Letters To The Editor

In reference to “Redesigning an inpatient pediatric service using lean to improve throughput efficiency”

© 2015 Society of Hospital Medicine

I read Beck et al.'s article titled Redesigning an Inpatient Pediatric Service Using Lean to Improve Throughput Efficiency with great interest.[1] Redesigning the rounding process using Lean not only created a standard workflow including seeing dischargeable patients first, involving interdisciplinary huddle, completing the discharge checklist at bedside, but also added a second attending physician, thereby decreasing the workload. Stein et al. demonstrated that restructured floor‐based patient care including unit‐based teams, interdisciplinary bedside rounds, unit‐level performance reporting, and unit‐level nurse and physician coleadership all improved workflow with an average of 12.9 patients per physician.[2] Another study showed that increased workload was associated with prolonged length of stay with a recommended number of patients per day per physician at 15.[3] I want to point out the number of patients per physician in these studies. Today's hospitalists in community hospitals are expected to see >18 patients per day, with the additional pressure of decreasing costs, readmission rates, length of stays, and time for discharge while increasing productivity and patient satisfaction. Michtalik et al.'s survey showed that 40% of hospitalists reported exceeding their own safe numbers. Regardless of any assistance, physicians reported that they could safely see 15 patients per shift if their effort was 100% clinical.[4] Therefore, despite the outstanding results of the above studies, I am hesitant as to whether similar interventions would be as successful in community hospitals with higher patient loads. We need further studies to determine the optimum number of patients per hospitalist for nonteaching community hospitals. Another concern is how to adopt the successful examples of academic centers in nonteaching community hospitals in the absence of interns. Expecting hospitalists to replace the intern role is worrisome for job satisfaction, especially in the presence of high burnout rates.

Eliminating waste and redesigning the rounding process initiatives will definitely be the norm over the next years. We need to define center‐specific right patient/hospitalist ratios with proper roles and responsibilities for hospitalists. What works in the presence of residents may not work for nonteaching community hospitals. Caution should be taken while restructuring hospital medicine.


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