When the ACGME released its new Common Program Requirements, many balked at the estimated cost of implementing and remaining compliant with the new rules. However, the University of California, San Francisco’s (UCSF) Benioff Children’s Hospital found that the right staffing model can reduce hospitalization costs by 11% and shorten lengths of stay by 18%, reports Hospitalist News Digital Network.
“In September 2008, UCSF expanded and reorganized its pediatric inpatient hospitalist service, moving from a traditional call model to a shift-based staffing model. In the process, the hospital eliminated cross-coverage of different teams in favor of dedicated night teams that were subsets of their day teams,” the article states.
I recently spoke with Russell Holman, MD, FHM, chief operating officer at Cogent Healthcare in Brentwood, TN, and past president of the Society of Hospital Medicine, for an article I’m writing on geographic rounds for the July issue of Hospitalist Leadership Advisor, a supplement to Medical Staff Briefing. He brought up an interesting point: geographic rounding can lead to hospitalist burnout if not designed appropriately. Here’s what he had to say:
If you have specialty units, like an oncology unit or a cardiac unit, you may not want to assign the same hospitalist to the same unit constantly because they might not find their work satisfying with that same population all the time. They may want some variety. If you do have specialty units, you should look at rotating hospitalists through different units.
If your hospitalist program is just getting off the ground, you may be wondering what type of scheduling system will work best. Staff size, hospital culture, and the type of coverage that your program is expected to provide will all factor into your scheduling decisions. Here is a rundown of the various options:
- Daytime coverage: Daytime coverage is typically defined as 7 a.m. to 5 p.m. The hopsitalist conducts daily rounds on all patients and conducts all admissions that occur during these hours. Referring physicians that use the hospitalist service provide the night call. Another option is to have the hopsitalist participate in the nighttime call on a regular rotating basis with the same frequency as the outpatient physicians.
- 24/7 coverage: This model is for a full-time hospitalist program that does not require full-time in-hospital presence. The practice is responsible for covering itself 24 hours a day/365 days a year. Most mature hospitalist programs provide this scope of coverage. [more]
In a recent article that appeared in the July issue of Today’s Hospitalist, I was struck by a quote from David Friar, MD, a hospitalist in Northwest Michigan: “This isn’t a sprint, and seven-on/seven-off is one of the mistakes that I think our field has made. We burn ourselves out, then we rush home to spend seven days driving our spouses crazy.” He adds that if hospitalists worked more days per year, they could see fewer patients in a day without sacrificing productivity and experience better work-life balance.
I know I wouldn’t enjoy that schedule. How about you–is the seven-day block schedule a solution or a nightmare?
In its July issue, Today’s Hospitalist dove into the quandary that hospitalists have been facing since day one: what is the right number of patients to see per day? This isn’t ninth grade algebra (which I flunked, by the way) where you can discover the value of X by plugging certain values into a predicable equation. In fact, multiple factors go into deciding how many patients a single hospitalist or a group should see in a single day.
There is, of course, patient load, but what about group culture, scope of practice, and experience? Then there’s ED call, the availability of advance practice professionals and other clinical support, and physicians’ willingness to see the standard 15 patients per day.
Rather than trying to create a benchmark for productivity—which can sharpen your math skills but may not get you very far in the physician satisfaction arena—should hospitalist groups start asking physicians how many patients per day they are comfortable seeing?
John Nelson, MD, also chimes in on this subject on his blog.
What’s your ideal patient census number?
For years at Inpatient Management Inc., we resisted the 7-days on/7-days off schedule for a whole host of reasons, but a couple of years ago, we stopped swimming against the current of the recruiting river. However, not everyone is enthralled with organizing their life in seven-day increments, and thus, the search for the elusive perfect schedule continues.
There are options designed to ease your scheduling pain, including traditional, block, and workload-based scheduling. With the block schedule, every other week can feel like a vacation. According to Today’s Hospitalist, citing the most recent data from the Society of Hospital Medicine, “40% of hospitalist groups now report using only shift-based scheduling.” The most common block schedule consists of seven days on and seven days off.
I have been thinking a lot about hospitalist schedules, both for my own program and for others that I am consulted on. I have tried for many years to set up eight-hour shifts, only to be told that “we need our days off”.
The seven-on/seven-off schedule holds a strange fascination for hospitalists, especially those who have recently completed residency. When you as the resident have worked 80 hours a week for three years, now doing so every other week, while collecting a salary close to $200,000, sounds like an incredible deal.
The fact is that a seven-on/seven-off schedule with 12-hour shifts comes out to 2,184 hours a year, which is very close that the maximum that people can generally sustain without burnout. During the “on” weeks, there is essentially no time for activities other than work and sleep. All of your personal activities must be conducted during the “off” weeks. The perception of vast amounts of free time is just an illusion.
There is also the matter of recovery after a fatiguing week that sometimes involves nighttime work. I am reminded of a recent TV clip. After Joaquin Phoenix appeared on the David Letterman Late Show and gave no evidence of participation, Letterman said to Phoenix, “It’s too bad that you couldn’t make it tonight.”
Q: When new hospitalist hires start working, should they have the option to pick their own schedule, or should we assign a schedule for them from the get-go?
While gearing up for a Webcast about recruitment and retention, HCPro talked to Kirk Mathews of Inpatient Management, Inc. and Carole Montgomery, MD of Butterworth Hospital, Grand Rapids, MI, about their recruitment methods and how they respond to what is likely the number one question candidates typically ask, “What will my schedule be like?” [more]
The Institute of Medicine (IOM) proposed revisions to medical residents sleep hours to reduce fatigue-related medical errors, in a report “Resident Duty Hours: Enhancing Sleep, Supervision, and Safety,” released this month. If enacted, the changes would require teaching hospitals to dedicate an additional $1.7 billion each year to shift the workload to other healthcare staff or additional residents, according to a Dec. 2 National Academies press release.
The IOM recommends maintaining the current duty-hour limits of 80 hours per week (averaged over four weeks), as dictated by the Accreditation Council for Graduate Medical Education (ACGME) since 2003. [more]
As the holiday season approaches, time off requests from your hospitalists are likely trickling in. We wrote an article “Six evergreen tips for holiday scheduling” in the December newsletter of Hospitalist Leadership Advisor about the best hints for this time of year. Sometimes, though, we can’t fit everything to print. Here is an extra tip that wasn’t included the upcoming issue:
Presbyterian Health Services uses AMION, developed by Spiral Software in Norwich, VT, to keep track of its hospitalist program’s schedules, said Mary Dallas, MD, medical information officer at Presbyterian Health Services in Albuquerque, NM. The password-protected online software works well to accommodate Presbyterian Health System’s shift-based hospitalist schedule. Because the system saves and tracks data year after year, Dallas can ensure that hospitalists who worked on Thanksgiving last year don’t this year—unless they want to. Dallas notes that the software is not used to pay hospitalists; it is used only to manage their schedules.
The purpose of creating a hospitalist performance committee is to improve quality, efficiency, and the bottom line for the program and the hospital. Provider productivity is essential to the financial viability of the practice, and clinical performance is integral to ensuring quality patient care and superior clinical outcomes.
When organizing a hospitalist performance committee membership, remember to include:
- Performance improvement director
- Quality assurance director
- Hospital vice president of medical affairs/medical director
- Hospitalist clinical/medical director
- Hospital chief financial officer
- Hospital administrator overseeing the hospitalist program
- Hospitalist practice manager
- Guests or representatives from ER, cardiology, nursing, social services, laboratory, radiology, and data analyst sector
Meeting frequency and attendees will vary according to the tasks at hand. In general though, the following guidelines should apply:
- Monthly meetings between hospital administrator and the hospitalist clinical/medical director will serve to review the following issues: average daily census and average length of stay, admission activity, delay days, ancillary utilization, cost per case, current in-house outliers, 30-day readmission rates, coding performance, and medical record completion data
- Quarterly meetings with all members to address the following issues: number of admissions/consultations, total patient visits/patient days, average daily census and average length of stay, delay days, ancillary utilization, cost per case, top 10 DRGs and payor mix, monthly/quarterly/year-to-date charges, hospitalist profit-and-loss reports, referral source (by provider and practice), clinical guideline utilization (pay-for-performance measures), 30-day readmission rates, return rate to the critical care unit/intensive care unit, medical record completion data, and coding audits
- Year-end meeting with all members to review performance
The above excerpt is adapted from Hospitalist Case Studies: Tactics and Strategies for 10 Common Hurdles by Kenneth G. Simone, DO, published by HCPro, Inc.
To ensure patient safety and continuity of care, hospitalists must not only establish strong communication links with PCPs, specialists, and patients, but also with other hospitalists in the program, nurses, and other providers. For hospitalist programs spanning multiple hospitals and numerous sites, this process becomes even more complex.
As a result, some hospitalist programs are turning to electronic means of communication: Web logs, patient “portals,” and other sites that update all parties on a patients’ status.
When a patient is discharged, the patient’s PCP can access the discharge summary on the Web log to view:
- Patient demographic information
- Brief summary of why the patient was admitted
- Patient’s discharge date, disposition, and follow-up appointment times
Staff at the outpatient sites should have “read only” access to the Web log to just view and print patient information for use when the patient returns to the outpatient office for a follow-up. Clerical staff should update and maintain the patient information and physician schedules daily. This information is considered a communication tool and not part of the patient record.
The above excerpt is adapted from Tools and Strategies for an Effective Hospitalist Program, by Jeffrey R. Dichter, MD, FACP and Kenneth G. Simone, DO, published by HCPro, Inc.