While the number of consecutive days of work is the most important variable in determining continuity, the way a group distributes new referrals can also have an effect. If a hospitalist doesn’t take on any new referrals on the day before starting a series of days off, there will be fewer patients to hand over to the doctor who takes over the next day. If every member of the practice is exempted from taking on new patients on the day before rotating off, then fewer patients will have a new hospitalist, which means continuity is better. Another way to think of this is that new referrals are “frontloaded” into the earlier days a hospitalist works in each series, and no new patients are assigned on the last day—or maybe more—of a hospitalist’s consecutive days of work.
In my experience, most groups try to distribute patients equally to each doctor each day. This means that a doctor who will be off starting tomorrow takes the standard portion of new referrals to the practice today. The fact that all of those patients will be turned over to a new hospitalist tomorrow, however, adversely affects continuity.
Note that exempting a group member from taking on new patients on the last day of a rotation means that the doctors can’t all rotate on and off on the same day. For example, if a group has four doctors working each day, and all rotate off on the same day—a common practice—then of course it is impossible to exempt all the doctors from new referrals on the day before going off. Instead, it will work best if only one doctor rotates on or off at a time. That leaves all the other doctors available to accept new referrals, while exempting the one about to rotate off.
This approach has benefits that go beyond improving continuity. It means a hospitalist’s workload the day before rotating off will be lighter than on other days. This provides extra time to “tee the patient up” for the next hospitalist—maybe write a more detailed note or dictate a discharge summary in anticipation of the patient leaving the next day—and/or it means a shorter day of work, assuming the doctors can leave the hospital when their work is done and aren’t required to stay around until the end of a pre-defined shift. This shorter day can mean an opportunity to do things like scheduling a flight to vacation late on the last day of work rather than the next morning, which might mean an extra day out of town.
And if a doctor isn’t assigned any new patients on the day prior to rotating off, there will be fewer patients to get to know for the doctor coming in the next day. The first day back on service will be less stressful and, arguably, more efficient.
A principle benefit of having all hospitalists switch on the same day is that the system quickly becomes transparent to the hospital staff. They learn that every Monday—or whatever day is decided upon—all of the hospitalists are getting to know patients for the first time and will probably round much more slowly. Many important processes, such as discharges, may be delayed until later in the day. If only one hospitalist switches at a time, hospital staff will have a hard time keeping up. Any inefficiencies caused by the switch will be spread over many days, however, and this may make it easier to handle. And if patients are teed up better for the new hospitalist and there are fewer patients on the list, the inefficiency that is caused by a new doctor getting to know the patients can be offset by the smaller number of patients. That means, for example, that discharges are much less likely to be delayed because of the smaller patient load on the doctor’s first day on service.