• Atul Vats, Kristin H Goin, and James D Fortenberry.
• Children's Healthcare of Atlanta, Atlanta, GA, USA. atul.vats@choa.org
• Pediatr Crit Care Me. 2011 Jul 1;12(4):415-21.

ObjectiveA physician group in a pediatric intensive care unit faced challenges when moving to a larger unit. Challenges included increased time for rounds, nonbillable attending physician hours, poor communication with pediatric intensive care unit staff, and meeting resident physician duty hours and teaching requirements. The purpose of this analysis was to identify waste and opportunities for improvement to improve physician efficiency.DesignHuman factor (observational data collection) techniques were used to capture >60 hrs of rounding data. Twelve attending physicians and their rounding teams were shadowed to capture rounds on 130 pediatric intensive care unit patients. Rounding events, times, and patient interactions were recorded. Lean methods and scenario analysis were used to analyze the data and identify opportunities for improvement. Rounding events were categorized to determine value-added and nonvalue-added activities. Value-added activities were subclassified as essential or nonessential to morning rounds.SettingThirty-bed pediatric intensive care unit in a children's hospital with academic affiliation. PATIENTS OR SUBJECTS: Eight attending pediatric intensivists and their physician rounding teams.InterventionsEight attending physician-led rounding teams were observed for 12 rounding events and a total of 130 patient contacts.Measurements And Main ResultsLarge variation existed in the rounding process. Nonessential activities was highly correlated with physician preference and created a wide range in rounding time per patient. Essential activities showed the least variation and represents a "lean process." Scenario analysis was used to determine the impact of removing waste and reallocating the nonessential activities outside of rounds. Results of the analysis indicated that rounds could be reduced by 42% and that plan of care completion would be timelier (decreased from a mean of 157 to 82 mins).ConclusionsIn a large physician group, essential activities showed the least variation. Practice variation focused on minimizing nonessential activities could have dramatic impacts on standardizing practice. Further study is indicated to determine whether standardizing rounds to focus on essential activities can lead to more effective processes that require fewer resources while improving outcomes for all stakeholders.

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