We achieved this goal by holding a series of meetings in which physicians, including hospitalists and administrators, worked continuously on these concerns. Also, more operational issues were identified. Among them:
- Giving telephonic verbal orders to nurses for medications, laboratory studies, and radiology procedures, which was not the case with residents;
- Easing restrictions on the use of different medicines that usually require approval of attending faculty for the resident teams; and
- Setting up new dictation lines for our hospitalists (residents have to write their own patient histories and physical assessments).
We resolved to ensure that the program would run like any other private hospitalist program.
Modifications and Scheduling
Other services, including pharmacy, wound care, medical records, and pathology, were also approached by the hospitalists—including the medical director and chief of general internal medicine. The pharmacy was approached to ease restrictions on the medicine prescribed by hospitalists (as opposed to rules for residents, who have to work under different restrictions because they are training.)
Wound-care nurses were asked to implement their orders after telephone approval by the hospitalists (again, this is not the case with resident services). The Medical Records Department created a separate way to handle incomplete medical records for hospitalists—one that takes into account their week-on/week-off schedule. All these requests are now in different phases of approval and implementation.
Overall Parkland has responded well to these changes by appointing senior leadership to fast-track several of these recommendations. Many more policies are under review to complete the transformation from a resident-run model to one that is run by hospitalists.
Like any other new program, the hospitalist program at Parkland went through the growing pains of choosing the right kind of schedule to meet the expectations of the hospital as well as the professional expectations of its doctors. As mentioned above, we currently employ eight hospitalists. Four hospitalists work a week of 12- to 13-hour shifts; they are then off the following week. At that time the other four hospitalists take over for their counterparts. We cover nights using nocturnists.
When the program was not fully staffed there were fewer teams, depending on the number of hospitalists on shift. After the first two hospitalists were hired, we added one team to bring the total number of teams to four. Our teams worked the week-on/week-off schedule. During our initial start-up, the odd-numbered hospitalist who didn’t have a partner to work in week-on/week-off mode worked Monday through Friday each week with weekends covered by one of the main teams.
One of the most important considerations in a hospitalist’s job is the need for flexibility in working hours as compared with the schedule used in a traditional internal medicine practice. At Parkland, hospitalists see 10 to 12 patients in a week. During their week off from patient duties, they are free from all clinical duties and can handle administrative duties, conduct research projects, and accomplish any other tasks awaiting their attention.