Steps hospitalist groups can take to make hospital care safer, faster, less costly and more satisfying
by Larry Beresford
Is there a role in HM for industrial engineering or industrial efficiency models? Jonathan Turner, PhD, thinks so. He is an industrial-engineer-turned-hospital-engineer whose job is to help make hospital care safer, faster, less costly, and more satisfying. He has few peers in this role, although any hospitalist group in the vicinity of a college department of engineering could seek out similar expertise there. Real-world problems make the best research projects, he says.
“I wrote my thesis on how a vascular surgery department could use computer simulation models to help balance multiple objectives in scheduling residents,” says Turner, who earned his doctorate at Northwestern University in Evanston, Ill.
His thesis examined, among other things, the need for pre-operative continuity of care and resident exposure to a variety of surgical experiences. He also found himself hanging around Northwestern’s Feinberg School of Medicine in Chicago at a time when Mark Williams, MD, MHM, chief of the division of hospital medicine, was looking for ways to build collaboration between Northwestern’s medical school, hospital, and department of engineering.
“Our objectives were the same,” says Turner, who was hired by Dr. Williams in May 2011.
Turner says many of the challenges of managing an HM group—making patient rounds better, improving length of stay (LOS) and throughput, or deciding how to incorporate technology into practice—can be scrutinized with an efficiency lens. At Northwestern, he optimized the HM group schedule and made it more appealing to the physicians. He examined the incremental costs incurred by patient handoffs and the effectiveness of consultations with medical specialists. He tackled technology, teamwork, and wait-time issues. He even helped surgeons standardize their instrument trays.
But every hospitalist group—from the three-FTE teams covering rural hospitals to high-volume groups with dozens of moving parts—has developed inefficient habits. Experts say most groups have never even thought of the problems, let alone the solutions—for example, regularly inputting data into spreadsheets that no one ever looks at.
Efficiency is an essential target for quality initiatives in the hospital, although the word means different things to different people. It typically involves trade-offs that need to be balanced if the system as a whole is to benefit. What makes an individual practice more efficient could make a group’s less so—and vice versa. What helps one department’s bottom line can harm another’s. Enhancing hospitalists’ work-life balance through schedule modification could make life harder for nurses.
One current example that cuts across HM groups of all shapes and sizes is the discharge process. Hospitalist groups speeding up discharges might lead to inadequately prepared patients leaving the hospital, which could mean post-discharge crises, which could lead to unnecessary readmissions, which certainly will mean government penalties. Pure efficiency, in terms of maximizing caseloads, also can conflict with patient safety or patient satisfaction. In many healthcare settings, approaching 100% of capacity limits the ability to respond to surges in demand, Turner says. That usually leads to backups, long waits, dissatisfaction, and even diversions from the ED, he explains.
HM groups have pursued a variety of tools and strategies to enhance efficiency. “One of the things we try to show is that you use these methods every day—but you can be more systematic in how you apply them,” Turner says. The character and personality of practicing hospitalists, who tend to be more quality-minded and focused on systems, might make them more open to becoming efficiency experts and willing to try new approaches.
Still, when engineers talk about efficiency, hospital professionals might feel that it cramps their practice style. “I need to be willing to listen to their concerns,” says Turner, who in September began a new position as director of systems engineering at University Hospital in Augusta, Ga.
“I don’t want to turn patients into widgets. I’d rather be thought of as an axe sharpener—helping people do their work more easily,” he says. “You can’t satisfy everybody, but you at least need to listen to everybody when you try to make their work lives more efficient.”
Following are some examples of how hospitalist groups have improved the efficiency of important aspects of their practice.
It is well known that some of the most challenging hospital patients consume a disproportionate share of costs and resources, says Rick Hilger, MD, SFHM, a hospitalist with HealthPartners at Regions Hospital in St. Paul, Minn. It can be controversial to suggest that these difficult patients should receive special handling, but Dr. Hilger, who presented a poster on the topic at HM12, says the current system isn’t safe for patients or sustainable in the long run.3
At Regions, about 70 high-utilizing patients have been given an ongoing, specialized care plan that is easily accessible in their electronic health record (EHR) whenever they present at a HealthPartners clinic, ED, or hospital. Patients include those with a history of drug-seeking behaviors, antisocial behavior disorders, aggression or noncompliance in the hospital, and a variety of traumatic brain injuries or memory deficits that might cause them to give a different story to every medical provider. They also include patients who simply have very complex medical conditions.
Referrals for a specialized care plan can come from any hospital staff member. A care-planning committee representing HM, case management, social work, emergency medicine, and administrative staffs meets monthly to review cases and decide if each patient would benefit from a specialized care plan. It offers quick access in the EHR to a cover page with common clinical scenarios, recent tests and procedures, and a template for optimal care that can save a lot of time and prevent duplicative or uncoordinated treatments, Dr. Hilger says. It also ensures that clinicians give a consistent message to the patient.
“Our mantra is that we want care plans that are easy to create, easy to find, easy to use, and likely to lead to better coordination of care,” he says. “We also say that if everybody has a specialized care plan, then nobody does. We want the provider—whether physician, case manager, or nurse—to walk away saying that the care plan saved them time and led to safer care.”
In its first two months, Regions saw a 68% reduction in total ED visits and hospital admissions for the 43 patients with specialized care plans.
A number of scheduling models are used for deploying hospitalists in larger groups, including seven on/seven off, five on/five off, weekdays versus weekends, zoned staffing, and admitters versus rounders. Research has shown an incremental cost for every handoff, and creating a work schedule that results in fewer handoffs might make patients more satisfied. But that goal needs to be balanced against provider schedules with an eye toward keeping caseloads localized in the hospital.
Shalini Chandra, MD, MS, FHM, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore, was co-presenter of a HM12 workshop on how to use performance-improvement principles to improve HM group schedules. She says the schedule needs to account for such variables as when hospitalists are assigned new patients, are required to interact with the ED, and are devoted to patient contact versus paperwork, which normally is greater at admission and discharge.
“You need to find the sweet spot between the hospital’s needs, the patient’s needs, and the doctor’s needs,” she says. “Our physicians felt they were being penalized for discharging patients in a timely manner [by receiving more new cases]. We had to go back and say, ‘OK, if somebody is doing a four-day stretch, how can we distribute patients more equitably?’”
Dr. Chandra’s quality team mapped out the entire admissions process and identified key metrics, then devised a model called CICLE (Creating Incentives and Continuity Leading to Efficiency in Hospital Medicine) for its four-day shift. The first day, which can be a long one, is front-loaded with new admissions. But on Day Two and Day Three, the hospitalist is largely protected from new admissions, thereby preserving the incentive to discharge patients when they are ready.
CICLE also results in fewer handoffs, with a third of patients seen by only one hospitalist, Dr. Chandra explains. That in turn translates into decreased LOS and cost.
The four-day schedule at Hopkins is complicated by the need to respond to other demands on the system, and Dr. Chandra says only 60 percent of the hospitalist caseload is scheduled this way.
The best schedule in the world can be turned upside down by vacations, sickness, or an open position that goes unfilled for months. Accounting for the nuances can be a full-time job.
At Northwestern, the hospitalist group is converting to scheduling software called Lightning Bolt (www.lightning-bolt.com) that provides flexibility to respond to varying needs among the 70-plus members of the group, including such needs as attending their children’s soccer games, says Charlotta Weaver, MD, assistant professor of medicine.
“An enormous amount of time, both administrative and medical, gets devoted to scheduling,” she says.
Each hospital and HM group is different, and each physician has varying desires from the schedule. “Things are constantly changing,” Dr. Weaver says. “People come and go or need to change jobs, there are changes in FTE allocations, physicians may get research grants, and there can be changes in hospital structure or service lines.”
The schedule also needs to facilitate “day trading” between members of the group, and Northwestern is experimenting with some new approaches, including pairing up two physicians on one service line and letting them work out their own schedules.
The group also needs a way to respond to admission surges beyond the capacity of scheduled physicians, which can be hard to predict, and the days when physicians call in sick.
“We have tried to develop a robust system of ‘jeopardy’ for first- and second-line backup,” Dr. Weaver says. Everyone in the hospitalist group has jeopardy one or two weeks per year, where they are in line to be called in if needed.
Franziska Jovin, MD, FHM, a hospitalist at the University of Pittsburgh Medical Center, says her group struggles with predicting patient peaks and valleys.
“One of our hospitalist teams is responsible for the transitional-care unit, and not every patient on that unit has to be seen every day,” Dr. Jovin says. “This person is already scheduled to work, but the responsibilities are not time-dependent. So we can pull in that doctor as needed to cover higher demand on the acute side.”
As most hospitalists know the winter months are busier, “and we staff accordingly,” she says, in response to higher incidence of flu, pneumonia, and the like.
Another challenge to scheduling is the rounding model used for daily care planning in the hospital. Various models have tried to address competing concerns of geography, schedule efficiency, and the needs of hospitalists, nurses, and other staff. At Emory Healthcare in Atlanta, an approach called Structured Interdisciplinary Bedside Rounds (SIBR) was described during an HM12 workshop and in a prize-winning poster presented by Christina Payne, MD (see “The Innovation Express,” May 2012, p. 27).
Dr. Payne described how SIBR works with two teaching hospitalist services on a 24-bed “accountable-care unit” at Emory University Hospital. Each team has a resident, three interns, a social worker, and the patient’s nurse, with the attending standing by.
“We round on each patient every day—beginning and ending on time,” 12 patients per hour, with five brisk minutes to report on each patient, she says. Rounding starts when the patient’s primary intern and nurse are both present in the patient’s room, and only ends when a plan of care for the day has been articulated—using a standardized script with safety and discharge planning checklists. The second intern enters the plan, in real time, into the EHR.
In addition to the time efficiency, this approach has posted positive outcomes, namely a 53% reduction in in-hospital mortality on the unit and an 11% reduction in LOS. With new residents and interns rotating through the unit every month, “We acknowledge to them that this will be difficult and they will be uncomfortable at first,” Dr. Payne says, “but by Week Two, we’re a well-oiled machine.”
Similar approaches have been implemented at other Emory hospitals.
Many hospitalist groups have integrated nonphysician providers (NPPs, or nurse practitioners and physician assistants) into the group’s practice or are considering such a move. Tracy Cardin, ACNP-BC, a nurse practitioner in hospital practice at the University of Chicago Medical Center, says it’s important to ask why a group is considering a role for NPPs.
“Is it to promote efficiency? Is it because you can’t attract enough physicians?” she says. “Clarify your hopes for the position and how you will define success.” She also says HM group leaders need to factor in the time needed to hire, orient, and train an NPP, with mentoring that includes structured teaching and feedback.
There are a lot of models for deploying NPPs, says Cardin, a Team Hospitalist member.
“We utilize shared billing and teams of a hospitalist and nurse practitioner. This allows the physician to see a larger number of patients and brings more than one set of eyes and ears to the complex patient,” she says. “We’ve developed a process over the past six years where the hospitalist and NPP together go over the patient list every day. Both will see the patient, but the NPP commonly writes the notes and orders.”
Cardin emphasizes NPPs cost less than physicians and “can do many of the same things,” but “they are not free.” The most resourceful HM group’s use NPPs to extend the physician’s practice. “They can carry a pager and respond to small crises that come up, or see the patient on discharge day,” she says. “In other settings, the NPP does admissions, serves on quality projects, takes on a patient cohort based on diagnosis, or calls the primary-care physician at discharge.”
Efficiency can be a tough nut to crack in the hospital. Turner, the engineer, says HM groups need to “remember that the hospital is a very complex environment, with cascades of reactions and downstream effects.”
Hospitalists need the support of other professionals, and quality-improvement (QI) initiatives need sufficient time and resources to succeed.
One way to start advancing the efficiency agenda is to look for bright spots among the hospitalist group’s members. “Talk to them,” Turner says. “Find out how they do their jobs. Learn from them.”
Larry Beresford is a freelance author in Oakland, Calif.
The Hospitalist newsmagazine reports on issues and trends in hospital medicine. The Hospitalist reaches more than 25,000 hospitalists, physician assistants, nurse practitioners, residents, and medical administrators interested in the practice and business of hospital medicine.