Accountable Care Units in Hospitals- A concept to increase performance and efficiency

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Accountable Care Units in Hospitals

A concept to increase performance and efficiency


During the course of my career one of the things that I had to give up was inpatient care. But in the mid-eighties, I was a hospitalist before we even had that name. I remember the efficiencies of staying in the hospital. I could round on patients throughout the day. If one patient was in X-ray, I could go visit another and not lose any time. I liked the fact that I did not have to go to and from an office. I missed the continuity of primary care internal medicine, but I also enjoyed the relative consistency of my work schedule. Unfortunately though, I had patients on all floors of the hospital, in virtually every unit. A different nurse took care of each of my patients. Some of my intrinsic efficiency of being in the hospital was lost.

To this day, not much has changed. Yes, the concept of the hospitalist has grown greatly, and despite some of the intrinsic inefficiencies of hospital medicine such as multiple physician coverage through the course of the patient stay and not usually having a prior doctor-patient relationship, the hospitalist movement has been a very sound concept. It also gives the ambulatory internist more flexibility in the office to see more patients.

On the other hand, the patients are still admitted to the floor with little regard for the rounding physician. Most hospitalists round all over the hospital. The structure of the basic floor is not efficient for the physician or the health care team; the care can be fragmented and given by multiple members without knowing what the other is doing. Outside of the medical record, there is little communication amongst the health care team members. Each would visit the patient separately and rarely meet as a group.

So although the hospitalist concept has been successful, it has still not addressed some of the basic inefficiencies of the hospital infrastructure– a very fragmented and inefficient patient floor or ward.

I had the opportunity to speak at the Society of Cardiovascular Patient Care Annual Symposium last month in San Antonio, and had the opportunity to listen to Dr. Jason Stein, Assistant Professor of Medicine at Emory University, speak about his concept of an Accountable Care Unit. It is a model that increases the efficiencies and improves outcomes at the unit level of care. It is based upon four key features:

  1. Unit-based teams- Physicians assign themselves to specific units to be able to care for patients on that home unit which allows them to form a multidisciplinary team with the nurses and other unit-based professionals. This minimizes the need for the care givers to have to go all around the hospital, and promotes predictability, shared workflow and better communication.
  2. SIBR rounds (Structured Interdisciplinary Bedside Rounds)- Rounds are coordinated together by all caregivers and occurs as a team- the patient’s physician, nurse, case managers, etc.,. A consistent agenda is developed for information sharing and treatment planning. As all significant perspectives are present, the patient’s issues, progress and daily plans are reviewed and discussed as a team.
  3. Unit level performance reporting- Data in terms of outcomes, experience and cost are aggregated for that particular unit. This allows more specific clinical, operational, and administrative actions based upon that unit’s actual experience.
  4. Unit-level Nurse and Physician co-leadership- The concept of the dyad as a central focus of the health care team’s management.

Where these programs have been put into place, they have been shown to improve clinical outcomes (improved safety and decreased adverse events), improve service (higher patient satisfaction and decreased employee turnover), and be cost-effective (reduced length of stay and total cost per case).

As Dr. Jason Stein says: “In short, the ACU care model is specifically designed to organize hospital physicians, nurses, and allied health professionals into high functioning, unit-based teams. It combines standard workflow, patient-centered communication, quality-safety checklists, best-practice protocols, performance measurement, and a nurse-physician leadership dyad.”.


It seems to me that as we look at improving Value in our hospitals, in addition to the hospitalist concept, a very good “low hanging fruit” is to actually enhance the infrastructure of our basic work units of care– the individual patient unit and floors. As we examine best practices across the country, the time for the Accountable Care Model may be now. This idea simply makes sense.


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