Boston Medical Center Childen's Hospital Boston
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Flower Other Recent Changes in the BCRP
Geographic Ward Team Structure at BCH, Family-Centered Rounds, Structured Approach to Sign-outs, and Duty Hours Improvements
The leadership, faculty, and residents of the BCRP created a new team structure for July 2008 on the inpatient wards of Boston Children's Hospital - the geographic system of inpatient ward teams. Over the past several decades, inpatient resident teams had evolved to single or multiple specialty-based teams often on several different units and floors of the hospital. This structure impacted efficiency, communication, and teamwork.

To improve patient care, optimize communication, and enhance efficiency of team function, the BCRP created multiple geographic (unit-based) ward teams. We continue to study the effects of the geographic system and have these objectives in mind as we continually improve the systems of care:

  • More time for patient interactions and teaching at bedside
  • More opportunity for family-centered rounds
  • Better care coordination and communication with nursing staff
  • Continued focused subspecialty education for our housestaff
In February of 2010, we implemented family-centered rounds on our general pediatrics teams at BCH and BMC. In order to facilitate this change in rounds format, we split our traditional four-intern teams (with one Senior and an Associate Senior) into two teams, each with its own Senior. The aim of this change was to increase time at the bedside, to empower interns with greater ownership of their patients and direct communication with patients and families on rounds, and to create a more efficient team structure. It has been a successful project thus far. We studied the impact on nurse-resident communication and found improvements (Gordon MB. Arch Pediatr Adolesc Med 2011; 165:424-428).
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Recent changes in the program provide more time with patients
As part of our aim to improve communication and patient safety (reduction in medical errors), we piloted and implemented a standardized approach to resident handoffs on the inpatient units with the introduction of the I-PASS handoff process. We employ a standard language for our verbal handoffs to focus the discussion at evening sign-out. Using our EMR, we developed an electronic handoff tool that imports medical information automatically and residents update text fields within the electronic handoff tool to provide timely information about illness severity, patient summary, action lists, situation awareness and contingency plans to ensure a shared mental model of the patients on the team between the incoming and outgoing teams. A pilot study demonstrated a 40% reduction in medical errors, a decrease of time at the computer (roughly 30 minutes per day), and increased time at the bedside (30 minutes per resident per day). On the basis of these results, we are beginning to implement the I-PASS handoff process across our program. More information about the I-PASS study and the educational curriculum is available at www.ipasshandoffstudy.com, on the MedEdPORTAL (https://www.mededportal.org/ publication/9311, https://www.mededportal.org/ publication/9402, https://www.mededportal.org/ publication/9397), and in several publications: Sectish TC. Pediatrics 2010;126:619-622, Starmer AJ. Pediatrics 2012;129:201-204, and O’Toole JK. J Peds 2013;162: 887-888.

We continue to refine our approach to improving duty hours within the BCRP and will monitor closely the impacts to education, patient care and continuity, resident workflow, patient safety, and work-life balance in the new inpatient team models. At the BCRP we pride ourselves in the rigorous approach we take to educational innovations and systems improvements.

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