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The impact of a lean rounding process in a pediatric intensive care unit*

Vats, Atul MD, FAAP; Goin, Kristin H. MSHS; Villarreal, Monica C. MS; Yilmaz, Tuba MS; Fortenberry, James D. MD, FAAP, FCCM; Keskinocak, Pinar PhD

doi: 10.1097/CCM.0b013e318232e2fc
Pediatric Critical Care

Introduction/Objective: Poor workflow associated with physician rounding can produce inefficiencies that decrease time for essential activities, delay clinical decisions, and reduce staff and patient satisfaction. Workflow and provider resources were not optimized when a pediatric intensive care unit increased by 22,000 square feet (to 33,000) and by nine beds (to 30). Lean methods (focusing on essential processes) and scenario analysis were used to develop and implement a patient-centric standardized rounding process, which we hypothesize would lead to improved rounding efficiency, decrease required physician resources, improve satisfaction, and enhance throughput.

Design: Human factors techniques and statistical tools were used to collect and analyze observational data for 11 rounding events before and 12 rounding events after process redesign. Actions included: 1) recording rounding events, times, and patient interactions and classifying them as essential, nonessential, or nonvalue added; 2) comparing rounding duration and time per patient to determine the impact on efficiency; 3) analyzing discharge orders for timeliness; 4) conducting staff surveys to assess improvements in communication and care coordination; and 5) analyzing customer satisfaction data to evaluate impact on patient experience.

Setting: Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation.

Patients/Subjects: Eight attending pediatric intensivists and their physician rounding teams.

Interventions: Eight attending physician-led teams were observed for 11 rounding events before and 12 rounding events after implementation of a standardized lean rounding process focusing on essential processes.

Measurements and Main Results: Total rounding time decreased significantly (157 ± 35 mins before vs. 121 ± 20 mins after), through a reduction in time spent on nonessential (53 ± 30 vs. 9 ± 6 mins) activities. The previous process required three attending physicians for an average of 157 mins (7.55 attending physician man-hours), while the new process required two attending physicians for an average of 121 mins (4.03 attending physician man-hours). Cumulative distribution of completed patient rounds by hour of day showed an improvement from 40% to 80% of patients rounded by 9:30 AM. Discharge data showed pediatric intensive care unit patients were discharged an average of 58.05 mins sooner (p < .05). Staff surveys showed a significant increase in satisfaction with the new process (including increased efficiency, improved physician identification, and clearer understanding of process). Customer satisfaction scores showed improvement after implementing the new process.

Conclusions: Implementation of a lean-focused, patient-centric rounding structure stressing essential processes was associated with increased timeliness and efficiency of rounds, improved staff and customer satisfaction, improved throughput, and reduced attending physician man-hours.

From the Children's Healthcare of Atlanta (AV, KHG, JDF), and Emory University School of Medicine (AV, JDF); and School of Industrial and Systems Engineering Georgia Institute of Technology (MCV, TY, PK), Atlanta, GA.

* See also p. 699.

Supported, in part, by a gift from the Critical Care Medicine research fund and a grant from the Clinical Outcomes Research and Public Health Pilot Grant Program, jointly sponsored by Georgia Tech and Children's Healthcare of Atlanta, and by the Harold R. and Mary Anne Nash Endowment and the Smalley Endowment at Georgia Tech.

The authors have not disclosed any potential conflicts of interest.

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© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins