--- name: coordinating-multidisciplinary-rounds language: en description: Synthesizes input from nursing, pharmacy, PT/OT, social work, and case management into unified care plans. Use when conducting interdisciplinary rounds, coordinating care teams, or documenting team-based decisions. tags: - coordination - hospital-medicine metadata: author: casemark practice_areas: - Hospital Medicine - Internal Medicine document_types: - Coordination Plan skill_modes: - Coordination --- # Coordinating Multidisciplinary Rounds Synthesizes input from nursing, pharmacy, PT/OT, social work, and case management into unified care plans for hospitalized patients. ## Why This Skill Exists Multidisciplinary rounds (MDR) are the primary mechanism for team-based care coordination in the inpatient setting. The Joint Commission standards for patient-centered care (PC.02.02.01) require interdisciplinary planning, and CMS expects documented evidence that care plans reflect input from multiple disciplines. Studies show that structured MDR reduce length of stay by 0.5-1.5 days, decrease 30-day readmission rates by 15-20%, and improve patient satisfaction scores. Without a structured approach, MDR devolve into passive listening sessions where information is shared but not synthesized into actionable plans. Effective MDR require a hospitalist-led framework that assigns accountability, sets deadlines, and documents team consensus. The most common failure mode is lack of follow-through — decisions made during rounds that are never translated into orders, referrals, or discharge actions. --- ## Checkpoint A: Pre-Draft Intake (Mandatory) Before conducting multidisciplinary rounds, confirm: 1. Which **team members** will participate — nursing, pharmacy, PT/OT, social work, case management, dietary, chaplaincy? *(Default: Core team = RN, pharmacist, CM, SW)* 2. What is the **patient census** and how many patients require MDR discussion? *(Default: All patients on service; prioritize those with LOS > geometric mean or discharge barriers)* 3. What is the **time allotment** per patient? *(Default: 2-4 minutes per patient)* 4. Are there **high-priority patients** requiring extended discussion — complex discharges, family conflicts, clinical deterioration? *(Default: Flag by case management or nursing pre-round)* 5. Is there a **standardized rounding template** in use at this facility? *(Default: Use the framework below)* 6. What **day of stay** is each patient on, relative to expected LOS? *(Default: Calculate from admission date vs. CMS geometric mean for MS-DRG)* ### Documents to Request - Patient census list with admission dates, diagnoses, and attending assignment - Case management tracking board (discharge disposition, barriers, target dates) - Pharmacy medication reconciliation reports and therapeutic monitoring alerts - PT/OT functional status assessments and mobility scores - Social work psychosocial screening results - Nursing care plan with active safety concerns (falls, skin, lines) - Dietary/nutrition screening results (MUST or NRS-2002 scores) --- ## Step 1: Structure the Rounding Format Use the following per-patient framework (target 3 minutes per patient): | Time | Speaker | Content | |------|---------|---------| | 0:00-0:30 | **Physician** | One-liner, clinical trajectory (improving/stable/worsening), anticipated discharge date | | 0:30-1:00 | **Nursing** | Overnight events, patient concerns, safety issues (falls, skin, pain control) | | 1:00-1:30 | **Pharmacy** | Medication concerns: interactions, renal dosing, IV-to-PO conversion, antibiotic stewardship | | 1:30-2:00 | **Case Management** | Insurance status, discharge disposition (home, SNF, LTACH, rehab), pending authorizations | | 2:00-2:30 | **Social Work** | Psychosocial barriers, caregiver assessment, community resource needs | | 2:30-3:00 | **PT/OT** | Functional status, mobility level, equipment needs, therapy recommendations | --- ## Step 2: Assign Accountability for Action Items Every MDR discussion must produce documented action items with ownership: **Action Item Template:** ``` Action: [Specific task] Owner: [Name and discipline] Deadline: [Date/time or "by discharge"] Status: [Not started / In progress / Complete / Blocked — reason] ``` **Common action categories:** - **Physician actions**: Order changes, consult requests, goals-of-care discussions, procedure scheduling - **Nursing actions**: Patient education, safety interventions, care coordination with family - **Pharmacy actions**: Medication optimization, discharge medication reconciliation, prior authorization for specialty drugs - **Case management actions**: Insurance authorization, facility placement, DME ordering, home health referral - **Social work actions**: Psychosocial assessment completion, community resource connection, guardianship or capacity evaluation - **PT/OT actions**: Functional assessments, equipment recommendations, home safety evaluation --- ## Step 3: Address Discharge Barriers Systematically For each patient with LOS approaching or exceeding the geometric mean, identify and categorize barriers: | Barrier Category | Examples | Responsible Discipline | |-----------------|----------|----------------------| | **Clinical** | Pending procedure, IV antibiotics, unstable vitals | Physician | | **Functional** | Not meeting therapy goals, unsafe mobility | PT/OT | | **Social** | No caregiver, homeless, unsafe home environment | Social work | | **Insurance/Authorization** | Pending SNF authorization, denied rehab | Case management | | **Patient/Family** | Refusing discharge, unrealistic expectations, family conflict | Team (physician-led) | | **Medication** | Prior authorization needed, patient cannot afford discharge meds | Pharmacy | | **Equipment** | Home O2, hospital bed, wheelchair not yet arranged | Case management | --- ## Step 4: Document Team Consensus After each patient discussion, document the following in the EMR: 1. **Interdisciplinary care plan update**: Summary of team input and agreed-upon plan 2. **Discharge readiness assessment**: Ready / Not ready — with specific unmet criteria 3. **Estimated discharge date**: Confirmed or revised based on MDR discussion 4. **Escalation needs**: Any issue requiring attending-to-attending communication, ethics consultation, or administrative intervention 5. **Patient/family communication plan**: Who will discuss what, and when --- ## Step 5: Track Metrics and Process Quality Monitor the following MDR effectiveness metrics: - **Attendance rate**: % of core team members present (target >= 90%) - **Action item completion rate**: % of assigned actions completed by deadline (target >= 85%) - **LOS vs. geometric mean**: Track daily for each patient; flag outliers - **Discharge before noon rate**: Percentage of discharges completed by 12:00 PM (target >= 30%) - **Readmission rate**: 30-day all-cause readmission for patients who went through MDR --- ## Checkpoint B: Post-Draft Alignment (Mandatory) After completing multidisciplinary rounds: 1. Does every patient have a documented **estimated discharge date**? 2. Are all **action items** assigned to a specific owner with a deadline? 3. Have **discharge barriers** been categorized and assigned for resolution? 4. Were any patients identified as needing **escalation** to attending, ethics, or administration? 5. Is the MDR documentation in the EMR and accessible to all team members? --- ## Quality Audit - [ ] All core disciplines participated or sent a representative - [ ] Each patient was discussed using the structured format - [ ] Estimated discharge date is documented for every patient - [ ] Active discharge barriers are identified and assigned - [ ] Medication reconciliation status is addressed for patients within 24h of discharge - [ ] Functional status and therapy goals are documented - [ ] Insurance and authorization status is current - [ ] Patient/family communication needs are identified - [ ] Action items have named owners and deadlines - [ ] High-priority patients received extended discussion time - [ ] Documentation is completed within 2 hours of rounds - [ ] LOS outliers are escalated with barrier analysis --- ## Guidelines - Hospitalist leads and time-keeps — do not allow single-discipline monologues exceeding their allotted time - Start with patients closest to discharge to capture early-morning discharge opportunities - Flag any patient on hospital day 3+ without a clear discharge plan for focused barrier analysis - Pharmacy should address antibiotic stewardship at every MDR — review indication, duration, and IV-to-PO conversion eligibility - Case management should present insurance status proactively, not reactively when discharge is imminent - Document MDR decisions as team consensus, not individual opinions — this is legally significant - When team members disagree on discharge readiness, document the disagreement and the resolution - Use a visual tracking board (whiteboard or EMR dashboard) that is updated in real-time during rounds