Published in the June 2015 issue of Today’s Hospitalist
ALMOST TWO YEARS AGO, our hospitalist group of 46 physicians decided to change to unit-based rounds. This made a lot of sense as our hospital has more than 800 beds between two separate buildings.
The new way to round brought many positives. Sicker patients can be seen sooner by their assigned hospitalist, who is only a few rooms away. Nurses and hospitalists can communicate more often and more effectively. And physician productivity has improved because we are no longer spending time walking halls, riding elevators, using stairways and criss-crossing a large hospital all day long.
But for the hospitalists, the change was unpopular due to the unequal size and population of the units. Think about it this way: I walk into work and am handed a workload that is twice that of the colleague next to me, even though we make the same amount of money. How is that fair?
Plus, our hospitalist group is split into two teams, each with a seven-on/seven-off rotation, and we try to keep physicians assigned to the same unit for two consecutive weeks. That means that hospitalists could find themselves assigned to a “heavily loaded” unit for 14 days out of the month. Plus we have subspecialized floors, so patients in some units tend to be more complex than those in others.
Hospitalists’ objections ranged from imbalanced patient loads to excessive patient handoffs. Our solution? We surveyed the hospitalists and had them rank each hospital unit on a 1-5 Likert scale where the highest-acuity units were scored as 5s.
By multiplying the number of patients for each physician in the morning census times that weight or score, we then created a relative work load value. Therefore, a doctor who has 10 patients on a unit with a weight of 2.0 was equal to a physician who had 5 patients on a unit with a weight of 4.0.
We called the resulting chart, which is revised constantly throughout the day and available to all of our providers online, the Equalizer.
How it works
As new patients are admitted through the ED, the triage staff simply checks the Equalizer prior to assigning a patient to a particular hospitalist. During the week, we do have a hospitalist in the ER who is doing only admissions, but that physician can’t see all the new admits.
After the Equalizer is checked, those physicians with the lowest relative work loads (as indicated by a green box in the “Relative Work Load” column) would get the new patient for admission. In the case of a patient suffering an AMI, for instance, that patient may be admitted to one of the hospitalists designated by green and then handed off to another physician on a cardiology unit.
Conversely, those doctors and units with a patient load that is greater than one standard deviation from the mean score of the other hospitalists are displayed in red. They would normally not get a new admit until the patient counts change.
We also use nurse practitioners. When physicians are assigned a nurse practitioner, we assume that they can see more patients than the group average, so we change that physician’s weighted score. While we debate the number of patients that NPs can see independently, we often assume that the number is 10.
If you take a look at the NP column, a 0.5 is displayed if the NP is split between two physicians. The chart also has separate columns for ED admissions, patients off your unit, postop patients (PACU), consults, direct admits and critical care transfers, with different weighted scores for each. We also use the tool to track data such as the number of admissions per day.
Our hospitalists are able to view the up-to-the-minute scoring (and their relative work loads) any time via the hospital’s Intranet Web page. While we do have some exceptions and other factors in determining which hospitalist gets a new admission, we find that the tool helps keep workloads relatively balanced.
As a result, it’s decreased the stress of geographic rounding, and our doctors are much happier. Because the Equalizer is kept up to date by a triage coordinator or nurse, the physicians can always see how busy the group is.
The weighting system continues to be a work in progress, and we’ve tweaked the Equalizer several times. When we first created this system, for instance, not all group members had rotated through all of the floors.
After everyone had a chance to round on all the different floors, we surveyed the doctors again and re-weighed the floors. (The revised weighted scores were actually very similar to our first survey.)
We also had to change the weights when our census increased and we had to divide some units. (We typically have one doctor per unit but some units have more rooms so are split between two hospitalists.)
As a further evolution in unit-based rounds, we are about to start multidisciplinary rounding. While we are constantly talking with staff about barriers to discharge in our current system, one goal of starting multidisciplinary rounds is to expedite discharges.
We don’t expect this tool to change once we start multidisciplinary rounds. But it has helped make our transition to unit-based care a success, and we expect to be using it for a long time to come.
Jon D. Girard, MD, is a hospitalist who is associate program medical director of the Miami Valley Hospitalist Group in Dayton, Ohio, and clinical assistant professor at Wright State University Boonshoft School of Medicine. Doug O. Koenig is a senior consultant and a Six Sigma Black Belt at Atrium Medical Center in Middletown, Ohio.