Bigger Isn’t Always Better

John Nelson, MD, FHM, FACP

Editor’s note: This is the second of a two-part series addressing issues at large HM groups.

Last month (“The Bigger They Are…,” May 2009, p. 58), I discussed the difficulty large HM groups (more than 20 full-time equivalent hospitalists) face in trying to ensure that nurses and other staff always know which hospitalist is attending a patient daily, as well as issues raised by the common practice of separating admitter and rounder shifts. This month, I want to address patient distribution and economic issues faced by large groups.

Patient Census

Large and small groups often work diligently to ensure all rounding doctors start the day with a nearly identical patient load. Such “load leveling” might take only a few minutes in groups of two or three rounding doctors, but it may take up to an hour a day if there are eight to 10 rounding doctors. Think about what this costs a large group. If a group has eight rounders spending the first 30 minutes of each day distributing patients, the practice is devoting 1,460 hours annually to this function. Those 1,460 hours equate to 0.7 FTE, and if each FTE costs the practice $220,000 annually in salary and benefits, then the practice is spending $154,000 per year to distribute patients each morning.

Is that the best way to use $154,000?

Unfortunately, any economy of scale for night-shift coverage usually is offset by inefficiencies and costs that larger practices incur—and small practices often don’t—such as a significant amount of management infrastructure, professional administration, dedicated physician leader time, and an information technology infrastructure.

An alternative is to establish a system that allows the evening and night admitters to know in advance which rounding doctor will assume each patient’s care the next morning. The night/evening admitters would then write “admit to Dr. Satriani” for the first new admission, and “admit to Dr. Johnson” for the second, and so on. The hospital would never list evening/night admitters as a patient’s attending on the chart or in the computer. And each rounding doctor could arrive in the morning to find a list of new patients from overnight, eliminating the need for a meeting of all rounding doctors just to distribute the patients. There may be other reasons to meet each morning, such as case management rounds, but eliminating the need to spend time distributing patients will make the meetings shorter and get everyone out to the floors to see patients more quickly.

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