Resident Restrictions Might Be HM Game-Changer
I have heard regulators are thinking about further restricting resident work hours. Is this true? Do you think this has helped or hindered patient care? Is there any discussion about restriction of hospitalist work hours? I am working harder than I ever did during training. Have these rules affected the hospitalist field?
H. Jackson, MD, Dover, Del.
Dr. Hospitalist responds:
In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established rules to limit the resident work schedule. The rules included an 80-hour limit on resident workweeks. Training programs around the country experienced difficulties in complying with the rules. Many hospitals established or expanded existing hospitalist programs to help their training programs comply with the rule change, which meant more jobs for hospitalists. From this perspective, the rules were a boon for hospitalists. But the rules also had some unintended consequences. Shorter resident shifts meant more handoffs, and this resulted in an increase in medical errors. Not only do we not do a good job of teaching patient handoffs to our trainees, but most attending physicians also do an inadequate job of communicating patient handoffs.
As you noted, a new report (www.nationalacademies.org/morenews/20081202.html) from the Institute of Medicine (IOM) called for changes to the ACGME rules. The IOM report does not call for a reduction in the 80-hour workweek, but it does recommend several changes to ACGME rules. The IOM calls for residents to work no more than 16 consecutive hours without sleep. It also calls for changes to the present ACGME rules regarding resident time off. Residents should:
- Have 12 hours off after every night shift, 10 hours off after every day shift, and 14 hours off after any shift of 30 hours;
- Not be on call in the hospital more frequently than every third night, with no averaging; and
- Have at least one day off per week, with no averaging.
The IOM report also calls for increased on-site supervision of residents, including immediate access to a supervisory physician for interns. For now, the IOM report is just that—a report. We’ll have to wait and see how ACGME reacts to these recommendations.
What is the potential impact for hospitalists? The work-schedule recommendations could mean residents will work fewer consecutive hours in the hospital. This has the potential to increase the demand for hospitalists to see patients, not only on the medical service, but on other clinical services as well. For example, we may see more hospitalists working with surgeons to manage surgical inpatients. Hospitalist programs will have to figure out a way to work with surgeons without feeling as though the surgeons are “dropping off” patients after surgeries.
With the current shortage of hospitalists, institutions and HM programs could hire more nonphysician clinical providers, such as nurse practitioners and physician assistants. Many hospitalist programs have struggled to incorporate these providers into their workflow in an efficient and cost-effective fashion. Such problems represent opportunities for HM.
The further fragmentation of the resident schedule could create additional patient handoffs. Early in the HM movement, the “voltage drop” issue was a hot topic. Since then, HM has not done enough to standardize the handoff and teach it to others. I encourage all HM programs to resolve the issue of patient handoffs. This is imperative to the safety of our patients.
Use Metrics to Identify Documentation and Coding Errors
I am the leader of a hospitalist group. We have a number of recent graduates in our group, and I have a feeling that not everyone is billing correctly. Do you have any suggestions on how I remedy this problem?
D. Perman, MD, Augusta, Ga.
Dr. Hospitalist responds:
I would not be surprised if your suspicions are correct. Unfortunately, many young physicians do not have a firm grasp on the rules and regulations surrounding coding and documentation. But before you set out to find a remedy, you need to identify and understand the problem.
I suggest you start by collecting data. This is most easily done by involving your administrative staff and billing service. Create individual and group dashboards to help you and the individual physicians examine the data. The first step is to determine whether the doctors in your group are submitting a bill with each clinical encounter. Measure the number of days between the date of service and the date they submit the bill. Create metrics and put them on the dashboard. For example, one could measure bills submitted divided by clinical encounters; another would calculate the percent of bills submitted within 72 hours of the service date.
Next, look at the individual and group code distributions. Assuming that all members of your group have a similar job description and see the same groups of patients, the code distribution should be similar. For example, the percentage of Level 3, Level 2, and Level 1 initial admission codes should be similar among all members of your group. A disparity would suggest that one or more physicians is not documenting and coding correctly.
Use your dashboard to compare individual and group distribution. In my group, I provide each physician with the metrics on their personal distribution of codes for the fiscal year, along with their distribution of codes from previous years. When I do this, I also provide each physician with our group’s distribution of codes for the present and previous years. This allows individual physicians to compare historical trends for themselves and the entire group. I do not share individual data with other individuals in the group.
Lastly, provide the distribution of codes for internal-medicine physicians from Medicare. This information is available at www.cms.hhs.gov/pqri/. It is important to note that I am not holding up the Medicare data or our group data as the standard; it is merely a reflection of how other internists in our group and across the country are billing.
This data is intended to supplement, not replace, our annual training on documentation, coding, and compliance. I have found that pushing this data to our physicians has helped them understand the importance of creating a system to ensure that all bills are submitted and coded appropriately to the level of service and documentation. TH