Value Time Out: Implementation of a Bedside Rounding Script to Improve Value Conversations

From the 2019 HVPAA National Conference

Ms. Yasmin Yazdani Farsad (University of Colorado), Ms. Lauren McBeth (University of Colorado School of Medicine), Dr. Jessica Camacho (University of Colorado School of Medicine), Dr. Roxana Naderi (University of Colorado School of Medicine), Dr. Christine Jones (University of Colorado School of Medicine), Dr. Christopher King (University of Colorado)

Background

Healthcare is the biggest cause of bankruptcy in the United States, significantly affecting patients’ quality of life. The medical school and residency from which a physician graduates impacts the value of care they provide for years after entering unsupervised practice. The clinical learning environment has not been well implemented into prior high value care curricula. In order to shape the practice of future physicians and improve healthcare value for patients now and in the future, high value care concepts must be brought to the bedside. The Value Time Out (VTO) curriculum was developed and implemented at the University of Colorado Hospital with the goal of placing an emphasis on patient values during rounds to align patients and the physician team while reducing low value practices.

Objectives

The VTO utilizes an experiential learning model with learners completing a bedside rounding script designed to foster conversations with patients focused on optimizing healthcare value. The curriculum was designed to help teams learn and practice the knowledge, skills, and attitudes necessary to practice high value care in a real world clinical setting.

Methods

The VTO was launched on January 2, 2019 and is designed to take place at the end of the traditional SOAP presentation. Each time out includes the Value Discussion (patients and team members identify and reconcile differences regarding value), Take Home Points (summation of the plan and value-added steps for patient care), and the Officer Checklist (a checklist to reduce low value practices, such as prolonged telemetry and Foley catheter use). Faculty, residents, medical students, and advanced practice (NP or PA) fellows are trained on the VTO curriculum rounding script through a reverse classroom model utilizing a training video followed by in-person training. Faculty receive focused communication training through a “pair share” exercise where they complete the VTO on a fictional patient encounter. All team members receive ongoing communication training through the Value Time Out Newsletter, which focuses on successful value communication tools and language. In order to assess the impact of our curriculum on resident teams’ behavior, we conducted a time-motion series (TMS) with 2 pre- and post-intervention rounding observations on each of the six inpatient medicine ward teams using the VTO.

Results

To date, over 131 medical students, residents, fellows, and faculty have been trained in use of the VTO. The average rounding time per patient increased from 15.0 minutes to 17.5 minutes after implementation of the VTO curriculum. The Value Discussion took an average of 21.2 seconds per patient, and the Officer Checklist took an average of 30.5 seconds per patient. Time spent on Take Home Points increased by 30 seconds. Patient/family participation increased from an average of 2.4 minutes per patient to 4.5 minutes per patient. Overall time spent at the bedside increased by 7%.

Conclusions

Implementation of a bedside rounding script focused on healthcare value increases the time spent discussing value, patient participation in rounds, and the time spent at the bedside during morning rounds.

Clinical Implications

Patients and physicians are often misaligned on what constitutes value in healthcare. The VTO script increases the amount of time spent discussing value with patients, providing the opportunity for improved alignment between patients and their physician team.

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