The Hospital Geographic Zone Debate Pendulum Is Swinging Back

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FIGURE 1: Conceptual model depicting impact of geographical localization of general medical teams on quality of care. Mediating factors that lead to better quality of care are described in blue boxes. Mediating factors that are unintended and lead to worsening quality of care are described in grey boxes. The impact on domains of quality of care is described in pink boxes. ‘↑’ indicates an increase; ‘↓’ indicates a decrease; IDR = Interdisciplinary Rounds.

Singh S, Fletcher KE. A qualitative evaluation of geographical localization of hospitalists: how unintended consequences may impact quality. J Gen Intern Med. 2014;29(7):1009-1016.

Geographic localization has been coupled with another innovation: separating the admitting role and the rounding role for hospitalists. Thus, the “triagist” role was born: One hospitalist will admit a patient (the triagist), while another subsequently manages care. Separating these roles improved efficiency and throughput.⁹ The triagist role allows the patient to be admitted in a timely fashion, and placed on the right unit and team later on. Another related improvement has been the multidisciplinary rounds, particularly those that focus on the discharge of the patient. Geography makes those team rounds more feasible. ¹⁰

Another strategy which optimizes hospital throughput involves adjusting the work schedules of hospitalists.¹¹ Schedules that promote continuity were associated with lower mortality, lower readmission rates, higher rates of discharge to home and lower 30-day post discharge Medicare costs.^12-13

Strategies that help reduce hospital length of stay and improve discharge efficiency and ultimately reduce boarding in the emergency department. Emergency physicians know first-hand the advantages in communication and workflow as most of us work in designated zones and lead care teams dedicated to the patients placed in a particular geographic area.

When hospitalists consider the “geography” question, we can bring an understanding of the issue both in the inpatient and ED universes. Supporting geographic localization strategy helps improve inpatient throughput help create open inpatient beds. And open beds are the only solution to the problem of emergency department boarding!

DR. WELCH has been a practicing emergency physician for over thirty years. She has written numerous articles and three books on ED quality, safety, and efficiency. She is a consultant with Quality Matters Consulting, and her expertise is in ED operations.

DR. VASQUEZ is an Assistant Professor of Medicine at Emory University. of Operations for the Division of Hospitalist Medicine at Emory. He writes a Hospitalist Medicine Blog focused on operational excellence.