The hospitalists’ schedule is challenging, particularly for doctors way past residency, involving 8 a.m. to 10 p.m. shifts on a three-week cycle that starts on a Friday. Physicians work eight 14-hour days, followed by a weekend off, then five days on (Monday-Friday) and six days off (Saturday-Thursday). The hospitalists don’t routinely cover night call. A full-time nocturnist, who started in 1992, and moonlighters cover the 10 p.m. to 8 a.m. shift seven days a week, with hospitalists covering only for major emergencies.
York Hospital’s ED and a cap on residents’ hours keep the Brockie hospitalists busy. But, early in 2005, it looked as if the workload had reached a plateau. Although Dr. Whitney suspected that the breather wouldn’t last, the group had no evidence that the tempo would increase and voted to maintain the number of hospitalists. The tempo picked up.
“We had estimated an 11 percent growth in RVUs, which actually grew by 23 percent last year,” says Dr. Whitney. Then a large primary care group agreed to shift its inpatient work to Brockie in 2006. Dr. Whitney estimated that assuming that practice’s hospital patients would add 5,000 RVUs and 600 more admissions.
“We realized we could approach a point of stress and burnout with the increased workload, so we recruited two new hospitalists,” says Dr. Whitney.
Still, the hospitalists face a balancing act of census peaks and valleys. “The variations with census and admissions go well beyond the bell curve,” says Whitney, who prepares for crunches by finding volunteers among the hospitalists to cover unexpected peaks.
If Brockie sounds like a Harvard case study on hospitalist medicine, it should. Its long tenure, physician leadership, and administrative support have shaped the business practices that facilitated the program’s growth. For one, the sophisticated compensation/productivity scheme didn’t come about by accident. Dr. McConville, a representative of WellSpan’s medical service line, meets with three Brockie hospitalists to fine-tune the program’s metrics. QI measures that are newly written each year, regular individual feedback, and inclusion of evidence-based guidelines contribute to measures and practices that address many of hospital medicine’s problems.
A Big Step to Little Things
But Brockie isn’t perfect. The responsibility of 24/7 coverage and 14-hour days allows little things to fall through the cracks—things like finding the time to promote the hospitalist service on the Web site, getting new formulary updates out quickly, and immediately informing all of those concerned that a patient has died. Brockie has addressed those and other issues that are the mortar to the bricks of a hospitalist practice by hiring David Orskey, an ex-Navy corpsman, as its senior practice manager in July 2006.
Orskey, co-chair of the medical group’s process improvement committee, sees his work as finding efficiencies, working for better care, and increasing patient satisfaction, plus attending to the budget and human resources issues and networking with outpatient practices.
“Twenty-one years in Navy medicine prepared me for this job,” says Orskey. “I’m enjoying this community, which has everything from farmland to executive homes and an influx of Hispanic migrants.”
He’s able to focus on both the details and the big picture, such as making sure that everyone works toward implementing and using the electronic medical record and improving after-hours answering services, as well as refining credentialing and risk management.
Brockie’s hospitalists also serve Mechanicsburg, Pa.,-based Select Medical Corporation’s long-term acute care (LTAC) unit, a 30-bed unit within York Hospital that supports patients needing a bridge between an acute hospital and skilled nursing care. The patients run the gamut in their needs—some have pulmonary/ventilator issues; others present medically complex situations such as heart failure, multi-system organ impairment, and cancer; some are neurosurgical/post trauma; and others need specialized wound care.