Focusing hospitalist roles on either admitting or rounding facilitates unit-based assignment and is associated with improved discharge efficiency

BACKGROUND: Unit-based teams may improve care delivery for hospitalized patients but can be challenging to implement broadly across all acute care units in a hospital. OBJECTIVE: To determine the effect of a Lean-guided transition to hospital-wide unit-based assignment on care delivery outcomes. DESIGN, SETTING, AND PARTICIPANTS: The study was a retrospective time-series with primary outcomes of discharge efficiency, 30-day readmissions, and length of stay, performed at a 336-bed tertiary academic referral hospital in the Pacific Northwest with approximately 17,000 admissions annually. INTERVENTION: Implementation of a Lean-guided quality improvement intervention included division of hospitalist duties into 'admitters' and 'rounders,' with simulated patient flow exercises to determine the optimal staffing model. MAIN OUTCOMES AND MEASURES: Discharge efficiency (number of patients discharged by hospitalists divided by the number of hospitalist patient encounter days per month) and 30-day readmissions were compared using the t-test or chi-square, and length of stay was analyzed in a multivariate time-series regression model. RESULTS: The intervention was associated with a significant improvement in discharge efficiency, by 0.014 (from 0.168 to 0.181) discharges/encounter (95% CI = 0.024, 0.004), p = 0.009. Mean length of stay decreased by 0.98 days (95% CI 0.50, 1.47) after adjustment for patient age, patient type (medical versus surgical), critical care admissions, and discharge disposition, without a corresponding change in 30-day readmission rate (12.2% (1948/15,902) pre-intervention to 11.7% (397/3379) post-intervention (p = 0.42)). CONCLUSIONS: Dividing hospitalist roles into admitters and rounders enabled implementation of unit-based teams across the hospital, with corresponding improvements in discharge efficiency and length of stay.