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The Bigger They Are ...


Editor’s note: This is the first of a two-part series addressing large HM group issues.

In the mid-1990s, when I first became interested in how other hospitalist groups were organized, I started surveying by phone all the groups I could find. It was really unusual to find a group larger than four or five full-time equivalent (FTE) hospitalists. Since then, the size of a typical hospitalist group has grown steadily, and data reported in SHM’s “2007-2008 Bi-Annual Survey on the State of Hospital Medicine” shows the median number of FTE physicians in HM groups is 8.0 (mean of 9.75). So in just a few years, our field has grown in such a way that half of all groups in operation now have more than eight physician FTEs. I think most future growth in numbers of hospitalists will be due to individual practices getting larger, rather than new practices starting up.

I work regularly with groups that have more than 20 FTEs, and I have found that large groups tend to have a number of attributes in common.

I worry about patient satisfaction if the evening/night admitter can’t tell the patient the name of the hospitalist who will take over in the morning. How can the patient feel that they’re getting personalized care when they’re told, “I don’t know which of my partners will take over your care tomorrow”?

Separate Daytime Admitter and Rounder Functions

Large groups almost always staff admitter and rounder functions with separate doctors around the clock. That means patients arriving during regular business hours are admitted by a different doctor (the admitter) than the doctor who will provide their care on Day Two and beyond (the rounder).

Although such a system is popular, I suggest every group challenge itself to think about whether it really is the best system. Most groups, regardless of size, have about a quarter to a third of their new admits and consults arrive between 7 a.m. and 5 p.m. If the group did away with a separate admitter during the day and moved all daytime admitters into additional rounder positions, all the daytime admissions could be rotated among all of the daytime doctors, and those patients would typically be seen by the same hospitalist the next day. That would improve hospitalist-patient continuity for the patients who arrive during the day, which might improve the group’s overall efficiency as well as quality and patient satisfaction. Each rounder would become responsible for seeing up to three new consults or admissions during the course of the daytime rounding shift, and the list of new patients to take over each morning—patients admitted by the evening and night admitters—would be smaller.

Of course, one significant benefit of having a separate admitter shift during the day is relieving the rounding doctors of the stress of interrupting rounds for an unpredictable number of new admissions each day. And if the new admissions arrive in the morning, throughput may suffer as it might mean the rounding doctor may see “dischargeable” patients later in the day.

I think there is room for debate about whether it is best for large groups to have a separate admitter during the day, but whatever approach a group chooses, it should acknowledge the costs of that approach and not just assume that it is the only one that is feasible or reasonable.

Who Is Caring for Whom?

The larger the hospitalist group, the more difficulty nurses and other staff have understanding exactly how patients are distributed among the doctors. When one hospitalist rotates “off service” to be replaced by another the next day, or when overnight admissions are “picked up” by a rounding doctor the next morning, it can be difficult for nurses to know which hospitalist is responsible for the patient at a given moment.

All groups, regardless of size, should ensure that the hospitalist who picks up patients from a colleague who has rotated off the day before writes an order in the chart indicating “change attending to Dr. Jones,” or clearly communicates who the new hospitalist is by some other means, such as an electronic medical record or a phone call from a clerk. It isn’t enough that patients are assigned to a particular team—say, the “white team” or the “green team”—for their entire stay. Nurses and other staff need to know which hospitalist is covering that team each day.

One test of how well your system is working is to assess how the nurse answers when a patient or family asks, “Which doctor will be in to see me today?” It isn’t good enough for the nurse to just say, “The green-team doctor will see you, but I don’t know who that is today.” The nurse needs to be able to provide the name of the doctor who will be in. If nurses at your hospital regularly page the wrong hospitalist, or must call around just to figure out who the attending hospitalist is for a particular patient, then you have an opportunity to improve how you communicate this information to the nurse and others.

Even if you have a system in which it is clear to everyone which hospitalist has taken over for one who has rotated off-service, you need to ensure that nurses can easily determine the attending hospitalist for patients admitted the night before. Night-shift staff not knowing which doctor will take over in the morning is an all-too-common problem, and it results in too many staffers not knowing who is caring for the patient from the time the night doctor goes off (e.g., 7 a.m.) until the rounder taking over gets to that patient on rounds. Having evening/night admitters assign attending, or rounder, hospitalists at the time of each admission is a great solution, and I’ll provide ideas about how to do this in next month’s column.

I worry about patient satisfaction if the evening/night admitter can’t tell the patient the name of the hospitalist who will take over in the morning. How can the patient feel that they’re getting personalized care when they’re told, “I don’t know which of my partners will take over your care tomorrow. They all get together and divide up the patients each morning and will assign a doctor to you then”? It’s different if the admitter tells the patient, “I’m on call for our group tonight, but will be home sleeping tomorrow and my colleague, Dr. Clapton, will take over your care in the morning.” I usually go on to say with a wink that the patient is getting an upgrade, because Dr. Clapton is so much smarter and better-looking than me. I’ll understand if the embellishment doesn’t feel right for you, but I think there is value in the admitter, or a hospitalist rotating off-service, taking a minute to say something nice about the hospitalist who will take over next.

Next month, I will continue to explore issues that are particularly problematic for larger groups. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. He also is part of the faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

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