A Time Motion Study Evaluating the Impact of Geographic Cohorting of Hospitalists
BACKGROUND: Geographic cohorting (GCh) localizes hospitalists to a unit. Our objective was to compare the GCh and non-GCh workday.
METHODS: In an academic, Midwestern hospital we observed hospitalists in GCh and non-GCh teams. Time in patient rooms was considered direct care; other locations were considered ‘indirect’ care. Geotracking identified time spent in each location and was obtained for 17 hospitalists. It was supplemented by in-person observation of four GCh and four non-GCh hospitalists for a workday each. Multilevel modeling was used to analyze associations between direct and indirect care time and team and workday characteristics.
RESULTS: Geotracking yielded 10,522 direct care episodes. GCh was associated with longer durations of patient visits while increasing patient loads were associated with shorter visits. GCh, increasing patient loads, and increasing numbers of units visited were associated with increased indirect care time. In-person observations yielded 3,032 minutes of data. GCh hospitalists were observed spending 56% of the day in computer interactions vs non-GCh hospitalists (39%; P < .005). The percentage of time spent multitasking was 18% for GCh and 14% for non-GCh hospitalists (P > .05). Interruptions were pervasive, but the highest interruption rate of once every eight minutes in the afternoon was noted in the GCh group.
CONCLUSION: GCh may have the potential to increase patient–hospitalist interactions but these gains may be attenuated if patient loads and the structure of cohorting are suboptimal. The hospitalist workday is cognitively intense. The interruptions noted may increase the time taken for time-intensive tasks like electronic medical record interactions.
© 2019 Society of Hospital Medicine
Geographic cohorting (GCh, also known as “localization” or “regionalization”) refers to the practice wherein hospitalists are assigned to a single inpatient unit. Its adoption is increasing and in 2017, 30% of surveyed United States hospital medicine group leaders reported that their clinicians rounded on 1-2 units daily.1 As a component of intervention bundles, GCh is associated with reductions in mortality, length of stay, and costs.2,3
However, details on how GCh affects the hospitalist workday are unknown. Most time-motion studies of inpatient clinicians have reported the experiences of physicians in training with few specifically evaluating the workflow of attending hospitalists.4 Three studies of the attending hospitalist’s workday that were performed a decade ago excluded teams with learners, had patient loads as low as 9.4 per day, and did not differentiate between GCh and non-GCh models.5-7
The objective of this observational study was to describe and compare the workday of GCh and non-GCh hospitalists by using automated geographical-tracking methods supplemented by in-person observations.
METHODS
Setting and Participants
This work was conducted at a large academic center in the Midwestern US which adopted GCh in 2012. During the study, hospitalists staffed 11 GCh and four non-GCh teams. GCh teams aim to maintain ≥80% of their patients on their assigned unit and conduct interprofessional huddles on weekdays.3 Some units specialize in the care of specific populations (eg, patients with oncologic diagnoses), while others serve as general medical or surgical units. Non-GCh teams are assigned patients without regard to location. Resident housestaff are assigned only to GCh teams and residents and advanced practice providers (APPs) are never assigned to the same team. Based on team members, this yielded five distinct team types: GCh-hospitalist, GCh-hospitalist with APP, GCh-hospitalist with resident, non-GCh-hospitalist, and non-GCh-hospitalist with APP. Hospitalists provided verbal consent to participate. The protocol was reviewed and approved by the Indiana University Institutional Review Board. Two complementary observation modalities were used. Locator badges were used to quantify direct and indirect time unobtrusively over long periods. In-person observations were conducted to examine the workday in greater detail. Data were collected between October 2017 and May 2018.
Observations by Locator Badges
Our institution uses a system designed by Hill-Rom® (Cary, North Carolina) to facilitate staff communication. Staff wear the I-Badge® Locator Badge, which emits an infra-red signal.8 Centrally located receivers tabulate time spent by the badge wearer in each location (Appendix Figure 1). Each hospitalist was given a badge to wear at work for a minimum of six weeks, after which the I-Badge® data were downloaded.
