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Agile Rounding: Implementing A Proven Process Around Patient Care

The revelation to repurpose my M.D and practice medicine as a product officer and health designer, rather than a clinician, happened during my third year of medical school while I juggled getting my first patient-care experience in clinical rotations, while also getting my first product design experience in a part-time consulting role for a medical VR education company. Simultaneously working as a part of the care team for an academic hospital and on a product team for a startup was a fascinating experience where I was exposed to two very different workflows. How though - could these two distinct industries, with different processes and work principles, learn from each other and make each other better? As someone who has walked both paths, I have a few ideas. This article will focus on one of those ideas - bringing Agile methodology into the hospital.


What is Agile & Sprint Methodology?

Over the past 20 years, the way software development companies approach project management and development has changed dramatically. The catalyst for this change has been a move to Agile methodology from the previously used waterfall approach. In a waterfall approach to development, an entire idea is thought out, from beginning to end, and is built out in a "big bang" approach, where everything is bet on the early-set assumptions, only allowing learning to occur at the very end of development when you are able to see if what you have created actually addresses the problem you sought to solve, or not. In Agile development, teams work incrementally in small development cycles, or sprints, and results are evaluated continuously so that learning can happen on-the-go, and change, or adaptation, can occur quickly. Crucial to the sprint methodology is the pre and post sprint meetings (or planning and retrospective sessions). At the end of every sprint cycle (usually two weeks in software development), the team debriefs on what worked and what didn't, or what took more or less time than they anticipated. Then, the next pre-planning session can occur, where past learnings are used to set new, measurable, two week objectives. At the end of each sprint, the cycle repeats - with each cycle becoming, ideally, more efficient than the last.



Developers Stand Up, Doctors Round

Also core to sprint methodology are stand-ups, where at the start of each day teams discuss what they did the day prior, what they are doing today, and any blockers that they have preventing them from making progress on tasks. Stand-ups are not unlike medicine's approach to patient management (a very specific type of project management) - rounding. In the early morning hours of the hospital, the hospital halls are bustling, as care teams "round" on their patients. Rounding does not have to be done in-person, but it generally means going door to door for each of your patient's hospital rooms, talking about them outside of the room (or inside, in front of the patient and/or family, if you are utilizing a patient-centered rounding approach common to many pediatric hospitals), and then doing a physical exam on the patient and setting the agenda for the rest of the day. The way rounding is done is very organized, often following the SOAP format. First a one liner is tossed out summarizing the patient's reason for being in the hospital, then, the subjective information (S) is discussed (how the patient feels), then objective information (O) (physical exam, vitals), followed by your assessment (A) (what it all means), and the plan (P) (what you are going to do). Rounding, and the SOAP method, are an effective way to work through a large list of patients in an organized manner, and even shares some similarities with project management strategies in software development. However, one thing missing from medicine's approach to patient management that exists in the Agile approach to product management is the sprint cycles that guide the entire process. Sprint cycles let you know, at any given point in time, where you are at, where are you going, and when you are going to get there. No such organized thing exists for healthcare, leading to some delays of care...or worse.


Hospital Limbo: The Effect of Unorganized Rounding

Unfortunately, it is not terribly uncommon in the hospital for a patient to get lost in the shuffle. When todays, and yesterdays, and the prior days' progress notes all look pretty much the same for a given patient, it is a good sign that, that patient is stuck in some form of hospital limbo. Often, this is due to a disconnect between different teams, or blockers, that are preventing one important step in the patient's management, and eventual discharge, from happening. This could look like a physician order that never got filled, a physical therapy session that never happened, a social work or insurance issue that is preventing a patient from getting to where they need to go (like a nursing facility or rehab center), an overflow problem, a procedure that keeps getting delayed, or other hold-ups. Usually, these delays just result in an extra 1-2 days spent in the hospital (and the thousands of dollars of associated costs with that), but I've also seen it result in extra weeks spent in the hospital, or patients who end up only getting sicker in the hospital, instead of better.


Rounding in Sprints: A Possible Solution To Hospital Limbo

Introducing sprint cycles into medicine could help further organize the care management plan, and help to eliminate stagnant progress in healthcare. The first step in implementing a sprint system into medicine would be to introduce pre and post sprint planning sessions into the care management workflow. Pre-planning sessions would be the first thing a team does after they first land eyes on a patient. From there, a sprint (a measurable set of goals over a specific time period) would be set in motion. The patient, and hospital, journey would have to be envisioned for each patient, and a plan would be set of what and when you think is going to happen. One patient's hospital stay may occur over multiple sprints, or just one - depending on the expected complexity of the case. Doctors and care teams would have to think in terms of time, and bite-sized progression steps, rather than just laying out an initial waterfall approach and letting the system dictate when the plan can progress. Each day (during rounds), the care team would review what happened yesterday, what is meant to happen today, and how it all fits into the larger sprint, or set of goals that is hoped to be accomplished in a pre-defined amount of time. Blockers that are preventing care teams from completing their objectives ("I can't discharge this patient until GI sees them") would be identified and communicated. In post sprint sessions, care teams would review their expectations and see what worked and what didn't, and what happened or didn't happen. Lastly, care teams use the sprint's learnings to reconfigure, troubleshoot, and set new, better informed, obtainable goals.


Learning On The Job

In some ways, post sprint sessions are similar to morbidity and mortality (M&M) conferences, where cases, often with poor outcomes, are presented to the entire medical staff in grand rounds for a specific specialty. M&M conferences set out to do the same thing as post sprint sessions - learn from our past processes, and ask if we could have done anything different, or better. The difference between the two, is that M&M conferences are usually scheduled after the fact, or at least on an as-needed-basis, but post sprint sessions are scheduled always, for every patient, in set intervals. In this way, we could make sure that we are always learning from our past processes, regardless of the outcomes, and always moving and learning to be more efficient.


Introducing Jira, And Other Workflow Tools, Into Healthcare

There are tools built to aid in sprint methodology that could be brought into healthcare. Jira is one example of a project tracking software. With Jira, "cards" can be created at the start of each sprint session and assigned to specific members of the team. Each card contains a specific task and a point value that represents the amount of time the task is anticipated to take. Jira cards offer some transparency in what every team member is working on and where they are at in completing them. Jira could be used for longer term tasks, like when a patient is admitted into the hospital, but could also be used for short-term tasks, like in the emergency department. "Clicking" off tasks is a nice way to see, at a glance, what still needs to be done for a patient before they could go home, and if any of those responsibilities are assigned to you. Platforms like Jira are specifically designed to boost team work and productivity - something that certainly can not be said for the infamous technology that is currently utilized in hospital systems - electronic health records, or EHRs. EHRs are currently used as a catch-all for any type of digital work or planning that is done in healthcare. EHRs though, are just what their name suggests they are - records. They are a place for documentation - so that patient information lives in a safe place, can be referred back to, and available in case of an inquiry is made (from a doctor, patient, payer, or lawyer). But doctors spend most of their day inside EHRs documenting, catching up on documentation, and placing orders. In the sea of of documentation, that one important note that you wrote 2 days ago could get lost and go unseen - again leading to another case of hospital limbo. Project management software, designed to boost productivity, team work, and communication would not replace EHRs, but they could compliment them quite well. Let the EHRs do what they do best (be a source for documentation), and lets use other tools that do what they do best to solve different problems.


Project/Product Managers in Medicine

The birth of agile development called for the creation of a new job - the project or product manager, or PM. The PM is the leader, and organizer, of the sprint cycles. The PM is the connective tissue between all the various interdisciplinary teams working on a project and is the best source of information on where a project is at, at any given moment. In healthcare, the lead attending physician usually takes on the role of the PM, to some degree, for his or her team. After all, the physician is the lead care-taker for his or her patient - it is their patient to manage. But a physician is a very busy role. They are masters of their own craft that includes rich knowledge of diseases, pharmacotherapy, and/or surgery, among other things. But to obtain an M.D. does not require you to have any team-management or leadership skills - this is not necessarily a craft of which every doctor would master, or should even have to master. Even if a one surgeon excels at care management, they may be in surgery all day - leaving little time for care coordination, and a delay of processes that is another risky path that can lead to hospital limbo for a patient. By implementing a new, PM-like role into the healthcare system, the burden of care-management can be lifted off of the physician and onto someone who's entire job exists to focus on it. This would not take away the importance of oversight from the leading physician, but it would provide them the support they need to efficiently lead, and manage their patients. As a side note, I happen to think that M.D.s can make excellent PMs (it is a role that I take on a lot, and does have cross-over into how I was trained as a doctor in terms of how you have to think), and perhaps this could be a new specialty for doctors to train into.


Conclusion


The healthcare system is a system driven by science, clinical studies, and process. While scientific methods and clinical outcomes are meticulously tracked and have their importance stressed, process, especially since the introduction of new technologies like electronic medical records, is given far less attention. As a result, doctors see and manage patients in the same way that they always have for generations even though the landscape of healthcare has drastically changed. There is now more interdisciplinary communication than ever before, more patients to see than ever before, more procedures to do, more forms to fill out, and less time to do it all in (the 15 minute patient visit window time is a real constraint). The new workflows call for new processes or the healthcare system will get overwhelmed and doctors will burn out (this is happening, now). To save our healthcare system, we must look at other industries who have been fine tuning and perfecting approaches to team-work and problem-solving. I've spent the entire amount of my early career walking both paths of medicine and design, and I've found that they are way more similar than they are different. As such, they have a lot to teach each other. But we have to be open to listening.



About The Author:

Amiad Fredman, MD is a health designer, content creator, and speaker for digital health and games for health companies. He specializes in the medical design of digital health products, digital therapeutics, and games for health or serious games, and does consulting in this space to help translate important concepts of both health and design to create the most effective and engaging health solutions. He is the co-founder and Chief Product Officer of Aegis Digital Health, where he is revolutionizing the remote patient monitoring space for patients living with diabetes and the doctors that care for them. He is passionate about creating conversation around good health design and games for health, and is an opinion leader on the interent, where he hosts his own games for health YouTube channel, Digital Doc Games, and the Health Design Blog.

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