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Hospitalist-nurse partnerships

I have written in previous posts about the importance of developing partnerships between hospitalists and nurses. The quality of those relationships may determine the difference between a hospital that succeeds and one that fails. The key to a successful partnership is rapid flow of information between the parties and the ability to trust each other. Consider the needs of each side: hospitalists need nurses who can make accurate patient assessments and provide timely alerts to changes in condition, while nurses need physicians who provide clear instructions and provide rapid and respectful responses to contacts from the nurses.

Let’s start with the basics. Nurses need to know at all times which doctor is responsible for each of their patients. It is not acceptable for nurses to have to guess, try several doctors, or call an office to figure out which hospitalist is caring for a patient. When patient responsibility is transferred from one physician to another, the primary nurse needs to have that information promptly, and every hospitalist program needs a system to relay that information. If a nurse is confused and calls the incorrect physician, hospitalists should not dismiss the call with a brusque “Call Dr. X.” If the problem is simple and does not require detailed knowledge of the patient, handle it yourself and then refer the nurse to the appropriate physician for additional assistance.

The next level involves changing the work dynamics between hospitalists and nurses. Nurses document reams of information about patients throughout the course of a day, most of which physicians ignore. Unlock that information by holding a daily meeting in which physicians and nurses share their knowledge about patients. Formal rounding is great if you can do it, but a quick huddle with the nurse to go over the nurse’s observations about the patient and the doctor’s plan for diagnosis and treatment can be tremendously valuable in speeding treatment plans and in reducing phone calls during the remainder of the day.

The final level involves breaking down the wall between the professional status of doctors and nurses. If the patient asks for a cup of water, do you need to ring for a nurse? Would it kill you to fill a cup from the sink and bring it to the bedside? If you do a bedside procedure, how about taking the used items and placing them in the proper receptacles? A little bit of humility goes a long way in helping nurses feel that they are valued colleagues, rather than servants.

Alligators in the hospital: Part II

My last two posts have dealt with the analogy between hospitalist program managers and civil engineers who find that they cannot drain the swamp as contracted because they are occupied with fighting off alligators. I want to discuss now the most prevalent type of alligators in hospitals—the nurses. Doctor-nurse relationships run deep and may well be the prime determinant between hospitals that fail and those that succeed. The nurse was historically a handmaiden to the physician and maintained extreme deference. Advances in nursing education have prepared nurses for a professional role that is still subordinate to the physician, but the relationship between the two varies from cooperative to antagonistic.

What makes a nurse into an alligator? Nurses are expected to carry out a daily care plan for a group of patients that may number from one (in the ICU) to 30 or more (typically on a night shift). They are expected to respond promptly to call buttons, answer calls from doctors and families, send patients off to scheduled tests and procedures, administer complex medication regimens correctly, and document their activities thoroughly. There is a lot to do in the course of a day and not quite enough time to do it. Years ago, all of a nurse’s patients might be in a single room and she (no male nurses back then) could see them all and shift attention quickly to those that needed it. Today’s nurse may have each patient in a different room and the rooms may be at opposite ends of the floor.

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Taming the alligators

My last post introduced the idea that hospitalist medical directors are in the position of an engineer hired to drain a swamp but distracted from doing so by the numerous alligators inhabiting the swamp. I would like to explore further the concept of keeping the alligators at bay so that one can concentrate on draining the swamp, that is, improving the quality of hospital care.

My only direct experience with real alligators occurred while I was bicycling along a path on Kiawah Island, SC.  An alligator was lying about 20 feet off the path. It paid no attention to me as I cycled pass. Under different circumstances, that alligator would have raced toward me and potentially been able to attack. Why not that time? I presume that the alligator had satisfied its food needs and I did not fit into its agenda. The point is that alligators are not naturally malevolent. They become dangerous when they are hungry.

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Pairing nurse directors with medical directors

In the September issue of Hospitalist Leadership Advisor, a supplement to Medical Staff Briefing, I spoke with Thomas Huth, MD, vice president of medical affairs at Reid Hospital and Health Care Services in Richmond, IN. Reid’s hospitalist program has implemented a nurse director role and, as a result, it has seen significant financial and operational improvements. The nurse director works closely with the medical director, serving as an extra pair of arms and legs to help the physician accomplish the many tasks that might be pushed by the wayside due to lack of time. For example, the nurse director might arrange for a patient to be transferred to a skilled nursing facility where the cost of providing care is less expensive, rather than having the patient stay in the hospital one more night while at-home care is being arranged. 

Huth provided a chart that compares the medical directors’ and nurse director’s roles. If your hospitalist program chooses to enlist the services of a nurse director, keep this chart handy to give you a sense of the medical director-nurse director relationship.

Live from SHM: Hospitalists and Healthcare reform — Q&A with Jonathan Lovins

We sat down with Jonathan Lovins, MD, SFHM, hospitalist and assistant clinical professor of medicine at Duke University Health System in Durham, NC, and contributing blogger at HosptialistLeadership.com on Friday at the Society of Hospital Medicine annual meeting. Hear what he has to say about how healthcare reform will roll out, why we can expect to see more patients in the future, and why we shouldn’t fear nonphysican providers.

Q: What do you see as being the biggest effect of healthcare reform on hospitals and hospitalists?

A: I think the biggest effect is going to be the access in care; that was the biggest accomplishment of the healthcare bill. Because of that, it will relieve a lot of stress. The response from the leaders of healthcare delivers has been very positive. In the short term, it will improve access, and there will be less of a two-tier system of the haves and have nots. So we won’t have as big an issue with patients who are uninsured or patients who come to the hospital when it’s too late, not being able to pay for their care.

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Live from SHM: No room for just one — The importance of having a common hospitalist office

One of the themes that came from Thursday’s Society of Hospital Medicine Best Practices pre-course is the idea of a shared office space for the hospitalist group.

“The communication gap could destroy your group,” Joseph Ming Wah Li, MD, SFHM, told one audience member who explained his situation of a poorly connecting group.

Most the panel speakers agreed that private hospitalist offices are not only unnecessary but could even hurt the group dynamics. Instead, opt for a communal work space for the group.

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Live from SHM: Tips for hosting hospitalist group meetings

SHM Best Practices Panel members answer attendees' questions. (HospitalistLeadership.com Photo / Karen M. Cheung)

In a “Rapid Fire” panel discussion, the experts weighed in on the question of “How often should you have hospitalist group meetings?”

Although there was some variation, in general, the panel suggested the optimal meeting frequency is approximately once a month for the group.

John Nelson, MD, FACP, FHM, medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, WA, and founder of Nelson/Flores Associates, has seen variations ranging from weekly to monthly, but found that monthly meetings work the best in the group. Nelson suggested marking down attendees’ names and then letting them know what their cumulative meeting attendee record is; that pushes them to attend.

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Live from SHM: How do you build camaraderie within the hospitalist group?

“It’s not a luxury item to a high-functioning group,” said Winthrop Whitcomb, MD, MHM, hospitalist at Mercy Medical Center, Springfield, MA, about the necessity of hospitalist group camaraderie.

Although the brothers-in-arms feeling come natural to some groups, that isn’t always the case for all groups. Here’s what the SHM Best Practices Pre-course panelists had to say ways to build up the team dynamics.


SHM Best Practices Panel members answer audience questions. (HospitalistLeadership.com Photo / Karen M. Cheung)


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Hospitalist nonphysician providers: Why it’s so controversial

Last month, I wrote an article for HealthLeaders Media, entitled, “Are Hospitalist Physician Assistants the Answer to Shortages?” based on a recent article by The Mayo Clinic, published in the January issue of Journal of Hospital Medicine. The Mayo Clinic Arizona announced the first PA program dedicated to hospital medicine, a 12-month program that Mayo explains has positive results—PAs function at the same level as those that have been learning on the job for three or four years. It’s one possible answer to mounting pressures of a nationwide doctor shortage, as well as resident duty hour restrictions.

"We have a critical staff shortage, and you're a physician assistant... Well, you just morphed into a hospitalist... Congratulations!" (Illustration / HCPro, Inc.)

"We have a critical staff shortage, and you're a physician assistant... Well, you just morphed into a hospitalist... Congratulations!" (Illustration / HCpro, Inc.

Readers from all departments certainly got fired up about the idea of the nonphysician provider (NPP), specifically the physician assistant (PA), in the inpatient setting.

Nurse practitioners (NP) wrote back about their own role in the hospital, in addition to the PA.

Alicia M. LePard, RN-BC, MSN, CDE, BC-ADM, said:

“I believe NPs are probably better suited to the inpatient hospital role over the PA by virtue of training. All nurses are initially introduced to the hospital role and largely perform most of their practice before graduate school in the hospital versus PAs who are largely trained for the office setting. Although many PAs may transition to surgery and other specialty that involve the hospitals, their primary training is not hospital based.  NPs may need additional training to incorporate some of the other critical care roles that acute care nurse practitioners (ACNP) concentrate in, but, by far, this should be less than that of the PA who attempts the same transition.  Despite the graduate level training of the ACNP, in truth, they are still a registered nurse and can be used for lots of other tasks inside the hospital that the PA would not be licensed nor suited to perform.”

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Health plan hospitalists: “Extensivists”?

By Kirk Mathews, MBA

In a recent article from Today’s Hospitalist, a concept emerges about a number of physicians called “extensivists” who are employed by health plans and work to increase post-discharge intervention. The primary goal of their post-discharge work is to reduce readmission rates.

Ensuring follow-up care upon discharge can be a challenge, especially with some unassigned, noncompliant patients. Most hospitalist programs encourage follow-up calls to primary care physicians (PCP) and patients within 72 hours of discharge, but health-plan hospitalists are doing more. According to this article, some health-plan hospitalists are going to see their discharged patients at integrated care centers and nursing homes after daily rounds in the hospital. And in some instances, they are rewarded with a significant bonus if readmission rate targets are met.

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Hospitalist programs and critical access hospitals collaborate: How it works

By Kirk Mathews, MBA

Many of the hospitalists that serve in our client hospitals regularly accept transfers from smaller facilities, including critical access hospitals (CAHs). This is a service to both institutions, as well as the patients, and has been part of our practice for a long time. However, we are now seeing referrals from some of our larger client hospitals back to the CAH where hospitalists also care for patients.

Hospitalist programs have been springing up in CAHs for some time now. CAHs face some of the same challenges as large hospitals but often have significantly less resources with which to confront them. So how can they make them sustainable?  Well, administrators at CAHs can be very resourceful and creative.

One of our hospitals receives quite a number of transfer patients from a CAH located about 50 minutes away. Our service is a sizable program at a busy full-service hospital. When this particular CAH wanted to start a hospitalist program, they spoke with our client hospital, as well as with our hospitalists. The resulting program provided a win for all involved.

Our service uses a seven-on/seven-off schedule. Each week, there are enough physicians off who are interested in moonlighting that they can cover the CAH for most of the daytime hours. They get help from the CAH emergency room docs when they cannot be there, including at night. Keep in mind that this hospital had an average daily census less than eight patients. The local over-burdened PCPs welcomed the program.

As you might suspect, patients scheduled for hip or knee replacement surgeries would go to the larger hospital for the surgery. However, the acute rehab facility at the larger hospital is very busy. Once the patient (from out of the area) is stable, they transfer back to the CAH for their rehab and are followed by the hospitalists. Since the physicians on both ends are on the same team, transfers are seamless. These rehab patients greatly help offset the cost of the hospitalist program.

This is just one example of a creative way to make the hospitalist model work at a CAH. There are many others. Please comment and tell us of your experience in this area.

Pennsylvania CRNPs granted greater prescribing authority

The Pennsylvania State Board of Nursing may have just paved the way for certified registered nurse practitioners (CRNP) to practice side by side with hospitalists and primary care physicians to ease the strain caused by the physician shortage. Although perhaps not explicitly for this reason, the state recently granted CRNPs greater drug prescribing authority, according to The Pennsylvania Bulletin. Our friends at the Med Law Blog sum it up nicely:

  • CRNPs can now prescribe Schedule II controlled substances for up to a 30-day supply, an increase from the previous limit of 72 hours
  • CRNPs are no longer required to notify their collaborating physician within 24 hours of prescribing a Schedule II controlled substance
  • CRNPs may now prescribe Schedule III and IV controlled substances for up to a 90-day supply, up from the previous 30-day limit 

Kirk Mathews said in a recent blog post, “It is clear that more and more hospital medicine programs are turning to NPs to supplement their practice in the face of a very challenging recruiting environment. I believe this is both logical and appropriate as the demand for hospitalists continues to grow.” (He goes on to offer a few words of caution that hospitalist programs should consider before throwing open the doors for NPs.)

 One of our readers also chimed in on the topic of including NPs in the hospital medicine setting: “The goal of easing the burden on PCP’s is an important goal, but there are differences in training, and to ignore these compromises patient care.” Needless to say, there is a debate raging in the field.

 If you’ve worked in healthcare for more than a day, you know there are no black or white answers—whether a hospitalist program opens the doors for NPs depends on the program, and, apparently, whether state regulations pave the path. 

We’d like to hear your arguments for or against giving NPs greater authority to treat patients and what you think about Pennsylvania State Board of Nursing’s decision.