Jungwha Lee, PhD, MPH

We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs).[1] We agree that a 7‐on/7‐off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7‐on/7‐off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work‐life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect.

We respectfully disagree with Dr. Kerman's concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under‐reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2‐stage method to identify and confirm AEs.[2] In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs.[3, 4, 5] A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This time‐consuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems.[6, 7]

With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs.[8] We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist.

We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity.[9] Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre‐post evaluation of a hospitalist staffing model specifically designed to improve continuity.[10] In the CICLE model, physicians work in a 4‐day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P=0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS.

Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and disadvantages. The disadvantages include time‐consuming cognitive work for the physician and the potential for information loss affecting patient care. The potential advantage is a second physician reassessing the diagnosis and management decisions established by the first, potentially correcting errors and optimizing care.

Ultimately, more research is needed to illuminate the effect of hospitalist continuity on patient outcomes. For now, we feel that hospital medicine group leaders need not institute lengthy rotations or staffing models that prioritize continuity above all other factors, as continuity appears to have little impact on patient outcomes.

We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs).[1] We agree that a 7‐on/7‐off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7‐on/7‐off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work‐life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect.

We respectfully disagree with Dr. Kerman's concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under‐reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2‐stage method to identify and confirm AEs.[2] In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs.[3, 4, 5] A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This time‐consuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems.[6, 7]

With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs.[8] We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist.

We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity.[9] Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre‐post evaluation of a hospitalist staffing model specifically designed to improve continuity.[10] In the CICLE model, physicians work in a 4‐day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P=0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS.

Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and disadvantages. The disadvantages include time‐consuming cognitive work for the physician and the potential for information loss affecting patient care. The potential advantage is a second physician reassessing the diagnosis and management decisions established by the first, potentially correcting errors and optimizing care.

Ultimately, more research is needed to illuminate the effect of hospitalist continuity on patient outcomes. For now, we feel that hospital medicine group leaders need not institute lengthy rotations or staffing models that prioritize continuity above all other factors, as continuity appears to have little impact on patient outcomes.

We greatly appreciate the thoughtful points made by Dr. Kerman regarding our recently published study evaluating the association of hospitalist continuity on adverse events (AEs).[1] We agree that a 7‐on/7‐off staffing model may limit discontinuity relative to models using shorter rotations lengths. Many hospital medicine programs use a 7‐on/7‐off model to optimize continuity. Longer rotation lengths are uncommon, as they may lead to fatigue and negatively affect physician work‐life balance. Shorter rotation lengths do exist, and we acknowledge that a study in a setting with greater fragmentation may have detected an effect.

We respectfully disagree with Dr. Kerman's concern that our methods for AE detection and confirmation may have been insensitive. We did not rely on incident reports, as these systems suffer from under‐reporting and often represent only a fraction of true AEs. We used a modified version of the classic 2‐stage method to identify and confirm AEs.[2] In the first stage, we used computerized screens, based on criteria from the Harvard Medical Practice Study and Institute for Healthcare Improvement global trigger tool, to identify potential AEs.[3, 4, 5] A research nurse created narrative summaries of potential AEs. A physician researcher then reviewed the narrative summaries to confirm whether an AE was truly present. This time‐consuming method is much more sensitive and specific than other options for patient safety measurement, including administrative data analyses and incident reporting systems.[6, 7]

With respect to other outcomes that may be affected by hospitalist continuity, we recently published a separate study showing that lower inpatient physician continuity was significantly associated with modest increases in hospital costs.[8] We found no association between continuity and patient satisfaction, but were likely underpowered to detect one. Interestingly, some of the models in our study suggested a slightly reduced risk of readmission with lower continuity. We were surprised by this finding and hypothesized that countervailing forces may be at play during handoffs of care from 1 hospitalist to another. Transitions of care introduce the opportunity for critical information to be lost, but they also introduce the potential for patient reassessment. A hospitalist newly taking over care from another may not be anchored to the initial diagnostic impressions and management plan established by the first. Of course, the potential benefit of a reassessment could only occur if the new hospitalist has time to perform one. At extremely high patient volumes, this theoretical benefit is unlikely to exist.

We did not include length of stay (LOS) as an outcome because hospitalist continuity and LOS are interdependent. Although discontinuity may lead to longer LOS, longer LOS definitely increases the probability of discontinuity. Thus, we controlled for LOS in our statistical models to isolate the effect of continuity. The study by Epstein and colleagues did not take into account the interdependence between LOS and hospitalist continuity.[9] Observational studies are not ideal for determining the effect of continuity on LOS. The Combing Incentives and Continuity Leading to Efficiency (CICLE) study by Chandra and colleagues was a pre‐post evaluation of a hospitalist staffing model specifically designed to improve continuity.[10] In the CICLE model, physicians work in a 4‐day rotation. On day 1, physicians exclusively admit patients. On day 2, physicians care for patients admitted on day 1 and accept patients admitted overnight. On days 3 and 4, physicians continue to care for patients received on days 1 and 2, but receive no additional patients. The remaining patients are transitioned to the next physician entering the cycle at the end of day 4. Chandra and colleagues found a 7.5% reduction in LOS and an 8.5% reduction in charges. Interestingly, they also found a 13.5% increase in readmissions that did not achieve statistical significance (P=0.08). The CICLE study suggests continuity does affect LOS, but is limited in that it did not account for a potential preexisting trend toward lower LOS.

Dr. Kerman presents data showing that it takes longer for a physician to care for a patient who is new to him or her than for a patient who is previously known. This finding has face validity. However, as we have suggested, the extra time spent by the oncoming physician may have both advantages and disadvantages. The disadvantages include time‐consuming cognitive work for the physician and the potential for information loss affecting patient care. The potential advantage is a second physician reassessing the diagnosis and management decisions established by the first, potentially correcting errors and optimizing care.

Ultimately, more research is needed to illuminate the effect of hospitalist continuity on patient outcomes. For now, we feel that hospital medicine group leaders need not institute lengthy rotations or staffing models that prioritize continuity above all other factors, as continuity appears to have little impact on patient outcomes.

Although definitions vary, continuity of care can be thought of as the patient's experience of a continuous caring relationship with an identified healthcare professional.[1] Research in ambulatory settings has found that patients who see their primary care physician for a higher proportion of office visits have higher patient satisfaction, better hypertensive control, lower risk of hospitalization, and fewer emergency department visits.[2, 3, 4, 5] Continuity with a single hospital‐based physician is difficult to achieve because of the need to provide care 24 hours a day, 7 days a week. Key clinical information may be lost during physician‐to‐physician handoffs (eg, at admission, at the end of rotations on service) during hospitalization. Our research group recently found that lower hospital physician continuity was associated with modestly increased hospital costs, but also a trend toward lower readmissions.[6] We speculated that physicians newly taking over patient care from colleagues reassess diagnoses and treatment plans. This reassessment may identify errors missed by the previous hospital physician. Thus, discontinuity may theoretically help or hinder the provision of safe hospital care.

We sought to examine the relationship between hospital physician continuity and the incidence of adverse events (AEs). We combined data from 2 previously published studies by our research group; one investigated the relationship between hospital physician continuity and costs and 30‐day readmissions, the other assessed the impact of unit‐based interventions on AEs.[6, 7]

METHODS

RESULTS

DISCUSSION

We found that hospitalist physician continuity was not associated with the incidence of AEs. Our findings are somewhat surprising because of the high value placed on continuity of care and patient safety concerns related to handoffs. Key clinical information may be lost when patient care is transitioned to a new hospitalist shortly after admission (eg, from a night hospitalist) or at the end of a rotation. Thus, it is logical to assume that discontinuity inherently increases the risk for harm. On the other hand, a physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This second look could potentially prevent missed/delayed diagnoses and optimize the plan of care.[19] These countervailing forces may explain our findings.

Several other potential explanations for our findings should be considered. First, the quality of handoffs may have been sufficient to overcome the potential for information loss. We feel this is unlikely given that little attention had been dedicated to improving the quality of patient handoffs among hospitalists in our institution. Notably, though a number of studies have evaluated resident physician handoffs, most of the work has focused on night coverage, and little is known about the quality of attending handoffs.[20] Second, access to a fully integrated electronic health record may have assisted hospitalists in complementing information received during handoffs. For example, a hospitalist about to start his or her rotation may have remotely accessed and reviewed patient medical records prior to receiving the phone handoff from the outgoing hospitalist. Third, other efforts to improve patient safety may have reduced the overall risk and provided some resilience in the system. Unit‐based interventions, including structured interdisciplinary rounds and nurse‐physician coleadership, improved teamwork climate and reduced AEs in the study hospital over time.[7]

Another factor to consider relates to the fact that hospital care is provided by teams of clinicians (eg, nurses, specialist physicians, therapists, social workers). Hospital teams are often large and have dynamic team membership. Similar to hospitalists, nurses, physician specialists, and other team members handoff care throughout the course of a patient's hospital stay. Yet, discontinuity for each professional type may occur at different times and frequencies. For example, a patient may be handed off from one hospitalist to another, yet the care continues with the same cardiologist or nurse. Future research should better characterize hospital team complexity (eg, size, relationships among members) and dynamics (eg, continuity for various professional types) and the impact of these factors on patient outcomes.

Our findings are important because hospitalist physician discontinuity is common during hospital stays. Hospital medicine groups vary in their staffing and scheduling models. Policies related to admission distribution and rotation length (consecutive days worked) systematically impact physician continuity. Few studies have evaluated the effect on continuity on hospitalized patient outcomes, and no prior research, to our knowledge, has explored the association of continuity on measures of patient safety.[6, 21, 22] Though our study might suggest that staffing models have little impact on patient safety, as previously mentioned, other team factors may influence patient outcomes.

Our study has several limitations. First, we assessed the impact of continuity on AEs in a single site. Although the 7 days on/7 days off model is the most common scheduling pattern used by adult hospital medicine groups,[23] staffing models and patient safety practices vary across hospitals, potentially limiting the generalizability of our study. Second, continuity can be defined and measured in a variety of ways. We used 2 different measures of physician continuity. As previously mentioned, assessing continuity of other clinicians may allow for a more complete understanding of the potential problems related to fragmentation of care. Third, this study excluded patients who experienced care transitions from other hospitals or other units within the hospital. Patients transferred from other hospitals are often complex, severely ill, and may be at higher risk for loss of key clinical information. Fourth, we used automated screens of an EDW to identify potential AEs. Although our prior research found that this method identified a similar number of AEs as manual medical record review screening, there was poor agreement between the 2 methods. Unfortunately, there is no gold standard to identify AEs. The EDW‐facilitated method allowed us to feasibly screen a larger number of charts, increasing statistical power, and minimized any potential bias that might occur during a manual review to identify potential AEs. Finally, we used data available from 2 prior studies and may have been underpowered to detect a significant association between continuity and AEs due to the relatively low percentage of patients experiencing an AE. In a post hoc power calculation, we estimated that we had 70% power to detect a 33% change in the proportion of patients with 1 or more AE for each 1‐unit increase in NPI, and 80% power to detect a 20% change for each 0.1‐unit decrease in UPC.

CONCLUSION

In conclusion, we found that hospitalist physician continuity was not associated with the incidence of AEs. We speculate that hospitalist continuity is only 1 of many team factors that may influence patient safety, and that prior efforts within our institution may have reduced our ability to detect an association. Future research should better characterize hospital team complexity and dynamics and the impact of these factors on patient outcomes.

Although definitions vary, continuity of care can be thought of as the patient's experience of a continuous caring relationship with an identified healthcare professional.[1] Research in ambulatory settings has found that patients who see their primary care physician for a higher proportion of office visits have higher patient satisfaction, better hypertensive control, lower risk of hospitalization, and fewer emergency department visits.[2, 3, 4, 5] Continuity with a single hospital‐based physician is difficult to achieve because of the need to provide care 24 hours a day, 7 days a week. Key clinical information may be lost during physician‐to‐physician handoffs (eg, at admission, at the end of rotations on service) during hospitalization. Our research group recently found that lower hospital physician continuity was associated with modestly increased hospital costs, but also a trend toward lower readmissions.[6] We speculated that physicians newly taking over patient care from colleagues reassess diagnoses and treatment plans. This reassessment may identify errors missed by the previous hospital physician. Thus, discontinuity may theoretically help or hinder the provision of safe hospital care.

We sought to examine the relationship between hospital physician continuity and the incidence of adverse events (AEs). We combined data from 2 previously published studies by our research group; one investigated the relationship between hospital physician continuity and costs and 30‐day readmissions, the other assessed the impact of unit‐based interventions on AEs.[6, 7]

METHODS

RESULTS

DISCUSSION

We found that hospitalist physician continuity was not associated with the incidence of AEs. Our findings are somewhat surprising because of the high value placed on continuity of care and patient safety concerns related to handoffs. Key clinical information may be lost when patient care is transitioned to a new hospitalist shortly after admission (eg, from a night hospitalist) or at the end of a rotation. Thus, it is logical to assume that discontinuity inherently increases the risk for harm. On the other hand, a physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This second look could potentially prevent missed/delayed diagnoses and optimize the plan of care.[19] These countervailing forces may explain our findings.

Several other potential explanations for our findings should be considered. First, the quality of handoffs may have been sufficient to overcome the potential for information loss. We feel this is unlikely given that little attention had been dedicated to improving the quality of patient handoffs among hospitalists in our institution. Notably, though a number of studies have evaluated resident physician handoffs, most of the work has focused on night coverage, and little is known about the quality of attending handoffs.[20] Second, access to a fully integrated electronic health record may have assisted hospitalists in complementing information received during handoffs. For example, a hospitalist about to start his or her rotation may have remotely accessed and reviewed patient medical records prior to receiving the phone handoff from the outgoing hospitalist. Third, other efforts to improve patient safety may have reduced the overall risk and provided some resilience in the system. Unit‐based interventions, including structured interdisciplinary rounds and nurse‐physician coleadership, improved teamwork climate and reduced AEs in the study hospital over time.[7]

Another factor to consider relates to the fact that hospital care is provided by teams of clinicians (eg, nurses, specialist physicians, therapists, social workers). Hospital teams are often large and have dynamic team membership. Similar to hospitalists, nurses, physician specialists, and other team members handoff care throughout the course of a patient's hospital stay. Yet, discontinuity for each professional type may occur at different times and frequencies. For example, a patient may be handed off from one hospitalist to another, yet the care continues with the same cardiologist or nurse. Future research should better characterize hospital team complexity (eg, size, relationships among members) and dynamics (eg, continuity for various professional types) and the impact of these factors on patient outcomes.

Our findings are important because hospitalist physician discontinuity is common during hospital stays. Hospital medicine groups vary in their staffing and scheduling models. Policies related to admission distribution and rotation length (consecutive days worked) systematically impact physician continuity. Few studies have evaluated the effect on continuity on hospitalized patient outcomes, and no prior research, to our knowledge, has explored the association of continuity on measures of patient safety.[6, 21, 22] Though our study might suggest that staffing models have little impact on patient safety, as previously mentioned, other team factors may influence patient outcomes.

Our study has several limitations. First, we assessed the impact of continuity on AEs in a single site. Although the 7 days on/7 days off model is the most common scheduling pattern used by adult hospital medicine groups,[23] staffing models and patient safety practices vary across hospitals, potentially limiting the generalizability of our study. Second, continuity can be defined and measured in a variety of ways. We used 2 different measures of physician continuity. As previously mentioned, assessing continuity of other clinicians may allow for a more complete understanding of the potential problems related to fragmentation of care. Third, this study excluded patients who experienced care transitions from other hospitals or other units within the hospital. Patients transferred from other hospitals are often complex, severely ill, and may be at higher risk for loss of key clinical information. Fourth, we used automated screens of an EDW to identify potential AEs. Although our prior research found that this method identified a similar number of AEs as manual medical record review screening, there was poor agreement between the 2 methods. Unfortunately, there is no gold standard to identify AEs. The EDW‐facilitated method allowed us to feasibly screen a larger number of charts, increasing statistical power, and minimized any potential bias that might occur during a manual review to identify potential AEs. Finally, we used data available from 2 prior studies and may have been underpowered to detect a significant association between continuity and AEs due to the relatively low percentage of patients experiencing an AE. In a post hoc power calculation, we estimated that we had 70% power to detect a 33% change in the proportion of patients with 1 or more AE for each 1‐unit increase in NPI, and 80% power to detect a 20% change for each 0.1‐unit decrease in UPC.

CONCLUSION

In conclusion, we found that hospitalist physician continuity was not associated with the incidence of AEs. We speculate that hospitalist continuity is only 1 of many team factors that may influence patient safety, and that prior efforts within our institution may have reduced our ability to detect an association. Future research should better characterize hospital team complexity and dynamics and the impact of these factors on patient outcomes.

Although definitions vary, continuity of care can be thought of as the patient's experience of a continuous caring relationship with an identified healthcare professional.[1] Research in ambulatory settings has found that patients who see their primary care physician for a higher proportion of office visits have higher patient satisfaction, better hypertensive control, lower risk of hospitalization, and fewer emergency department visits.[2, 3, 4, 5] Continuity with a single hospital‐based physician is difficult to achieve because of the need to provide care 24 hours a day, 7 days a week. Key clinical information may be lost during physician‐to‐physician handoffs (eg, at admission, at the end of rotations on service) during hospitalization. Our research group recently found that lower hospital physician continuity was associated with modestly increased hospital costs, but also a trend toward lower readmissions.[6] We speculated that physicians newly taking over patient care from colleagues reassess diagnoses and treatment plans. This reassessment may identify errors missed by the previous hospital physician. Thus, discontinuity may theoretically help or hinder the provision of safe hospital care.

We sought to examine the relationship between hospital physician continuity and the incidence of adverse events (AEs). We combined data from 2 previously published studies by our research group; one investigated the relationship between hospital physician continuity and costs and 30‐day readmissions, the other assessed the impact of unit‐based interventions on AEs.[6, 7]

METHODS

RESULTS

DISCUSSION

We found that hospitalist physician continuity was not associated with the incidence of AEs. Our findings are somewhat surprising because of the high value placed on continuity of care and patient safety concerns related to handoffs. Key clinical information may be lost when patient care is transitioned to a new hospitalist shortly after admission (eg, from a night hospitalist) or at the end of a rotation. Thus, it is logical to assume that discontinuity inherently increases the risk for harm. On the other hand, a physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This second look could potentially prevent missed/delayed diagnoses and optimize the plan of care.[19] These countervailing forces may explain our findings.

Several other potential explanations for our findings should be considered. First, the quality of handoffs may have been sufficient to overcome the potential for information loss. We feel this is unlikely given that little attention had been dedicated to improving the quality of patient handoffs among hospitalists in our institution. Notably, though a number of studies have evaluated resident physician handoffs, most of the work has focused on night coverage, and little is known about the quality of attending handoffs.[20] Second, access to a fully integrated electronic health record may have assisted hospitalists in complementing information received during handoffs. For example, a hospitalist about to start his or her rotation may have remotely accessed and reviewed patient medical records prior to receiving the phone handoff from the outgoing hospitalist. Third, other efforts to improve patient safety may have reduced the overall risk and provided some resilience in the system. Unit‐based interventions, including structured interdisciplinary rounds and nurse‐physician coleadership, improved teamwork climate and reduced AEs in the study hospital over time.[7]

Another factor to consider relates to the fact that hospital care is provided by teams of clinicians (eg, nurses, specialist physicians, therapists, social workers). Hospital teams are often large and have dynamic team membership. Similar to hospitalists, nurses, physician specialists, and other team members handoff care throughout the course of a patient's hospital stay. Yet, discontinuity for each professional type may occur at different times and frequencies. For example, a patient may be handed off from one hospitalist to another, yet the care continues with the same cardiologist or nurse. Future research should better characterize hospital team complexity (eg, size, relationships among members) and dynamics (eg, continuity for various professional types) and the impact of these factors on patient outcomes.

Our findings are important because hospitalist physician discontinuity is common during hospital stays. Hospital medicine groups vary in their staffing and scheduling models. Policies related to admission distribution and rotation length (consecutive days worked) systematically impact physician continuity. Few studies have evaluated the effect on continuity on hospitalized patient outcomes, and no prior research, to our knowledge, has explored the association of continuity on measures of patient safety.[6, 21, 22] Though our study might suggest that staffing models have little impact on patient safety, as previously mentioned, other team factors may influence patient outcomes.

Our study has several limitations. First, we assessed the impact of continuity on AEs in a single site. Although the 7 days on/7 days off model is the most common scheduling pattern used by adult hospital medicine groups,[23] staffing models and patient safety practices vary across hospitals, potentially limiting the generalizability of our study. Second, continuity can be defined and measured in a variety of ways. We used 2 different measures of physician continuity. As previously mentioned, assessing continuity of other clinicians may allow for a more complete understanding of the potential problems related to fragmentation of care. Third, this study excluded patients who experienced care transitions from other hospitals or other units within the hospital. Patients transferred from other hospitals are often complex, severely ill, and may be at higher risk for loss of key clinical information. Fourth, we used automated screens of an EDW to identify potential AEs. Although our prior research found that this method identified a similar number of AEs as manual medical record review screening, there was poor agreement between the 2 methods. Unfortunately, there is no gold standard to identify AEs. The EDW‐facilitated method allowed us to feasibly screen a larger number of charts, increasing statistical power, and minimized any potential bias that might occur during a manual review to identify potential AEs. Finally, we used data available from 2 prior studies and may have been underpowered to detect a significant association between continuity and AEs due to the relatively low percentage of patients experiencing an AE. In a post hoc power calculation, we estimated that we had 70% power to detect a 33% change in the proportion of patients with 1 or more AE for each 1‐unit increase in NPI, and 80% power to detect a 20% change for each 0.1‐unit decrease in UPC.

CONCLUSION

In conclusion, we found that hospitalist physician continuity was not associated with the incidence of AEs. We speculate that hospitalist continuity is only 1 of many team factors that may influence patient safety, and that prior efforts within our institution may have reduced our ability to detect an association. Future research should better characterize hospital team complexity and dynamics and the impact of these factors on patient outcomes.

Communication among hospital care providers is critically important to provide safe and effective care.15 Yet, studies in operating rooms, intensive care units (ICUs), and general medical units have revealed widely discrepant views on the quality of collaboration and communication between physicians and nurses.68 Although physicians consistently gave high ratings to the quality of collaboration with nurses, nurses rated the quality of collaboration with physicians relatively poorly.

A significant barrier to communication among providers on patient care units is the fluidity and geographic dispersion of team members.8 Physicians, nurses, and other hospital care providers have difficulty finding a way to discuss the care of their patients in person. Research has shown that nurses and physicians on patient care units do not communicate consistently and frequently are not in agreement about their patients' plans of care9, 10

Interdisciplinary Rounds (IDR) have been used as a means to assemble patient care unit team members and improve collaboration on the plan of care.1114 Prior research has demonstrated improved ratings of collaboration on the part of physicians,13, 14 but the effect of IDR on nurses' ratings of collaboration and teamwork has not been adequately assessed. One IDR study did not assess nurses' perceptions,13 while others used instruments not previously described and/or validated in the literature.12, 14 Regarding more concrete outcomes, research indicates variable effects of IDR on length of stay (LOS) and cost. Although 2 studies documented a reduction in LOS and cost with the use of IDR,12, 13 another study showed no effect.15 Furthermore, prior studies evaluated the use of IDR on resident‐covered teaching services. The effect IDR has on collaboration, LOS, and cost in a nonteaching hospitalist service setting is not known.

This study had 3 aims. The first was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. The second was to assess the feasibility and sustainability of the intervention. The third was to assess the impact of the intervention on hospital LOS and cost.

Methods

Results

Ratings of Teamwork and Perceptions of SIDR

As shown in Figure 1, a larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05).

Figure 1

Nurses' ratings of the teamwork and safety climate are summarized in Table 2. The median teamwork climate score was 85.7 (interquartile range [IQR], 75.092.9) for the intervention unit as compared to 61.6 (IQR, 48.283.9) for the control unit (P = 0.008). The median safety climate score was 75.0 (IQR, 70.581.3) for the intervention unit as compared to 61.1 (IQR, 30.281.3) for the control unit (P = 0.03).

Table 2.Nurses' Ratings of Teamwork and Patient Safety Climate by Unit

	Control Unit, n = 24	Intervention Unit, n = 25	P Value
Abbreviation: IQR, interquartile range.
Median Teamwork Climate Score (IQR)	75.0 (70.581.3)	61.6 (48.283.9)	0.008
Median Safety Climate Score (IQR)	85.7 (75.092.9)	61.1 (30.281.3)	0.03

Sixty‐five of 88 (74%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved the efficiency of their work day. Eighty of 88 (91%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved team collaboration. Seventy‐six of 88 (86%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved patient care. Sixty‐seven of 88 (76%) hospitalists and 22 of 25 (88%) nurses indicated that they wanted SIDR to continue indefinitely.

Discussion

We found that nurses working on a unit using SIDR rated the quality of communication and collaboration with hospitalists significantly higher as compared to a control unit. Notably, because hospitalists worked on both the intervention and control unit during their weeks on service, nurses on each unit were rating the quality of collaboration with the same hospitalists. Nurses also rated the teamwork and safety climate higher on the intervention unit. These findings are important because prior research has shown that nurses are often dissatisfied with the quality of collaboration and teamwork with physicians.68 Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6 Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.22, 23 SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.

Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.15 Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.2426 Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.

The majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their workday and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.11 Incorporating the input of frontline providers into the design of SIDR allowed us to create a sustainable intervention which fit into daily workflow.

Our bivariate analyses found significant patient case‐mix differences between the intervention and control unit, limiting our ability to perform direct comparisons in LOS and cost. Pre‐post analyses of LOS and cost may be affected by cyclical or secular trends. Because each approach has its own limitations, we felt that analyses using both an historic as well as a concurrent control would provide a more complete assessment of the effect of the intervention. We included case mix, among other variables, in out multivariable regression analyses and found no benefit to SIDR with regard to LOS and cost. Two prior studies have shown a reduction in LOS and cost with the use of IDR.12, 13 However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.12 The second study used a pre‐post study design which may not have accounted for unmeasured confounders affecting LOS and cost.13 A third, smaller study showed no effect on LOS and cost with the use of IDR.15 No prior study has evaluated the effect of IDR on LOS and cost in a nonteaching hospitalist service setting.

Our study has several limitations. First, our study reflects the experience of an intervention unit compared to a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizability of our findings. Second, we did not conduct preintervention provider surveys for comparison ratings of collaboration and teamwork. A prior study, conducted by our research group, found that nurses gave low ratings to the teamwork climate and the quality of collaboration with hospitalists.8 Because this baseline study showed consistently low nurse ratings of collaboration and teamwork across all medical units, and because the units in the current study were identical in size, structure, and staffing of nonphysician personnel, we did not repeat nurse surveys prior to the intervention. Third, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit.

In summary, SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a nonteaching hospitalist unit. Future research efforts should assess whether improved teamwork as a result of SIDR also translates into safer patient care.

Communication among hospital care providers is critically important to provide safe and effective care.15 Yet, studies in operating rooms, intensive care units (ICUs), and general medical units have revealed widely discrepant views on the quality of collaboration and communication between physicians and nurses.68 Although physicians consistently gave high ratings to the quality of collaboration with nurses, nurses rated the quality of collaboration with physicians relatively poorly.

A significant barrier to communication among providers on patient care units is the fluidity and geographic dispersion of team members.8 Physicians, nurses, and other hospital care providers have difficulty finding a way to discuss the care of their patients in person. Research has shown that nurses and physicians on patient care units do not communicate consistently and frequently are not in agreement about their patients' plans of care9, 10

Interdisciplinary Rounds (IDR) have been used as a means to assemble patient care unit team members and improve collaboration on the plan of care.1114 Prior research has demonstrated improved ratings of collaboration on the part of physicians,13, 14 but the effect of IDR on nurses' ratings of collaboration and teamwork has not been adequately assessed. One IDR study did not assess nurses' perceptions,13 while others used instruments not previously described and/or validated in the literature.12, 14 Regarding more concrete outcomes, research indicates variable effects of IDR on length of stay (LOS) and cost. Although 2 studies documented a reduction in LOS and cost with the use of IDR,12, 13 another study showed no effect.15 Furthermore, prior studies evaluated the use of IDR on resident‐covered teaching services. The effect IDR has on collaboration, LOS, and cost in a nonteaching hospitalist service setting is not known.

This study had 3 aims. The first was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. The second was to assess the feasibility and sustainability of the intervention. The third was to assess the impact of the intervention on hospital LOS and cost.

Methods

Results

Ratings of Teamwork and Perceptions of SIDR

As shown in Figure 1, a larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05).

Figure 1

Nurses' ratings of the teamwork and safety climate are summarized in Table 2. The median teamwork climate score was 85.7 (interquartile range [IQR], 75.092.9) for the intervention unit as compared to 61.6 (IQR, 48.283.9) for the control unit (P = 0.008). The median safety climate score was 75.0 (IQR, 70.581.3) for the intervention unit as compared to 61.1 (IQR, 30.281.3) for the control unit (P = 0.03).

Table 2.Nurses' Ratings of Teamwork and Patient Safety Climate by Unit

	Control Unit, n = 24	Intervention Unit, n = 25	P Value
Abbreviation: IQR, interquartile range.
Median Teamwork Climate Score (IQR)	75.0 (70.581.3)	61.6 (48.283.9)	0.008
Median Safety Climate Score (IQR)	85.7 (75.092.9)	61.1 (30.281.3)	0.03

Sixty‐five of 88 (74%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved the efficiency of their work day. Eighty of 88 (91%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved team collaboration. Seventy‐six of 88 (86%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved patient care. Sixty‐seven of 88 (76%) hospitalists and 22 of 25 (88%) nurses indicated that they wanted SIDR to continue indefinitely.

Discussion

We found that nurses working on a unit using SIDR rated the quality of communication and collaboration with hospitalists significantly higher as compared to a control unit. Notably, because hospitalists worked on both the intervention and control unit during their weeks on service, nurses on each unit were rating the quality of collaboration with the same hospitalists. Nurses also rated the teamwork and safety climate higher on the intervention unit. These findings are important because prior research has shown that nurses are often dissatisfied with the quality of collaboration and teamwork with physicians.68 Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6 Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.22, 23 SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.

Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.15 Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.2426 Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.

The majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their workday and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.11 Incorporating the input of frontline providers into the design of SIDR allowed us to create a sustainable intervention which fit into daily workflow.

Our bivariate analyses found significant patient case‐mix differences between the intervention and control unit, limiting our ability to perform direct comparisons in LOS and cost. Pre‐post analyses of LOS and cost may be affected by cyclical or secular trends. Because each approach has its own limitations, we felt that analyses using both an historic as well as a concurrent control would provide a more complete assessment of the effect of the intervention. We included case mix, among other variables, in out multivariable regression analyses and found no benefit to SIDR with regard to LOS and cost. Two prior studies have shown a reduction in LOS and cost with the use of IDR.12, 13 However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.12 The second study used a pre‐post study design which may not have accounted for unmeasured confounders affecting LOS and cost.13 A third, smaller study showed no effect on LOS and cost with the use of IDR.15 No prior study has evaluated the effect of IDR on LOS and cost in a nonteaching hospitalist service setting.

Our study has several limitations. First, our study reflects the experience of an intervention unit compared to a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizability of our findings. Second, we did not conduct preintervention provider surveys for comparison ratings of collaboration and teamwork. A prior study, conducted by our research group, found that nurses gave low ratings to the teamwork climate and the quality of collaboration with hospitalists.8 Because this baseline study showed consistently low nurse ratings of collaboration and teamwork across all medical units, and because the units in the current study were identical in size, structure, and staffing of nonphysician personnel, we did not repeat nurse surveys prior to the intervention. Third, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit.

In summary, SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a nonteaching hospitalist unit. Future research efforts should assess whether improved teamwork as a result of SIDR also translates into safer patient care.

Communication among hospital care providers is critically important to provide safe and effective care.15 Yet, studies in operating rooms, intensive care units (ICUs), and general medical units have revealed widely discrepant views on the quality of collaboration and communication between physicians and nurses.68 Although physicians consistently gave high ratings to the quality of collaboration with nurses, nurses rated the quality of collaboration with physicians relatively poorly.

A significant barrier to communication among providers on patient care units is the fluidity and geographic dispersion of team members.8 Physicians, nurses, and other hospital care providers have difficulty finding a way to discuss the care of their patients in person. Research has shown that nurses and physicians on patient care units do not communicate consistently and frequently are not in agreement about their patients' plans of care9, 10

Interdisciplinary Rounds (IDR) have been used as a means to assemble patient care unit team members and improve collaboration on the plan of care.1114 Prior research has demonstrated improved ratings of collaboration on the part of physicians,13, 14 but the effect of IDR on nurses' ratings of collaboration and teamwork has not been adequately assessed. One IDR study did not assess nurses' perceptions,13 while others used instruments not previously described and/or validated in the literature.12, 14 Regarding more concrete outcomes, research indicates variable effects of IDR on length of stay (LOS) and cost. Although 2 studies documented a reduction in LOS and cost with the use of IDR,12, 13 another study showed no effect.15 Furthermore, prior studies evaluated the use of IDR on resident‐covered teaching services. The effect IDR has on collaboration, LOS, and cost in a nonteaching hospitalist service setting is not known.

This study had 3 aims. The first was to assess the impact of an intervention, Structured Inter‐Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork. The second was to assess the feasibility and sustainability of the intervention. The third was to assess the impact of the intervention on hospital LOS and cost.

Methods

Results

Ratings of Teamwork and Perceptions of SIDR

As shown in Figure 1, a larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05).

Figure 1

Nurses' ratings of the teamwork and safety climate are summarized in Table 2. The median teamwork climate score was 85.7 (interquartile range [IQR], 75.092.9) for the intervention unit as compared to 61.6 (IQR, 48.283.9) for the control unit (P = 0.008). The median safety climate score was 75.0 (IQR, 70.581.3) for the intervention unit as compared to 61.1 (IQR, 30.281.3) for the control unit (P = 0.03).

Table 2.Nurses' Ratings of Teamwork and Patient Safety Climate by Unit

	Control Unit, n = 24	Intervention Unit, n = 25	P Value
Abbreviation: IQR, interquartile range.
Median Teamwork Climate Score (IQR)	75.0 (70.581.3)	61.6 (48.283.9)	0.008
Median Safety Climate Score (IQR)	85.7 (75.092.9)	61.1 (30.281.3)	0.03

Sixty‐five of 88 (74%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved the efficiency of their work day. Eighty of 88 (91%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved team collaboration. Seventy‐six of 88 (86%) hospitalists and 18 of 24 (75%) nurses agreed that SIDR improved patient care. Sixty‐seven of 88 (76%) hospitalists and 22 of 25 (88%) nurses indicated that they wanted SIDR to continue indefinitely.

Discussion

We found that nurses working on a unit using SIDR rated the quality of communication and collaboration with hospitalists significantly higher as compared to a control unit. Notably, because hospitalists worked on both the intervention and control unit during their weeks on service, nurses on each unit were rating the quality of collaboration with the same hospitalists. Nurses also rated the teamwork and safety climate higher on the intervention unit. These findings are important because prior research has shown that nurses are often dissatisfied with the quality of collaboration and teamwork with physicians.68 Potential explanations include fundamental differences between nurses and physicians with regard to status/authority, gender, training, and patient care responsibilities.6 Unfortunately, a culture of poor teamwork may lead to a workplace in which team members feel unable to approach certain individuals and uncomfortable raising concerns. Not surprisingly, higher ratings of teamwork culture have been associated with nurse retention.22, 23 SIDR provided a facilitated forum for interdisciplinary discussion, exchange of critical clinical information, and collaboration on the plan of care.

Our findings are also important because poor communication represents a major etiology of preventable adverse events in hospitals.15 Higher ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.2426 Further research should evaluate the impact of improved interdisciplinary collaboration as a result of SIDR on the safety of care delivered on inpatient medical units.

The majority of providers agreed that SIDR improved patient care and that SIDR should continue indefinitely. Importantly, providers also felt that SIDR improved the efficiency of their workday and attendance was high among all disciplines. Prior studies on IDR either did not report attendance or struggled with attendance.11 Incorporating the input of frontline providers into the design of SIDR allowed us to create a sustainable intervention which fit into daily workflow.

Our bivariate analyses found significant patient case‐mix differences between the intervention and control unit, limiting our ability to perform direct comparisons in LOS and cost. Pre‐post analyses of LOS and cost may be affected by cyclical or secular trends. Because each approach has its own limitations, we felt that analyses using both an historic as well as a concurrent control would provide a more complete assessment of the effect of the intervention. We included case mix, among other variables, in out multivariable regression analyses and found no benefit to SIDR with regard to LOS and cost. Two prior studies have shown a reduction in LOS and cost with the use of IDR.12, 13 However, one study was conducted approximately 15 years ago and included patients with a longer mean LOS.12 The second study used a pre‐post study design which may not have accounted for unmeasured confounders affecting LOS and cost.13 A third, smaller study showed no effect on LOS and cost with the use of IDR.15 No prior study has evaluated the effect of IDR on LOS and cost in a nonteaching hospitalist service setting.

Our study has several limitations. First, our study reflects the experience of an intervention unit compared to a control unit in a single hospital. Larger studies will be required to test the reproducibility and generalizability of our findings. Second, we did not conduct preintervention provider surveys for comparison ratings of collaboration and teamwork. A prior study, conducted by our research group, found that nurses gave low ratings to the teamwork climate and the quality of collaboration with hospitalists.8 Because this baseline study showed consistently low nurse ratings of collaboration and teamwork across all medical units, and because the units in the current study were identical in size, structure, and staffing of nonphysician personnel, we did not repeat nurse surveys prior to the intervention. Third, as previously mentioned, our study did not directly assess the effect of improved teamwork and collaboration on patient safety. Further study is needed to evaluate this. Although we are not aware of any other interventions to improve interdisciplinary communication on the intervention unit, it is possible that other unknown factors contributed to our findings. We believe this is unlikely due to the magnitude of the improvement in collaboration and the high ratings of SIDR by nurses and physicians on the intervention unit.

In summary, SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a nonteaching hospitalist unit. Future research efforts should assess whether improved teamwork as a result of SIDR also translates into safer patient care.