which these discussions occur: They are more systematic than in the past, and they are now interdisciplinary.

The challenges in the daily coordination of care have become increasingly intense in recent years for two major reasons, Dr. Rosenthal notes. First, given the growing number of health services that can be provided on an outpatient basis, patients who are hospitalized are much sicker than in previous times.

The difficulties in managing these complex cases have been compounded in recent years by the restrictions on residents’ work hours. “It used to be you’d have a team of residents taking care of patients, with oversight from an attending physician,” Dr. Rosenthal explains. “They were the glue – they coordinated all of the care, and there were no handoffs necessary because it was basically the same doctors 24/7. With resident-work-hour restrictions, they began changing shifts more often and sometimes working only a week at a time, and that has increased the chances for daily care to become disorganized.”

One of the responses has been to formalize the way nurses and physicians communicate with each other on a daily basis. “In healthcare, there has always been some kind of rounding by each service, but on the acute-care floors it tended to be haphazard,” says Cathy R. Ward, R.N., D.N.Sc., UCLA Health System’s director of nursing. “The doctors would come through and see the patient, and they might not even see the nurse to have a coordinated discussion about the care.”

As patients’ acuity has increased, Ward contends, so has the need for good communication. “There is a lot of evidence that says the better communication and collaboration you have amongst the team, the better the outcomes will be,” she says. “There are so many things that have to get done during a patient’s stay, and often the nurses weren’t aware of the plan. When all team members are hearing the same thing, they can act right away.”

Now each service runs its own version of a program called Every Patient Every Day in which the entire care team discusses each case during rounds – ideally with the patient and family present – on a daily basis. The team – which, in addition to nurses and physicians, includes the care coordinator and other relevant disciplines such as social work, physical therapy and pharmacy – discusses the care plan and sets daily goals as well as the goals toward discharge. In some cases, a plan is written on a whiteboard in the patient’s room to ensure that all parties are aware of the direction being taken.

“In the complex, fast-paced environment of a teaching hospital, it’s easy for decisions to be made without pivotal members of the team being present or becoming aware of them in a timely fashion,” says Mark Flitcraft, R.N., M.S.N., unit director of the medical intensive care unit at Ronald Reagan UCLA Medical Center. The interdisciplinary rounds enable key team members, each of whom offers a different perspective, to participate in those decisions, Flitcraft notes. It also ensures that the desires of the patient and patient’s family remain central to the discussion.

Ward’s team studied the effect of the interdisciplinary rounds and found that across the board, nurses and physicians at the hospital believe care has improved on their units as a result of the clearer and shared decision-making, and that patients are more likely to know what to expect. The study also found that average length of stay and hospital readmissions have been reduced.

> THE EMERGENCE OF HOSPITALISTS IN RECENT YEARS has also helped to address concerns about continuity of care at a time when residents no longer work the long shifts that enabled them to manage patients through much of their stay – even as it raised concerns about levels of fatigue among residents.

Hospitalists are physicians devoted almost entirely to inpatient care. As such, they are skilled in the management of the acute conditions that get patients admitted to the hospital and adept at navigating the often complex hospital system. Moreover, their constant presence in the facility makes them highly accessible to patients.

“We provide a continuous presence in the hospital,” says Michael Lazarus, M.D., medical director of the hospitalist service for UCLA Health System. “It makes the handovers and transitions of care more seamless when you have someone who understands the intricacies of care in that part of the hospital and is always there.”

Dr. Lazarus notes that there is greater recognition of the importance of transitions of care. “This is a critical time when you don’t want anything to slip through the cracks,” he explains. The keys to successful transitions, Dr. Lazarus says, involve communication with the patient’s primarycare physician to ensure that information about the patient’s status and needs is clearly understood and appropriately acted on.

UCLA Health System is in the process of expanding its hospitalist program significantly – from 26 to 40 full-time physicians. Traditionally confined to medicine units, the hospitalist role is also expanding to surgical services – including orthopaedics, urology and, within the next year, neurosurgery – as a way of freeing up surgical house staff to spend more time in the operating room.

> ALL OF THESE DEVELOPMENTS ARE HAVING A MAJOR IMPACT ON THE TRAINING OF NEW PHYSICIANS, Dr. Tillisch notes. Now that residents are less likely to manage patients throughout their hospital stay, a greater emphasis is being placed on interpersonal matters. Residents are being taught to make sure they introduce themselves to the patient every time they enter a room, explain what they’re about to do, and assure the patient that, despite being a new face, they are well versed in the intricacies of the case. A detailed computer signout system has been developed for house staff to ensure that no information is lost in handoffs.

Other changes are related to a widening of the physician’s scope as UCLA moves toward a more integrated healthcare system. “Because of all these system needs, it’s important to train physicians much more broadly,” Dr. Tillisch explains. “We have to teach them not just how to treat disease but also how to help patients navigate through that system to get the support they need. Particularly for the physicians who are most involved with a continuum of care, we’re teaching them how to participate in a more collaborative way. That’s a different kind of teaching, going beyond understanding the fundamental mechanism of disease. So the content of medical education continues to expand, even as the training hours are reduced.”

For all of the challenges in teaching physicians in new ways, though, Dr. Tillisch believes the move toward a more integrated, systematic approach is to everyone’s benefit. Dr. Rosenthal agrees. “Our goal is to deliver reliably excellent care, 100 percent of the time,” he says. “To do that, we need to look at all of the processes and explicitly determine the best ways to operate. At the end of the day, all of these changes are being made in the service of making the patient experience better, and we have clear evidence that we are succeeding in doing that.” Dan Gordon is a regular contributor to UCLA Medicine.

Dan Gordon is a regular contributor to UCLA Medicine.

 

 





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