Published in the April 2007 issue of Today’s Hospitalist
Like many hospitalist services, the program at Charleston Area Medical Center (CAMC) in Charleston, W.Va., has struggled to figure out how to best utilize its staff of midlevels.
By mid-2006, the hospitalist program at the 893-bed academic medical center included 10 physicians and six midlevels, both nurse practitioners (NPs) and physician assistants (PAs). But Kathleen Mimnagh, MD, who became the program’s medical director last year, could see that the physicians and midlevels were not quite working in sync.
For one, there was less than optimal communication among the hospitalists, midlevels, and nursing and ED staff.
None of the midlevels wanted to work at night, despite the rising number of night-time admissions and physician services. And NPs and PAs were being assigned to too many hospitalists at any one time. The result, says Dr. Mimnagh, was wasted time and effort.
"One midlevel would be working with three physicians and struggling to prioritize all those patients," she says. "Doctors were confused about when a midlevel’s service would be available."
At the same time, she adds, "I got a sense that certain extenders worked much better with certain doctors, so all their energy could be focused on good patient care." She found the answer to better efficiency in a well-known physician tradition: holding a midlevel match day, with individual extenders and hospitalists choosing who to team up with.
Match ground rules
Dr. Mimnagh proposed the match process to program members last summer and explained the ground rules. Over a six-week trial period, midlevels would rotate with different hospitalists so they’d all have a chance to work together.
At the end of the trial period, each hospitalist was asked to rank his or her choice of midlevel, while the midlevels were asked to rank their choice of hospitalist, with one caveat: If they got to work exclusively with their No. 1 choice, they would be willing to work nights with that physician.
The possibility of working with their physician of choice proved to be just the "low-hanging carrot" the midlevels needed, says Dr. Mimnagh, to break the night-shift logjam. They jumped at the chance to rotate with their physician of choice, even for night rotations.
Last August, the program staged "match day," holding a special lunch to kick off the event, with all of the physicians and midlevels attending. Four of the extenders’ choices turned out to be a "perfect match," says Dr. Mimnagh, and they were each teamed up with their first physician choice.
For the other two midlevels “who were quickly joined by two other newly-hired extenders “Dr. Mimnagh decided to not pair them with any one physician. "I’d rather let them have an opportunity to rotate through different physicians," she says, noting that there are now 14 hospitalists in the program, "so they would have a little variety and make it more interesting."
That doesn’t mean that the un-matched midlevels have gone back to the former chaotic model. Instead, they now rotate a week at a time with a different hospitalist, which helps standardize their workload and enables the hospitalists to take on more patient encounters.
In the several months since the match, the staffing redesign has already begun to realize one major goal: more efficient use of time and energy.
However, "I still have a lot of wasted energy of a doctor having to cover five floors and four intensive care units to do his or her rounds," Dr. Mimnagh says. "They’re pulled in all kinds of directions, as families or nurses need them or patients need directions."
This was even a bigger challenge at the medical center because hospitalists and midlevels serve two separate facilities that are part of the Charleston system: CAMC Memorial Hospital and CAMC General Hospital. Dr. Mimnagh has divided the clinicians across hospitals, assigning one physician-extender team to the smaller General, and four hospitalists as well as two extenders during the day at Memorial.
Jacqueline Ranson, RN, MSN, a certified family nurse practitioner who was teamed with hospitalist Vijaya Chintala, MD, now works at CAMC General.
In a typical day, Ms. Ranson will first talk to patients and their families on admission and order the tests that patients need. "The patient’s treatment course has already been initiated because I’ve gotten there first," she says. "The physician comes in behind us and verifies everything that needs to be done."
As part of a two-clinician team, Ms. Ranson says she can spend more time talking with family members, case coordinators and social workers. While Dr. Chintala reviews and signs off on Ms. Ranson’s orders, she can devote more time to the generally sicker patients that CAMC General treats, many of whom have acute strokes or myocardial infarctions as well as comorbidities. Dr. Chintala can also spend more time with patients in the ICU.
"A physician/extender team," says Ms. Ranson, "can significantly increase the number of patients you see."
According to Dr. Mimnagh, a hospitalist without an extender can carry 15 patients in a daily census; with an extender, that number jumps to about 22 or more.
And the newly-paired teams are having a big impact on discharges, she adds. The midlevels are able to accelerate the process by making sure loose ends are tied up and "that the final word with the consultants happens," Dr. Mimnagh says. "The extenders know the pulse of the doctor they’re working with."
Growing the program
While the new teams may generate more patient encounters, that productivity has not come at the expense of quality, Dr. Mimnagh points out.
In recent second-year data from the Hospital Quality Improvement Demonstration project funded by the Centers for Medicare and Medicaid Services, Charleston scored in the top 10% of participating hospitals for its care of such conditions as coronary artery bypass grafts, hip/knee replacements and congestive heart failure. Its second-year performance, in fact, earned the medical center the second highest incentive award in the country, totaling more than $700,000.
One key factor to maintaining that level of quality is to hold on to the hospitalists and midlevels, says Dr. Mimnagh, boosting their job satisfaction while hiring more clinicians.
She plans to have about 22 hospitalists and 10 midlevels in the program by the end of this summer, and she wants to assign both physicians and extenders to specific floors and ICUs.
She’s seeing a new sense of professionalism among the program’s physicians. "They’re talking about growing professionally in terms of developing expertise in certain areas to improve quality," Dr. Mimnagh says, "whether it’s sepsis, pneumonia management or heart failure."
They’re also looking at more opportunities to do research and teaching, a level of professional growth that she credits at least in part to the fact that "they’re working more effectively and efficiently" with their midlevel team members.
Dr. Mimnagh also points to perhaps the best metric of clinician satisfaction: retention. Each of the program’s hospitalists used to stay only an average of three years. Now both hospitalists and extenders are staying longer.
"I haven’t lost an extender since last summer, and I have loads of applications," says Dr. Mimnagh.
Ms. Ranson, who was the first NP hired at Charleston more than five years ago, agrees that the match has helped boost her job satisfaction. Along with the close working relationship with a physician, she likes the block schedule that she calls "one of the most satisfying parts" of her job.
The 80-hour one-week-on/one-week-off schedule "really allows me to accelerate my professional career" during the work week, Ms. Ranson says. "But on my week off, I’m able to enjoy my family life."
Janice C. Simmons is a freelance health care writer based in Alexandria, Va.