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.
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?
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.
There are two simple ways the evening/night admitters can know how to assign new patients to the rounding doctors for the next morning. If the group wants to have each rounding doctor start with a nearly identical patient load, then the rounding doctors could indicate their load at the end of each day and the evening/night admitters would follow an algorithm of assigning the first admissions to the doctor who finished the prior day with a lighter load. The other option is for evening/night admitters to assign new patients through the night according to a fixed protocol, which wouldn’t vary based on the current patient load of each rounder. Of course, this will mean daily patient load could vary significantly from one rounder to the next, but over any long period, the workloads will tend to even out.
Elusive Economy of Scale
Hospitalists and hospital executives tend to have a different view of the benefits of practice growth to require more hospitalist FTEs. The hospitalists themselves often are convinced that when the group has more doctors, there will be more scheduling flexibility for each individual doctor, and perhaps each doctor will have to work fewer weekends. Sadly, neither is true to any significant degree in most practices. Some aspects of scheduling are easier when there are more doctors. For example, it usually is easier to find someone to fill in for an unexpected absence in larger groups. However, each doctor’s schedule usually doesn’t get much better or more flexible.