Set reasonable expectations. The patient or family may have many questions during rounds. If time does not permit, especially when you are rounding with housestaff, it is more efficient to say, “We need to move on for now, but one of us will return later to discuss all of this in more depth.”
For particularly demanding patients and families, manage expectations by communicating honestly about your other patient care responsibilities, while still acknowledging their needs. In these situations, setting up a family meeting to discuss plans of care early in the hospital course can be very productive.
Integrate inter-professional care when possible: Rounding with a care coordinator or the patient’s nurse allows you to share clinical information and plans of care in real time. This can help minimize interruptions and pages later in the day, while enhancing patient safety by limiting communication failures.
Perform tasks “as you go.” Entering orders and calling urgent consults as you round not only provides timely medical care but, by limiting unfinished tasks, also reduces the chances of medical errors.
Post Rounds (Follow-Up Care and Planning)
Start discharge planning on day 1. As you gain experience, predicting patients’ hospital stays and anticipating their discharge needs becomes part of your hospitalist “sixth sense.” Obtaining timely therapy, social work, and case management consults is fundamental to your efficiency as a hospitalist. It is also prudent to keep patients and their families updated on discharge plans.
Delegate responsibilities when possible. Efficiency can be fueled by sharing your workload, especially non-clinical tasks such as obtaining occupational safety and health records, completing SNF forms, or scheduling follow-up appointments. Potential resources include ward secretaries, nurses, or, for more clinical tasks, housestaff, nurse practitioners, or physician assistants. The availability of this support varies substantially between institutions. Still, your goal should be to advocate for a collaborative work environment where support staff are expected to contribute to team efficiency and, by corollary, patient satisfaction.
Document succinctly and in a timely manner. Your notes should reflect the patient’s clinical progress and your thought process. You don’t need to import every detail that can be found elsewhere in the EHR, and you should refrain from long, cut and pasted notes that are often meaningless “note bloat.” Likewise, discharge summaries should be high quality informative documents that list key elements, including discharge diagnoses, discharge medications, follow-up appointments, procedures, and a brief hospital course. These are best done in real time or even the day before, when the case is fresh in your memory. Spending an extra 15 – 30 minutes on this important task is well worth it. Do not let records pile up!
“Run the list.” Among the million other things you’re doing all day, this quick end-of-the-day review of your patient list helps you prepare for the next day. It’s an opportunity to ready things for potential next day discharges, discontinue redundant lab testing, remove unnecessary Foley catheters and lines, and identify any medication order errors.
In Sum
Many personal habits can improve the quality and efficiency of patient care, and hospitalist efficiency is intimately related to system performance. As hospitalists, each one of us can enhance the system, whether we do so by facilitating patient throughput, improving communication, or utilizing resources in a cost-conscious manner. Volunteering to serve on information technology or quality assurance committees is also a “big picture” way of contributing. It is our hope that the tips in this article will have a qualitative impact on both your work habits and your organization’s performance, thereby improving patient care and, ultimately, your own career satisfaction.