The Flip Side
Adam Singer, MD, CEO of North Hollywood, Calif.-based IPC: The Hospitalist Company, points out that an overly low census can prove just as problematic, contributing to revenue and efficiency concerns. A hospitalist’s core ability to drive a delivery system, he says, requires sufficient exposure to a facility’s range of patients and contact with enough other staff members to propel a process of positive change.
“If you only have a few patients and your rounds are done in an hour, how engaged are you?” he asks.
Dr. Singer says his company’s more than 2,000 HM providers see roughly 15 to 18 patients on any given day. Even so, he says, the appropriate census for each practice can vary widely based on its structure, patient population, and the quality and experience of individual providers.
In a recent survey, 40% of physicians said that more than once a month their typical inpatient census exceeded the level they deemed safe and appropriate; 36.1% said that was true more than once per week.
To ensure the numbers remain in the right range, Dr. Singer says, the company provides “complete transparency across the medical group, so that every doctor in the group sees exactly how many people everybody else is seeing.” If one doctor is seeing six patients and another is seeing 20, the group can self-regulate its census.
IPC also closely monitors a core series of clinical measures to ensure quality, ranging from ACE inhibitor use to length of stay and readmission rates. If one of the clinical measures starts to degrade, Dr. Singer says, the company can spot the problem and provide counseling or staffing assistance to right the ship. Hiring more doctors might be the most effective solution, but if a facility cannot afford more FTEs and quality is diminishing, he suggests collaborating with local primary-care physicians or even a less-busy hospitalist group to help share the load.
Safe Patients, Satisfied Providers
Ruth M. Kleinpell, PhD, RN, FAAN, FCCM, professor of nursing at Rush University Medical Center in Chicago and a nurse practitioner at Mercy Hospital and Medical Center, says each institution needs to do a self-assessment based on clinician feedback. Is the workload manageable? Can the providers take breaks? What do their satisfaction surveys suggest? What are the turnover and burnout rates?
“We have clinicians who report that they don’t even get a lunch break,” Kleinpell says. “That’s not safe, and that’s not lending itself to a work environment that’s satisfying for the practitioners.”
We took the focus on productivity and just elevated it higher to overall organizational finance. We answered the age-old question: Is it better and financially more productive for the organization to lower he average starting census and to pay for the extra physician? And the answer is a resounding yes for us.
—David Yu, MD, MBA, SFHM, FACP, medical director, adult inpatient medicine service, Presbyterian Medical Group, Albuquerque, N.M.
Dr. Mitchell has seen overwhelmed hospitalists defer the care of patients they could normally handle to specialists, which leads to higher costs. Ultimately, Dr. Mitchell says, group leaders, administrators, and staff can all help set the right tone. “In the group I’m with now, there’s positive peer pressure to do the right thing, to be efficient, to communicate,” he says, “and if someone doesn’t do it, then it kind of stands out.”
Truly overwhelmed hospitalists can’t continue working well at an unsustainable pace. “It’s an extremely tricky situation, and I think for me it comes down to working with doctors that I trust and working with an administration that trusts us to say, ‘This is what’s best for patient care,’” Dr. Mitchell says. “And you need to prove that by getting the patient feedback and staff feedback that says, ‘Hey these guys are doing a good job.’”