Location, location, location: New unit-based care model gaining traction in hospitals

Are the physicians and nurses in your hospital suffering from change fatigue?

There’s a new model of care that supporters say could help alleviate the weariness from continual quality improvement projects and process changes. It’s called an Accountable Care Unit, and though the name sounds a lot like an Accountable Care Organization, the two ideas have little in common.

Accountable Care Units (ACUs) are essentially geographic-based hospital units where the staff are held accountable for their patients’ outcomes. The four defining features of an ACU are unit-based teams, structured interdisciplinary bedside rounds, unit-level performance reporting, and unit-level nurse and physician coleadership.

Under this collaborative care model, hospitalists are assigned to a "home" unit where nearly all of their patients are located. The physician-leader partners with a nurse-manager to run the unit, and together with a team that includes allied health professionals, they conduct daily bedside rounds. A unique piece of the ACU model is the accountability. Instead of trying to discern performance based on facility-level or physician service line data, the hospital provides the ACU with unit-level data to help improve outcomes.

ACUs, which are the brainchild of hospitalist Dr. Jason Stein at Emory University in Atlanta, are currently up and running in multiple units across the Emory system, along with hospitals in seven U.S. states and more than 15 hospitals in Australia. The care model can be found in medical units, surgical units (including neurosurgery, orthopedic surgery, and general surgery), intensive care units, emergency departments, obstetrics units, pediatric units, psychiatry units, and long-term acute care units.

To help hospitals launch ACUs across their facilities, Dr. Stein founded Centripital, nonprofit organization whose mission is to train hospital professionals to work together in "high performing, patient-centered teams." The company has licensed implementation tools, including customized workflow diagrams, comprehensive training for front-line staff, and a train-the-trainer program with feedback tools so local leaders can spread the success of an initial ACU within their system.

Dr. Stein describes the model as a "Swiss Army knife" for the hospital. The idea is that instead of constantly ramping up for the next quality improvement project, the structure of the ACU allows physicians and nurses to target improvements without fundamentally changing their workflow.

"Whatever the metric is, whether it’s a clinical outcome or a utilization outcome, ... if you choose to focus on any of those items, we think you’re very likely to improve those outcomes," said Dr. Stein, who is the director for quality and research in Emory’s division of hospital medicine.

Dr. Stein launched the first ACU in 2010 in a 24-bed medical unit at Emory University Hospital. During the first year, the length of stay fell from an average of 5 days to 4.5 days. And in-hospital mortality dropped from 2.3 deaths per 100 encounters to 1.1 deaths. Initial results also have been similar in other hospitals that have launched ACUs, he said.

Costs, continuity, and ‘accountability’

At Emory, the gains were achieved at little cost to the system, Dr. Stein said, other than compensation for a part-time physician medical director and some staff training.

The biggest challenge in making the shift to an ACU model of care is the creation of unit-based teams, he said. "Physicians need to be able to share time and space throughout the day with the nurses with whom they share patients," Dr. Stein said.

One potential downside to making geography the primary driver of how physicians are assigned to patients is that there can be a break in the continuity of care. For example, if a patient cared for in an ACU must be transferred to the intensive care unit, after recovery the patient could potentially be transferred to a unit with a different team of physicians.

But Dr. Stein said it’s a manageable problem and one that is worth the trade-off.

Accountability on an ACU has multiple meanings. The first level of accountability is between members of the care team.

"There’s accountability at the bedside every day, because we are either showing up prepared to offer perspectives and answer questions in a structured way, or we’re not," Dr. Stein said. "That’s a massive daily accountability moment."

The second level comes from being able to review data that’s specific to the ACU. Dr. Stein recommends that ACU teams hold quarterly meetings that include specialty directors and service line chiefs to review unit-level performance reports. That type of public reporting among peers can be very powerful, he said.

The structure of the ACU model or a similar version of it "is probably the type of model that will make the most sense for the future," said Dr. Elizabeth Harry, a hospitalist at Presbyterian/ St. Luke’s Medical Center in Denver.

Dr. Harry helped implement an ACU at her institution about a year and a half ago and now serves as the medical director for that unit. So far, they have been able to reduce length of stay on the unit from an average of 5.3 days to 4 days and reduce costs by more than $800,000 since implementation.

"But more importantly," she said, "the ACU has been able to get physicians, nurses, pharmacists, case management, and therapy out of their individual silos and encourage collaboration."

"Having solo practitioners who care about their patients is not enough," Dr. Harry said. The model of care also needs to simplify the environment and increase communication among everyone who cares for patients to avoid errors and mitigate potential harm.

Dr. Harry also advises against taking the ACU model apart and applying just one piece. "It’s the combination of geographic units, interdisciplinary rounds, paired leadership, and data monitoring that will achieve results," she said.

Dr. Stein said he expects the model will continue to take hold. "There’s an understanding that we need a convergent solution," he said. "We need a solution that stops nibbling around the edges."

Care teams find new energy

Palmetto Health in Columbia, S.C., launched its first ACU in April, so it’s too soon to tell if they will see significant improvements in quality or cost. But the model has already brought "new life" to the physicians and nurses on the unit, said Carolyn Swinton, chief nursing officer at Palmetto Health Richland, a level I trauma academic medical center.

"There were team members on that unit who had been there for 20 years who we thought had lost their spark and their commitment, and they knocked it out of the park," Ms. Swinton said. "They were very engaged."

Palmetto Health wanted to try out the ACU concept as part of a broader push to improve the experience for patients and families. And they also saw it as a way to standardize the communication and care processes within the hospital, Ms. Swinton said.

So last fall, they traveled to Emory University to observe the ACU model in action and receive training about how to implement it. Earlier this year, they selected a unit where they already had strong physician engagement. The providers on the unit held a retreat where they developed a unit covenant and even practiced how they would talk to patients during the interdisciplinary bedside rounds.

Palmetto modified the Emory approach to the ACU slightly. In addition to having providers from pharmacy and social work, they added a nurse technician who could provide information about ambulation, toileting, and dietary intake.

The effect on morale within the unit was immediate.

"There was one nurse who was in tears," Ms. Swinton said. "She said it meant so much to her to have an opportunity to show her commitment and her skill and her passion for this work."

And Ms. Swinton said she also heard from the unit’s attending physician that the new process made her day easier, because everyone on the team knew the plan of care.

"The team is happy; you can feel it," she said. "On the unit, people are stepping up. They’re collaborating."

The next step is to begin rolling out the ACU concept unit by unit. They have identified a slate of units and plan to switch over one unit at a time every 120 days, Ms. Swinton said.

[email protected]

On Twitter @maryellenny

Are the physicians and nurses in your hospital suffering from change fatigue?

There’s a new model of care that supporters say could help alleviate the weariness from continual quality improvement projects and process changes. It’s called an Accountable Care Unit, and though the name sounds a lot like an Accountable Care Organization, the two ideas have little in common.

Accountable Care Units (ACUs) are essentially geographic-based hospital units where the staff are held accountable for their patients’ outcomes. The four defining features of an ACU are unit-based teams, structured interdisciplinary bedside rounds, unit-level performance reporting, and unit-level nurse and physician coleadership.

Under this collaborative care model, hospitalists are assigned to a "home" unit where nearly all of their patients are located. The physician-leader partners with a nurse-manager to run the unit, and together with a team that includes allied health professionals, they conduct daily bedside rounds. A unique piece of the ACU model is the accountability. Instead of trying to discern performance based on facility-level or physician service line data, the hospital provides the ACU with unit-level data to help improve outcomes.

ACUs, which are the brainchild of hospitalist Dr. Jason Stein at Emory University in Atlanta, are currently up and running in multiple units across the Emory system, along with hospitals in seven U.S. states and more than 15 hospitals in Australia. The care model can be found in medical units, surgical units (including neurosurgery, orthopedic surgery, and general surgery), intensive care units, emergency departments, obstetrics units, pediatric units, psychiatry units, and long-term acute care units.

To help hospitals launch ACUs across their facilities, Dr. Stein founded Centripital, nonprofit organization whose mission is to train hospital professionals to work together in "high performing, patient-centered teams." The company has licensed implementation tools, including customized workflow diagrams, comprehensive training for front-line staff, and a train-the-trainer program with feedback tools so local leaders can spread the success of an initial ACU within their system.

Dr. Stein describes the model as a "Swiss Army knife" for the hospital. The idea is that instead of constantly ramping up for the next quality improvement project, the structure of the ACU allows physicians and nurses to target improvements without fundamentally changing their workflow.

"Whatever the metric is, whether it’s a clinical outcome or a utilization outcome, ... if you choose to focus on any of those items, we think you’re very likely to improve those outcomes," said Dr. Stein, who is the director for quality and research in Emory’s division of hospital medicine.

Dr. Stein launched the first ACU in 2010 in a 24-bed medical unit at Emory University Hospital. During the first year, the length of stay fell from an average of 5 days to 4.5 days. And in-hospital mortality dropped from 2.3 deaths per 100 encounters to 1.1 deaths. Initial results also have been similar in other hospitals that have launched ACUs, he said.

Costs, continuity, and ‘accountability’

At Emory, the gains were achieved at little cost to the system, Dr. Stein said, other than compensation for a part-time physician medical director and some staff training.

The biggest challenge in making the shift to an ACU model of care is the creation of unit-based teams, he said. "Physicians need to be able to share time and space throughout the day with the nurses with whom they share patients," Dr. Stein said.

One potential downside to making geography the primary driver of how physicians are assigned to patients is that there can be a break in the continuity of care. For example, if a patient cared for in an ACU must be transferred to the intensive care unit, after recovery the patient could potentially be transferred to a unit with a different team of physicians.

But Dr. Stein said it’s a manageable problem and one that is worth the trade-off.

Accountability on an ACU has multiple meanings. The first level of accountability is between members of the care team.

"There’s accountability at the bedside every day, because we are either showing up prepared to offer perspectives and answer questions in a structured way, or we’re not," Dr. Stein said. "That’s a massive daily accountability moment."

The second level comes from being able to review data that’s specific to the ACU. Dr. Stein recommends that ACU teams hold quarterly meetings that include specialty directors and service line chiefs to review unit-level performance reports. That type of public reporting among peers can be very powerful, he said.

The structure of the ACU model or a similar version of it "is probably the type of model that will make the most sense for the future," said Dr. Elizabeth Harry, a hospitalist at Presbyterian/ St. Luke’s Medical Center in Denver.

Dr. Harry helped implement an ACU at her institution about a year and a half ago and now serves as the medical director for that unit. So far, they have been able to reduce length of stay on the unit from an average of 5.3 days to 4 days and reduce costs by more than $800,000 since implementation.

"But more importantly," she said, "the ACU has been able to get physicians, nurses, pharmacists, case management, and therapy out of their individual silos and encourage collaboration."

"Having solo practitioners who care about their patients is not enough," Dr. Harry said. The model of care also needs to simplify the environment and increase communication among everyone who cares for patients to avoid errors and mitigate potential harm.

Dr. Harry also advises against taking the ACU model apart and applying just one piece. "It’s the combination of geographic units, interdisciplinary rounds, paired leadership, and data monitoring that will achieve results," she said.

Dr. Stein said he expects the model will continue to take hold. "There’s an understanding that we need a convergent solution," he said. "We need a solution that stops nibbling around the edges."

Care teams find new energy

Palmetto Health in Columbia, S.C., launched its first ACU in April, so it’s too soon to tell if they will see significant improvements in quality or cost. But the model has already brought "new life" to the physicians and nurses on the unit, said Carolyn Swinton, chief nursing officer at Palmetto Health Richland, a level I trauma academic medical center.

"There were team members on that unit who had been there for 20 years who we thought had lost their spark and their commitment, and they knocked it out of the park," Ms. Swinton said. "They were very engaged."

Palmetto Health wanted to try out the ACU concept as part of a broader push to improve the experience for patients and families. And they also saw it as a way to standardize the communication and care processes within the hospital, Ms. Swinton said.

So last fall, they traveled to Emory University to observe the ACU model in action and receive training about how to implement it. Earlier this year, they selected a unit where they already had strong physician engagement. The providers on the unit held a retreat where they developed a unit covenant and even practiced how they would talk to patients during the interdisciplinary bedside rounds.

Palmetto modified the Emory approach to the ACU slightly. In addition to having providers from pharmacy and social work, they added a nurse technician who could provide information about ambulation, toileting, and dietary intake.

The effect on morale within the unit was immediate.

"There was one nurse who was in tears," Ms. Swinton said. "She said it meant so much to her to have an opportunity to show her commitment and her skill and her passion for this work."

And Ms. Swinton said she also heard from the unit’s attending physician that the new process made her day easier, because everyone on the team knew the plan of care.

"The team is happy; you can feel it," she said. "On the unit, people are stepping up. They’re collaborating."

The next step is to begin rolling out the ACU concept unit by unit. They have identified a slate of units and plan to switch over one unit at a time every 120 days, Ms. Swinton said.

[email protected]

On Twitter @maryellenny

Are the physicians and nurses in your hospital suffering from change fatigue?

There’s a new model of care that supporters say could help alleviate the weariness from continual quality improvement projects and process changes. It’s called an Accountable Care Unit, and though the name sounds a lot like an Accountable Care Organization, the two ideas have little in common.

Accountable Care Units (ACUs) are essentially geographic-based hospital units where the staff are held accountable for their patients’ outcomes. The four defining features of an ACU are unit-based teams, structured interdisciplinary bedside rounds, unit-level performance reporting, and unit-level nurse and physician coleadership.

Under this collaborative care model, hospitalists are assigned to a "home" unit where nearly all of their patients are located. The physician-leader partners with a nurse-manager to run the unit, and together with a team that includes allied health professionals, they conduct daily bedside rounds. A unique piece of the ACU model is the accountability. Instead of trying to discern performance based on facility-level or physician service line data, the hospital provides the ACU with unit-level data to help improve outcomes.

ACUs, which are the brainchild of hospitalist Dr. Jason Stein at Emory University in Atlanta, are currently up and running in multiple units across the Emory system, along with hospitals in seven U.S. states and more than 15 hospitals in Australia. The care model can be found in medical units, surgical units (including neurosurgery, orthopedic surgery, and general surgery), intensive care units, emergency departments, obstetrics units, pediatric units, psychiatry units, and long-term acute care units.

To help hospitals launch ACUs across their facilities, Dr. Stein founded Centripital, nonprofit organization whose mission is to train hospital professionals to work together in "high performing, patient-centered teams." The company has licensed implementation tools, including customized workflow diagrams, comprehensive training for front-line staff, and a train-the-trainer program with feedback tools so local leaders can spread the success of an initial ACU within their system.

Dr. Stein describes the model as a "Swiss Army knife" for the hospital. The idea is that instead of constantly ramping up for the next quality improvement project, the structure of the ACU allows physicians and nurses to target improvements without fundamentally changing their workflow.

"Whatever the metric is, whether it’s a clinical outcome or a utilization outcome, ... if you choose to focus on any of those items, we think you’re very likely to improve those outcomes," said Dr. Stein, who is the director for quality and research in Emory’s division of hospital medicine.

Dr. Stein launched the first ACU in 2010 in a 24-bed medical unit at Emory University Hospital. During the first year, the length of stay fell from an average of 5 days to 4.5 days. And in-hospital mortality dropped from 2.3 deaths per 100 encounters to 1.1 deaths. Initial results also have been similar in other hospitals that have launched ACUs, he said.

Costs, continuity, and ‘accountability’

At Emory, the gains were achieved at little cost to the system, Dr. Stein said, other than compensation for a part-time physician medical director and some staff training.

The biggest challenge in making the shift to an ACU model of care is the creation of unit-based teams, he said. "Physicians need to be able to share time and space throughout the day with the nurses with whom they share patients," Dr. Stein said.

One potential downside to making geography the primary driver of how physicians are assigned to patients is that there can be a break in the continuity of care. For example, if a patient cared for in an ACU must be transferred to the intensive care unit, after recovery the patient could potentially be transferred to a unit with a different team of physicians.

But Dr. Stein said it’s a manageable problem and one that is worth the trade-off.

Accountability on an ACU has multiple meanings. The first level of accountability is between members of the care team.

"There’s accountability at the bedside every day, because we are either showing up prepared to offer perspectives and answer questions in a structured way, or we’re not," Dr. Stein said. "That’s a massive daily accountability moment."

The second level comes from being able to review data that’s specific to the ACU. Dr. Stein recommends that ACU teams hold quarterly meetings that include specialty directors and service line chiefs to review unit-level performance reports. That type of public reporting among peers can be very powerful, he said.

The structure of the ACU model or a similar version of it "is probably the type of model that will make the most sense for the future," said Dr. Elizabeth Harry, a hospitalist at Presbyterian/ St. Luke’s Medical Center in Denver.

Dr. Harry helped implement an ACU at her institution about a year and a half ago and now serves as the medical director for that unit. So far, they have been able to reduce length of stay on the unit from an average of 5.3 days to 4 days and reduce costs by more than $800,000 since implementation.

"But more importantly," she said, "the ACU has been able to get physicians, nurses, pharmacists, case management, and therapy out of their individual silos and encourage collaboration."

"Having solo practitioners who care about their patients is not enough," Dr. Harry said. The model of care also needs to simplify the environment and increase communication among everyone who cares for patients to avoid errors and mitigate potential harm.

Dr. Harry also advises against taking the ACU model apart and applying just one piece. "It’s the combination of geographic units, interdisciplinary rounds, paired leadership, and data monitoring that will achieve results," she said.

Dr. Stein said he expects the model will continue to take hold. "There’s an understanding that we need a convergent solution," he said. "We need a solution that stops nibbling around the edges."

Care teams find new energy

Palmetto Health in Columbia, S.C., launched its first ACU in April, so it’s too soon to tell if they will see significant improvements in quality or cost. But the model has already brought "new life" to the physicians and nurses on the unit, said Carolyn Swinton, chief nursing officer at Palmetto Health Richland, a level I trauma academic medical center.

"There were team members on that unit who had been there for 20 years who we thought had lost their spark and their commitment, and they knocked it out of the park," Ms. Swinton said. "They were very engaged."

Palmetto Health wanted to try out the ACU concept as part of a broader push to improve the experience for patients and families. And they also saw it as a way to standardize the communication and care processes within the hospital, Ms. Swinton said.

So last fall, they traveled to Emory University to observe the ACU model in action and receive training about how to implement it. Earlier this year, they selected a unit where they already had strong physician engagement. The providers on the unit held a retreat where they developed a unit covenant and even practiced how they would talk to patients during the interdisciplinary bedside rounds.

Palmetto modified the Emory approach to the ACU slightly. In addition to having providers from pharmacy and social work, they added a nurse technician who could provide information about ambulation, toileting, and dietary intake.

The effect on morale within the unit was immediate.

"There was one nurse who was in tears," Ms. Swinton said. "She said it meant so much to her to have an opportunity to show her commitment and her skill and her passion for this work."

And Ms. Swinton said she also heard from the unit’s attending physician that the new process made her day easier, because everyone on the team knew the plan of care.

"The team is happy; you can feel it," she said. "On the unit, people are stepping up. They’re collaborating."

The next step is to begin rolling out the ACU concept unit by unit. They have identified a slate of units and plan to switch over one unit at a time every 120 days, Ms. Swinton said.

[email protected]

On Twitter @maryellenny