Making sense: duty hours, work flow, and waste in graduate medical education

Association of Mobile Workstations and Rounding-in-Flow with Resident Efficiency: A Controlled Study at an Academic Internal Medicine Department

BACKGROUND

Residents commonly use a batched workflow to round on hospitalized patients, creating redundancy and decreasing efficiency.

OBJECTIVE

To improve resident efficiency through a novel workflow using mobile laptops and modified rounding-in-flow.

DESIGN, SETTING, PARTICIPANTS

A controlled experimental study conducted at an academic medical center for 3 months. One internal medicine team served as the intervention group, and two other teams served as a control group; 34 interns and 20 senior residents participated.

INTERVENTION

Residents in the intervention group were provided a novel workflow and a mobile laptop to allow them to round "in-flow." Control group residents rounded as usual (batched workflow without laptops).

MAIN MEASURES

Fourteen interns were monitored for a time-motion study. Time-stamped electronic medical record (EMR) data were used to assess percentage of progress notes and orders placed during rounds (9 a.m.-12:30 p.m.) and percentage of discharge summaries signed within 24 h of discharge. A post-intervention survey measured perceived efficiency.

RESULTS

A time-motion study showed non-significant differences between time in the intervention group and that in the control group: communication time with patients (128 min vs 105 min, p = 0.37) and computer time (289 min vs 306 min, p = 0.71). EMR data for 664 visits in the control group and 374 in the intervention group showed that rounding-in-flow was associated with an odds ratio (OR) of 1.5 for placing progress notes during rounds (95% CI: 1.2-1.7, p < 0.001), an OR of 1.1 for placing non-discharge orders during rounds (95% CI: 1.0-1.2, p = 0.01), and an OR of 3.9 for signing discharge summaries within 24 h of discharge (95% CI: 2.3-7.2, p < 0.001). Post-intervention survey, completed by 23 of 34 interns, showed that interns in the intervention group perceived that orders were completed during rounds more often than the control group (OR 7.8; 95% CI: 1.3-60.1, p = 0.03).

CONCLUSIONS

Using mobile laptops with modified rounding-in-flow was associated with earlier completion of residents' work, suggesting improved efficiency.

Incorporation of lean methodology into pharmacy residency programs

PURPOSE

The implementation of lean methodology into pharmacy residency programs at a community teaching hospital is described.

SUMMARY

New Hanover Regional Medical Center, a community teaching hospital in southeastern North Carolina, fully adopted a lean culture in 2010. Given the success of lean strategies organizationally, this methodology was used to assist with the evaluation and development of its pharmacy residency programs in 2014. Lean tools and activities have also been incorporated into residency requirements and rotation learning activities. The majority of lean events correspond to the required competency areas evaluating leadership and management, teaching, and education. These events have included participation in and facilitation of various lean problem-solving and communication tools. The application of the 4 rules of lean has resulted in enhanced management of the programs and provides a set of tools by which continual quality improvement can be ensured. Regular communication and direct involvement of all invested parties have been critical in developing and sustaining new improvements. In addition to program enhancements, lean methodology offers novel methods by which residents may be incorporated into leadership activities.

CONCLUSION

The incorporation of lean methodology into pharmacy residency programs has translated into a variety of realized and potential benefits for the programs, the preceptors and residents, and the health system. Specific areas of growth have included quality-improvement processes, the expansion of leadership opportunities for residents, and improved communication among program directors, preceptors, and residents.