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When time is money, you need a better way to divvy up patients

May 2007

Published in the May 2007 issue of Today’s Hospitalist.

In his travels around the country as a consultant to hospitalist programs, John Nelson, MD, often sees workflow solutions that just don’t work.

A case in point is the system that Dr. Nelson found in one practice to assign overnight admissions to the day-shift hospitalists. Every morning, all six daytime doctors spend an hour reviewing those patients. After looking for re-admits of patients they’ve recently cared for, the hospitalists parse out the night admissions
among themselves, factoring in patient acuity and their current patient load.

While the morning meetings can lead to good handoffs and enhance collegiality, Dr. Nelson says, "that’s six hours seven days a week, which adds up to one full-time equivalent of physician time. In effect, the practice is spending around $200,000 a year to divide up patients."

Instead of devoting that kind of time and money on what he views as a simple administrative task, Dr. Nelson’s practice at Overlake Hospital in Bellevue, Wash., takes another tack. It uses an automatic assignment system that needs very little daily tweaking and makes it easy for everyone, including nurses, specialists and patients’ families, to know which hospitalist is in charge of which patient.

Dr. Nelson, who is director of the hospitalist program at Overlake, says the simple assignment system not only causes less confusion among staff members, but allows hospitalists to hit the ground running as soon as they arrive. And instead of devoting $200,000 of physician time to daily meetings, that time can instead be applied to patient care.

A predictable system
Overlake’s assignment system is relatively straightforward. Every night when the night hospitalist comes on duty, he or she checks the schedule and makes a list of the names of the four physicians who will be working the next day. As admissions come in overnight, the night hospitalist goes down the list of daytime physicians, assigning them each one admission and starting over with the first physician after four admissions have come in.

To preserve continuity, Dr. Nelson says, daytime doctors who are going off service within 24 hours are not assigned overnight admissions.

Every time the emergency department secretary calls the night physician down for another admission, the secretary asks the hospitalist which daytime doctor the patient is being assigned to. "From the moment of admission," Dr. Nelson explains, "the correct doctor’s name is on the chart and in the computer on all the records."

As a result, the night hospitalist can tell family members who the patient’s physician will be and who they should contact the next day. Nurses, who may need to call the attending physician the next morning, won’t find the night physician’s name on the chart after he or she has left the building. And radiologists reviewing the patient’s overnight X-ray or CT scan at 7:30 in the morning know exactly who to call with results.

"It’s an error to ever put the name of the night physician who admitted the patient in the admitting system," Dr. Nelson notes. "The big benefit is that the moment the night physician leaves at 7 a.m., it’s clear to everybody what doctor is responsible for the patient."

A little horsetrading
According to Dr. Nelson, the automatic assignment system has other advantages. For one, it gives the day physicians some flexibility as to when they show up; they don’t need to be at a meeting or even see the night physician if they don’t make it to the hospital before 7 a.m.

And physicians, when they arrive, have a printout of overnight admissions already waiting for them to merge into their existing census. That makes it easier to just start rounding, which helps facilitate daily discharges.

Do the Overlake physicians ever trade overnight patients on their list? Occasionally, Dr. Nelson says. "I may take patients whom I’ve treated before or who I discharged just five days ago," he notes. Or a daytime physician who has a light patient load may offer to take some night admissions from a busier colleague. (In such cases, Dr. Nelson says, the receiving physician has to make sure the physician’s name is changed on all the patient’s records, which can be labor intensive for clerical staff.)

But such swaps, he says, may take place only once a week, and are informally arranged by the two doctors in the hall. "More than 90% of the time," Dr. Nelson says, "we do it just how the cookie crumbles."

A preoccupation with parity
If Overlake’s assignment system runs so smoothly, why don’t more hospitalist practices follow suit? Because, says Dr. Nelson, too many physicians are preoccupied with making sure that every physician starts each day with nearly the same number of patients.

To his way of thinking, that concern is overblown. "We have occasional inequity in patient load," he admits, "but our data prove that it comes out very similarly at the end of the year. It’s a wash over time."

But he acknowledges that ensuring parity in census figures is no small concern, particularly when physicians are paid a straight salary. "If you go on productivity for a large portion of your compensation, then your paycheck follows when you take on additional patients," Dr. Nelson says, pointing out that productivity is a large component of compensation at his hospital. But for doctors on straight salary who work the same number of hours and shifts, "most groups say, ‘We want it even every day.’ "

He points out, however, that the Overlake system can be easily adapted to programs where physicians insist on an equal roll of the dice. To do so, day physicians need only to leave the night physician a brief note that explains their expected census for the next day.

"That way," says Dr. Nelson, "if I’ve got 12 patients already and someone else has 15, I’m going to get more of the overnight admissions."

Finally, Dr. Nelson insists that he’s not necessarily opposed to the idea of holding group meetings, which can serve a good purpose.

Such meetings can be part of an effective handoff between the night and day doctors. And meetings with case managers where team members decide which patients need to be "teed up early" for discharge are also valuable, he says.

But many practices spend too much time in group meetings "just out of habit, and that’s very costly." Instead, Dr. Nelson says, practices should always be looking for ways to streamline time and money.

"Make sure you structure any type of distribution or signoff," he says, "in the most efficient way."

Phyllis Maguire is Executive Editor of Today’s Hospitalist.