title: Transforming Ward Rounds Through Rounding-in-Flow.
abstract: BACKGROUND
  Traditional "batched" bedside clinical care rounds, where rounds for all patients precede clinical tasks, may delay clinical care and reduce resident work efficiency.
  
  
  METHODS
  Using Lean concepts, we developed a novel "Rounding-in-Flow" approach, with the patient care team completing all tasks for a single patient before initiating any tasks for the next patient. Outcome measures included timely patient discharge and intern work hours.
  
  
  METHODS
  We performed a retrospective cohort study with historic and contemporaneous control groups, with time series adjustment for underlying temporal trends at a single medical center. Primary outcomes were timely patient discharge orders and resident duty hours. Participants were 17 376 consecutive hospital inpatients between January 1, 2011, and June 30, 2012, and medical ward rounding teams of interns, residents, and attending hospitalists.
  
  
  RESULTS
  Timely discharge orders, defined as written by 9:00 am, improved from 8.6% to 26.6% (OR, 1.55; 95% CI 1.17-2.06; P  =  .003). Time of actual patient discharge was unchanged. Resident duty hour violations, defined as less than 10 hours between clinical duties, decreased from 2.96 to 0.98 per intern per rotation (difference, 1.98; 95% CI 1.09-2.87; P < .001). Average daily intern work hours decreased from 12.3 to 11.9 hours (difference, 0.4 hours; 95% CI 0.16-0.69; P  =  .002).
  
  
  CONCLUSIONS
  Compared with batched rounding, Lean Rounding-in-Flow using "1-piece flow" principles was associated with more discharge orders written before 9:00 am and fewer violations in the 10-hour break rule, with minimal changes to intern total work hours and actual patient discharge time.
authors.forename: Alvin S
authors.initials: AS
authors.lastname: Calderon
authors.forename: C Craig
authors.initials: CC
authors.lastname: Blackmore
authors.forename: Barbara L
authors.initials: BL
authors.lastname: Williams
authors.forename: Kavita P
authors.initials: KP
authors.lastname: Chawla
authors.forename: Dana L
authors.initials: DL
authors.lastname: Nelson-Peterson
authors.forename: Michael D
authors.initials: MD
authors.lastname: Ingraham
authors.forename: Donna L
authors.initials: DL
authors.lastname: Smith
authors.forename: Gary S
authors.initials: GS
authors.lastname: Kaplan