Still, when engineers talk about efficiency, hospital professionals might feel that it cramps their practice style. “I need to be willing to listen to their concerns,” says Turner, who in September began a new position as director of systems engineering at University Hospital in Augusta, Ga.
“I don’t want to turn patients into widgets. I’d rather be thought of as an axe sharpener—helping people do their work more easily,” he says. “You can’t satisfy everybody, but you at least need to listen to everybody when you try to make their work lives more efficient.”
Following are some examples of how hospitalist groups have improved the efficiency of important aspects of their practice.
1. Specialized Care Plans
It is well known that some of the most challenging hospital patients consume a disproportionate share of costs and resources, says Rick Hilger, MD, SFHM, a hospitalist with HealthPartners at Regions Hospital in St. Paul, Minn. It can be controversial to suggest that these difficult patients should receive special handling, but Dr. Hilger, who presented a poster on the topic at HM12, says the current system isn’t safe for patients or sustainable in the long run.3
At Regions, about 70 high-utilizing patients have been given an ongoing, specialized care plan that is easily accessible in their electronic health record (EHR) whenever they present at a HealthPartners clinic, ED, or hospital. Patients include those with a history of drug-seeking behaviors, antisocial behavior disorders, aggression or noncompliance in the hospital, and a variety of traumatic brain injuries or memory deficits that might cause them to give a different story to every medical provider. They also include patients who simply have very complex medical conditions.
Referrals for a specialized care plan can come from any hospital staff member. A care-planning committee representing HM, case management, social work, emergency medicine, and administrative staffs meets monthly to review cases and decide if each patient would benefit from a specialized care plan. It offers quick access in the EHR to a cover page with common clinical scenarios, recent tests and procedures, and a template for optimal care that can save a lot of time and prevent duplicative or uncoordinated treatments, Dr. Hilger says. It also ensures that clinicians give a consistent message to the patient.
“Our mantra is that we want care plans that are easy to create, easy to find, easy to use, and likely to lead to better coordination of care,” he says. “We also say that if everybody has a specialized care plan, then nobody does. We want the provider—whether physician, case manager, or nurse—to walk away saying that the care plan saved them time and led to safer care.”
In its first two months, Regions saw a 68% reduction in total ED visits and hospital admissions for the 43 patients with specialized care plans.
2. Scheduling Models
A number of scheduling models are used for deploying hospitalists in larger groups, including seven on/seven off, five on/five off, weekdays versus weekends, zoned staffing, and admitters versus rounders. Research has shown an incremental cost for every handoff, and creating a work schedule that results in fewer handoffs might make patients more satisfied. But that goal needs to be balanced against provider schedules with an eye toward keeping caseloads localized in the hospital.
Shalini Chandra, MD, MS, FHM, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore, was co-presenter of a HM12 workshop on how to use performance-improvement principles to improve HM group schedules. She says the schedule needs to account for such variables as when hospitalists are assigned new patients, are required to interact with the ED, and are devoted to patient contact versus paperwork, which normally is greater at admission and discharge.