To be unit-based does not mean unit-bound: Dispelling the Myths of Geographic Cohorting and How it Benefits Both Physicians and Patients
Introduction
Geographic cohorting (GCh), or geographic localization, is the grouping of patients with similar needs in specific units. In the US, the hospitalist movement is the largest professional group in acute care hospitals and is often the target of geographic cohorting initiatives, alongside other specialty services. Beyond the US, patients are often still cared for under specialties, which may adopt a ‘physician of the week’ approach for GCh. GCh is often met with resistance from physicians. While initially understandable, many of these concerns stem from misconceptions about its implementation and effects, or a failure to leverage GCh to the advantage of physicians. We will try to dispel common myths surrounding GCh and demonstrate its potential to improve both physician satisfaction and clinical, cost and efficiency outcomes.
Myth 1: Loss of Autonomy
Some physicians worry that cohorting on specialty units reduces their autonomy, as they may feel more like consultants than primary leaders of patient care. However, effective cohorting still requires that the geographically cohorted physician maintains clear leadership and accountability over patient care.
Reality and Evidence
Geographic cohorting (GCh) does not diminish autonomy but rather supports a collaborative care approach where physicians remain in charge of diagnoses, treatment plans, and overall management. This model optimizes resources and fosters communication with specialists. GCH physicians therefore become the ‘orchestra conductor’, weaving together the key players, their updates and insights into a symphony of coordinated and efficient care.
Being assigned to a specific unit can actually enhance physicians' sense of ownership and control (Carlson et al., 2022). Carlson et al. (2022) found that unit-based work improved job satisfaction, with physicians feeling more empowered over their schedule and workflow. Additionally, GCh reduces interruptions and pages, allowing physicians to focus more fully on patient care and other tasks (Bryson et al., 2017, Carlson et al., 2022).
Myth 2: Workload Imbalance
Workload variability across units is a frequent concern with cohorting, as patient acuity and admission patterns can impact daily workloads (Carlson et al., 2022, Bryson et al., 2017, Kara et al., 2018, Jolly Graham et al., 2024). However ‘to be unit-based, does not mean unit-bound’. It works best when physicians primarily work on a designated unit but rotate periodically to ensure exposure to varied cases and acuities.
Reality and Evidence
Flexible cohorting models help balance workloads, especially when institutions set clear workload caps and use real-time monitoring to adjust patient distribution promptly (Kara et al., 2018, Carlson et al., 2022, Singh et al., 2012) Furthermore, clear communication and coordination between admitting physicians and geographically cohorted teams can improve patient allocation.
Geographic cohorting also enhances rounding efficiency by reducing travel time, allowing hospitalists more time for direct patient care or to end their day earlier. (Stein et al., 2015, Kara et al., 2022, Klein et al., 2022, Carlson et al., 2022). For example, Carlson et al. (2022) found that geographic rounding led to an average 29-minute earlier completion of progress notes, with after-hours note completion dropping from 25.1% to 20% (p < 0.001).
Myth 3: Increased Interruptions
Physicians often worry that being co-located with other care team members will lead to more interruptions, as their proximity and availability on the unit could invite frequent face-to-face inquiries and increased interruptions in their cognitive work.
Reality and Evidence
In reality, geographic cohorting can streamline communication. By grouping patients with similar needs, cohorting facilitates more focused interactions with colleagues who bring relevant insights. Though it doesn’t inherently reduce interruptions, geographic cohorting combined with structured communication practices like interdisciplinary rounds (IDRs) or huddles can minimize ad-hoc interruptions (Bryson et al., 2017, Fanucchi et al., 2014, O'Leary et al., 2009). Unfortunately, O'Leary et al. (2017) highlighted that many institutes have implemented cohorting alone, with few implementing a supportive bundled approach to truly benefit from the cohorting and optimise care outcomes.
Physicians report that with SIBR rounds, most questions are handled early in the day, leading to fewer interruptions overall. Additionally, the shared understanding within cohorted teams makes any interruptions more meaningful, as team members are well-informed on patients' recent progress and pending needs.
Research supports a reduction in paging interruptions with GCh (Carlson et al., 2022, Bryson et al., 2017, Singh et al., 2012, O'Leary et al., 2009). For example, Singh et al. (2012) observed a 51% decrease in pages received by localized teams likely due to the increased opportunity for direct communication.
Myth 4: Concerns about Patient Continuity
Many physicians express concerns that GCh may disrupt physician-patient continuity, fearing negative impacts on outcomes due to increased intra-unit transfers or the handover from admitting to unit-based physicians. However, once a patient is on a cohorted unit, the benefits, such as enhanced team consistency and increased physician-patient interaction, should create a safer environment.
As a patient, would you rather be on a unit with your physician also there, or know that they are mostly somewhere else in the hospital?
Reality and Evidence
Geographic cohorting does not inherently reduce patient continuity or add more handovers. Hospitals with frequent lateral transfers, however, may need to optimize their bed management strategies. Studies show that GCh fosters improved communication and collaboration among team members by bringing them into closer physical proximity, allowing more consistent and efficient interactions (Kara et al., 2018, Bryson et al., 2017, Olson et al., O'Leary et al., 2009). Jolly Graham et al. (2024) found that hospitals utilizing GCh reported higher physician-patient consistency, fewer handovers, and improved team communication
By reducing travel time and streamlining access to resources, cohorting enables physicians to spend more time with individual patients. This added time fosters stronger patient relationships, more thorough assessments, and clearer communication about diagnoses and care plans (Kara et al., 2022, O'Leary et al., 2009).
Myth 5: Increased Throughput Burdens
Physicians sometimes fear a surge in workload—a "bolus" effect—when newly empty beds quickly refill after discharges (Kara et al., 2018).
Reality and Evidence
While geographic cohorting may require initial adjustments, it ultimately streamlines workflows, reducing administrative tasks. Working closely within a unit allows care teams to adopt standardized protocols and share responsibilities more effectively, which helps manage increased throughput. As one hospitalist put it, “It’s like we have twice the number of hands on deck, but we haven’t hired anyone new. We’ve just trained everyone to coordinate with each other and with greater purpose.”
It is our experience that GCh units utilizing a formal IDR process often achieve more morning discharges, and discharge planning typically leads to a steady spread of discharges throughout the day, as evidenced by Molla et al. (2018). This proactive approach, with families and post-acute services engaged well before discharge, avoids the last-minute "hero" discharges late in the day. Cohorted units also tend to have discharge notes and prescriptions prepared earlier, further improving efficiency (Keating et al., 2019, Stone et al., 2024, Carlson et al., 2022).
In hospitals with multiple acute and general medicine units, patient admissions are typically distributed across units, preventing a "bolus" effect. For example, Emory University Hospital’s Accountable Care Unit alternated on-call teams daily to balance the load (Stein et al., 2015).
Myth 6: Impact on Teaching and Training
Some physicians and trainees worry that geographic cohorting might limit learning and teaching opportunities.
Reality and Evidence
Geographic cohorting can actually enhance training by allowing residents and fellows to gain concentrated experience with specific patient populations, observe specialists handle complex cases, collaborate with specialized nursing and allied health teams, and participate in interdisciplinary rounds focused on relevant expertise. This consistency reduces extraneous cognitive load, enabling trainees to focus on patient care without constantly adjusting to new teams, populations, or unit cultures (Klein et al., 2022).
In our experience, physicians are often oriented to a main unit but rotate to others to gain broader exposure. As mentioned above ‘to be unit-based, does not mean unit-bound’. Dedicated time with specific patient populations supports deeper experience, learning and skill development.
Myth 7: Perceived Ineffectiveness or Doubts About Impact
Some physicians question the effectiveness of GCh, arguing that the potential benefits are either unproven or do not outweigh the concerns. Jolly Graham et al. (2024) noted “many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions”, while stressing that cohorting requires additional team-based interventions to yield meaningful outcomes.
This aligns with our experience in creating and launching Accountable Care Units with Structured Interdisciplinary Bedside Rounds (SIBR® rounds). Initially, after the physician teams were geographically cohorted and IDRs began, there was no efficiency or efficacy in the process – everyone just looked to the physicians to take the lead. It was only after months of iterative PDSA cycles that the current highly-reliable form of SIBR rounds evolved.
Reality and Evidence
While skepticism towards change is understandable, numerous studies demonstrate the positive impact of geographic cohorting on patient outcomes, including reduced length of stay (Jolly Graham et al., 2024), fewer patient deaths (Loertscher et al., 2021), lower readmission rates (Molla et al., 2018), earlier discharges (Molla et al., 2018) and nurse-physician engagement (O'Leary et al., 2009). However, these improvements are often the result of coupling cohorting with another intervention, often a form of IDRs.
In addition to these reported outcomes, several other benefits of GCh have been highlighted:
Improvements in inter- and intra- professional collaboration and communication (Kara et al., 2018)
Care efficiency (Kara et al., 2018)
Patient-centeredness (Kara et al., 2018)
Nursing satisfaction (Kara et al., 2018)
GCh facilitating other interventions (Kara et al., 2018)
87% of physicians believed geography had a positive impact on the overall quality of care (Bryson et al., 2017)
Increased time spent with patient/caregivers to discuss plan of care (p < 0.001) (Bryson et al., 2017)
Improved communication with nurses (p = 0.0009) (Bryson et al., 2017)
Increased sense of teamwork with nurses/case managers (p < 0.001) (Bryson et al., 2017)
Higher team performance on complex cognitive tasks (Iyasere et al., 2022)
Cohorted teams generated 2.20 more relative value units (RVUs) per day compared to historical controls. (Singh et al., 2012)
A higher percent-age of patients’ nurses and physicians able to correctly identify one another (93% vs. 71%; p<0.001 and 58% vs. 36%; p<0.001, respectively) (O'Leary et al., 2009)
More frequent communication after cohorting (68% vs. 50%; p<0.001 and 74% vs. 61%; p<0.001, respectively) (O'Leary et al., 2009)
Nurse-physician agreement improved for two aspects of the plan of care: planned tests and anticipated length of stay. (O'Leary et al., 2009)
The percentage of discharge orders released by 10:00 a.m. increased by 21.3 points ( p < 0.001), and the percentage of patients discharged by noon increased by 7.5 points (p=0.001) (Molla et al., 2018)
Conclusion
Geographic cohorting, when implemented thoughtfully and supported by adequate resources and bundled with other interventions, such as IDRs, offers a valuable framework for optimizing patient care and improving physician satisfaction. By challenging the myths surrounding GCh and highlighting its evidence-based benefits, healthcare institutions can encourage physician buy-in and lead the way to a more efficient and effective healthcare system.
References
Bryson, C., Boynton, G., Stepczynski, A., Garb, J., Kleppel, R., Irani, F., Natanasabapathy, S. & Stefan, M. S. 2017. Geographical assignment of hospitalists in an urban teaching hospital: feasibility and impact on efficiency and provider satisfaction. Hospital Practice, 1-8.
Carlson, K. J., Matthias, T. H., Birge, J. R., Bulian, B. P., Richards, S. E. & Shiffermiller, J. F. 2022. The effect of geographic rounding on hospitalist work experience: a mixed-methods study. Hospital Practice, 50, 124-131.
Fanucchi, L., Unterbrink, M. & Logio, L. S. 2014. (Re) turning the pages of residency: the impact of localizing resident physicians to hospital units on paging frequency. Journal of Hospital Medicine, 9, 120-122.
Iyasere, C. A., Wing, J., Martel, J. N., Healy, M. G., Park, Y. S. & Finn, K. M. 2022. Effect of Increased Interprofessional Familiarity on Team Performance, Communication, and Psychological Safety on Inpatient Medical Teams: A Randomized Clinical Trial. JAMA Internal Medicine, 182, 1190-1198.
Jolly Graham, A., Platt, A., Knutsen, K., Fletcher, E. & Gallagher, D. 2024. Impact of geographical cohorting, multidisciplinary rounding and incremental case management support on hospital length of stay and readmission rates: a propensity weighted analysis. BMJ Open Quality, 13, e002737.
Kara, A., Johnson, C. S., Hui, S. L. & Kashiwagi, D. 2018. Hospital-Based Clinicians’ Perceptions of Geographic Cohorting: Identifying Opportunities for Improvement. American Journal of Medical Quality, 33, 303-312.
Kara, A., Kashiwagi, D. & Burden, M. 2022. Closer to or Farther away from an Ideal Model of Care? Lessons Learned from Geographic Cohorting. Journal of General Internal Medicine, 37, 3162-3165.
Keating, A., Frederikson, P., Williams, D., Nakagaki, M. & Johnstone, S. 2019. Collaborative communication is key to delivering better patient outcomes in acute bone marrow transplant and haematology patients Blood 2019. Perth: Haematology Society of Australia and New Zealand, Australian and New Zealand Society of Blood Transfusion and Thrombosis, and Thrombosis and Haemostasis society of Australia and New Zealand.
Klein, A. J., Veet, C., Lu, A., Kennedy, A. J., Agonafer, E., Grau, T., Rothenberger, S. D. & Corbelli, J. 2022. The Effect of Geographic Cohorting of Inpatient Teaching Services on Patient Outcomes and Resident Experience. Journal of General Internal Medicine, 37, 3325-3330.
Loertscher, L., Wang, L. & Sanders, S. S. 2021. The impact of an accountable care unit on mortality: an observational study. J Community Hosp Intern Med Perspect, 11, 554-557.
Molla, M., Warren, D. S., Stewart, S. L., Stocking, J., Johl, H. & Sinigayan, V. 2018. A lean six sigma quality improvement project improves timeliness of discharge from the hospital. The Joint Commission Journal on Quality and Patient Safety, 44, 401-412.
O'Leary, K. J., Johnson, J. K., Manojlovich, M., Astik, G. J. & Williams, M. V. 2017. Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey. The Joint Commission Journal on Quality and Patient Safety, 43, 573-579.
O'Leary, K. J., Wayne, D. B., Landler, M. P., Kulkarni, N., Haviley, C., Hahn, K. J., Jeon, J., Englert, K. M. & Williams, M. V. 2009. Impact of localizing physicians to hospital units on nurse—physician communication and agreement on the plan of care. Journal of general internal medicine, 24, 1223-1227.
Olson, D. P., Fields, B. G. & Windish, D. M. Geographic Localization of Housestaff Inpatients Improves Patient–Provider Communication, Satisfaction, and Culture of Safety. Journal for Healthcare Quality, n/a.
Singh, S., Tarima, S., Rana, V., Marks, D. S., Conti, M., Idstein, K., Biblo, L. A. & Fletcher, K. E. 2012. Impact of localizing general medical teams to a single nursing unit. Journal of Hospital Medicine, 7, 551-556.
Stein, J., Payne, C., Methvin, A., Bonsall, J. M., Chadwick, L., Clark, D., Castle, B. W., Tong, D. & Dressler, D. D. 2015. Reorganizing a hospital ward as an accountable care unit. Journal of Hospital Medicine, 10, 36-40.
Stone, S., Pugh, Z., Perry, A., Mahlum, M., Venner, L. & Hawley, M. 2024. Accountable Care Unit improves length of stay and patient experience. SHM Converge 2024. Rancho Palos Verdes, California: Society of Hospital Medicine.
Keep Exploring Our Work
