Dr. Yu says many medical directors see the administration’s chief financial officer as an adversary when they should be working together. That kind of collaboration means coming up with strategies, metrics, and models that a financial department can relate to.
“You can’t just complain,” he says. “If your hospital is losing money, your program is going to shut down. But if you provide bad care, the hospital is going to do badly. Both sides have very legitimate points, and one of the jobs of a good medical director is to bridge those two worlds.”
Once the administration is on board, though, each facility must devise the right remedy for a chronically frenetic workload. John Nelson, MD, MHM, FACP, medical director of the hospitalist practice at Overlake Hospital Medical Center in Bellevue, Wash., says facilities can relieve overworked doctors by relieving them of tasks that other staff members could easily do.
“There are places I go where the hospitalists are doing things like arranging follow-up appointments themselves. That’s just nuts,” says Dr. Nelson, a co-founder and past president of SHM, practice management consultant, and columnist for The Hospitalist. “Or the hospitalists themselves are tasked with printing out a copy of their discharge summary and faxing it themselves.”
Other solutions depend on the makeup of clinical teams. “Do you have the ability to integrate nurse practitioners or physician assistants into the team?” Kleinpell asks. “Because certainly they can help maximize the hospitalist’s efficiency by seeing patients who maybe are less severely ill, or new admissions.”
Calling upon other providers to do patient histories, physical exams, or discharges, she says, also removes some of the burden.
Geographical rounding at one facility where he still occasionally practices, Dr. Knight says, “has made all the difference in the world” in improved efficiency. Responsibilities can be subdivided based on more than geography, too. At Palmetto, a team of nurse practitioners does all of the day-to-day management of stroke patients, helping to provide more standardized, reliable care.
A more evolved strategy, Dr. Singer says, is to develop hospitalist-only floors, which allow providers to see a higher volume of patients very effectively. Yet another technique is to assign a case manager to a specific provider instead of by disease or floor. That way, Dr. Singer says, a hospitalist facing a high patient census can round with the same case manager and much more effectively direct management resources.
Like other hospitalists, Dr. Nelson says hard caps should be considered “only in the most dire circumstances or only when all other options have been exhausted.” Sending patients away during peak times, he says, does nothing to address unusually slow days. Apart from the economic consequences, instituting a cap also can fuel the perception that an HM group isn’t pulling its own weight and raises questions about who else will have to take the group’s patients.
There may not be any one-size-fits-all solution, but observers say they are seeing a growing maturity and sophistication in how hospitals are dealing with patient censuses. At first, facilities may view volume and production as the most important considerations.
“Over time, they realize that’s a self-defeating way to operate because it does lead to more errors, it leads to more complications, it leads to longer length of stay,” says Dr. Knight. Eventually, he adds, most organizations come around to the realization that a more modest number of patients, perhaps 15 to 20 per day, may be more realistic for achieving quality and efficiency.
“Common sense tells you that if you’re running around trying to see 40 patients a day, you can’t just pay attention to the things you need to provide high-quality and efficient care,” Dr. Knight says. “You’re just running around and putting out fires.”