Published in the June 2014 issue of Today’s Hospitalist
JUST TWO SUMMERS AGO, the relaxation that lures so many tourists to the beach in Hyannis, Mass., was in marked contrast to the stressed-out hospitalists at Cape Cod Hospital. The seasons 20% jump in patient volume led to a daily census for each doctor that topped 20 patients. That overload in turn led to increased lengths of stay and reduced patient satisfaction “and an exodus of hospitalists.
“The volume was not sustainable,” says Ann Marie Kelly, MD, director of the hospitalist program at the 259-bed facility. “It wasn’t safe for patients, quality, throughput or physicians’ quality of life.”
Before more hospitalists saw red, the program went orange ” adding an additional team of rounders from June through September to its typical six rounding teams. Because the teams are coded by color, the seventh is known as the orange team.
That added team, which was launched last summer, is kicking in again this month. Because everyone rotates through nights, swing shifts and vacation coverage, the seventh team consists of two of the program’s 22 hospitalists who would usually cover vacation requests.
“It’s hard to tell a physician that he or she cannot take family vacation in the summer,” Dr. Kelly points out, “so we still do use limited locum support in that flex period.”
Adding another team brought the summer patient census closer to what Dr. Kelly calls the sweet spot “15 “where physicians can do effective discharges without feeling rushed and provide afternoon relief to a busy ED. Given the reduced stress and greater job satisfaction, physician turnover stabilized.
Cape Cod offers a good example of how anticipating and planning are key to any flexing strategy, regardless of why or when census spikes occur. Surges in volume have led groups to be creative about how to staff up “and how to find other services when doctors are not so swamped.
The yang to the yin of Cape Cod’s swelling summer census can be found in Phoenix, which sees an uptick in snowbirds from September to April. Obinna Egbo, MD, the Phoenix regional medical director with IPC The Hospitalist Company Inc., the nation’s largest hospitalist physician group practice company, explains how big-picture planning has worked when staffing the 600-bed St. Joseph’s Hospital.
“We hire hospitalists for an average number of patients throughout the year,” Dr. Egbo says. “So we brace for the winter months, and in the summer” ” when the census may drop as low as eight or 10 patients per physician “”everybody takes vacation and more time off.” In the summer, the hospitalists are more likely to also care for patients in IPC’s long-term or skilled nursing facilities. Dr. Egbo plans to spend two weeks in Europe this summer.
It wasn’t always so smooth. When Dr. Egbo started in 2005, there were only five doctors and he worked every weekend in winter.
At the time, “it was stressful,” he says. “We had between three and five doctors every day, each responsible for between 18 and 20 patients.” But only two or three doctors worked on the weekends, each carrying between 35 and 40 patients, including new admits and follow-ups. “Folks didn’t do their homework and didn’t anticipate this was going to be the case.”
He began implementing changes in 2008, tracking the group’s patient data, determining when the best times for vacation would be and making the case for hiring more doctors.
That effort paid off. Now that more physicians have been hired and limits put on taking vacations in the winter, nobody’s leaving, Dr. Egbo points out. And there’s no more talk about burnout. “We don’t dread the winter months because we’re staffed to suit,” he says. “I know what to expect.”
Structuring a plan
That raises the question: Is it better to plan for the busy times or the lean ones?
David M. Grace, MD, senior medical officer of hospital medicine for The Schumacher Group, a physician staffing company based in Lafayette, La., recommends planning baseline staffing for the slow season and developing ways to manage the high season. Instead of maintaining a seven-on/seven-off schedule through a busy winter, for instance, the schedule could switch to 10-on/five-off. “That creates one extra doctor per day,” he explains.
The risk of planning for the busy season is that someone may decide that program costs are too high. “They may say, ‘We can’t pay 10 doctors to do five doctors’ worth of work the rest of the year. We have to cut staffing rather than add during peak season,’ ” Dr. Grace says.
In Phoenix, the hospitalists at St. Joseph’s know to expect a flood of patients during the winter. Each of the 10 IPC hospitalists works 22 days each month in that season, including one night per two-week block and two weekends. They are in by 7 a.m., out by 5 p.m. and on beeper until 7 p.m. Each physician typically carries 15 patients.
If the individual census rises to 20, the physician on back-up is called in. “That back-up hospitalist can’t go far in the winter unless there’s an emergency,” says Dr. Egbo. “You have to be willing to be available then.”
An average census of more than 16 patients per physician triggers the jeopardy system at the 350-bed St. Mary’s Hospital and Regional Medical Center in Grand Junction, Colo. During flu season last January, the jeopardy doctor was called in almost every day, says Daniel Harris, MD, medical director of the hospitalist program. This summer, the hospital’s 15 employed hospitalists may see a surge from trauma, such as all-terrain vehicle rollovers, as well as from people making their way to Utah and the national parks.
The flexing plan is designed to handle unpredictable daily surges as well as flu season. “It helps with patient satisfaction and doctor satisfaction to keep average daily census around 15 per doctor,” Dr. Harris says.
Typically, the doctor on jeopardy covers sick days and high census days and is called in between six and eight times a month. The program also staffs a half shift (4 p.m.-9 p.m.) to deal only with admissions, as well as a float shift (1 p.m.-11 p.m.) to support the regular 10-hour day-shift physicians.
“It’s unique for a hospitalist group to have this flexibility instead of having patients wait in the ER,” Dr. Harris says. The different shift options also give the program more hands on deck during surges.
Increasing the number of back-ups
Cobbling together a personalized plan with flexibility can be complicated. Dr. Kelly admits that’s the case at Cape Cod Hospital.
Nixing the seven-on/seven-off option as too strenuous, hospitalists there do five-on/five-off in four-week blocks. “Our flexing strategy does not force moonlighting or restrict vacation requests,” Dr. Kelly points out. “That goes against our program goals of sustainability and retention.”
Even a hospital like Cape Cod, which found a successful way to flex up, can get slammed by a bad flu season. Dr. Kelly recalls February 2013 as particularly tough. She says the hospital’s CEO recognized the added stress and found funds to pay for moonlighters and staff physicians to work extra shifts.
Flu, not tourism, accounts for the 20%-30% census hike between October and March at Legacy Health in Portland, Ore. To offset a last-minute staffing crisis, the physician for the 28-physician group who’s on call for illness coverage two or three times a quarter is also on call for a census surge, explains Ross Tangum, MD, the site medical director for the hospitalist program at Legacy Good Samaritan Medical Center.
That person is on pager from 7 a.m. to 9 a.m. After the group’s 7 a.m. meeting looks at night admissions and ICU transfers, the back-up is activated if the scheduled per physician patient load is greater than between 14 and 16.
This year, the Legacy hospitalist group had to double down, adding a voluntary second back-up to prepare for days when more than one back-up was needed. The second back-up physician provides surge coverage when the first back-up’s capacity is exceeded or coverage for physicians who become ill.
“We schedule our second back-up during times the first back-up is being used a lot,” says Dr. Tangum, “and we feel like we’re at greater risk.”
Does flexing pay?
Devising flexing plans comes down to determining how to spend the same pot of money, points out Dean Dalili, MD, vice president of medical affairs in the hospitalist division of Hospital Physician Partners in Rockledge, Fla.
“FTE allocation is just dollars, and how we allocate it is up to us,” he says. Always staffing the peak even where volume disappears is an expensive tactic, he says. “And it doesn’t work the 50% of the year when you’re not overwhelmed.”
During peak winter months when daily census increases 30%, Dr. Dalili asks for another full-time provider to volunteer as needed at the 285-bed Wuesthoff Medical Hospital.
Thanks to compensation “that shift is paid at the same rate as regular hours “there’s always a taker, usually from the same three or four physicians who are particularly interested in earning overtime, he says. Typically, that extra doctor will take three shifts on his week off.
Places like IPC in Phoenix, where hospitalists work hard in the busy season and have an easier off-season, pay accordingly. According to Dr. Egbo, physicians are paid based on their number of encounters, productivity and ability to meet discharge quality measures.
As a result, they earn more in the winter than the summer. That works as long as doctors see it coming, he says.
“If you make, say, $10,000 per year, it doesn’t matter if that’s $6,000 in the winter and $4,000 in the summer,” as long as you plan for the times when revenue is down, Dr. Egbo says.
For other groups that use back-ups to flex up, money is less of an issue. At Legacy, for example, if the jeopardy physician is called in, he or she gets paid for a full shift. Otherwise, payment is 2.4 hours at the base salary just for being available, says Dr. Tangum.
In Colorado, Dr. Harris says back-up physicians are paid $250 just for being available “and they additionally get paid for hours worked if they’re called in.
And continued rising census is changing his group’s flexing tools. One of the half-shift positions may evolve into a second full float shift within the next six months, says Dr. Harris. He’s also looking to hire two new physicians in that time period to handle increasing business.
According to Dr. Tangum, the census never seems to go back to baseline after a spike. “The challenge is knowing when it’s a temporary surge or far enough along to justify adding a new physician,” he says. A sign that you need to expand your full-time staff, he says, is when a program brings in a back-up physician every day for five months.
In one hospital in Portland, says Dr. Tangum, backup physicians were being called in so frequently and asked to manage such excessive patient loads that they burned out. He’s now trying to find a way to offset that at the five hospitals that Legacy staffs.
His idea was to have the physicians cross-credentialed for more than one facility so they can function like a nurse float pool. However, faced with initial physician concern about staffing an unfamiliar facility, he’s now seeing if the possibility of a financial bonus could garner more support for the plan.
When flexing up, be careful not to overutilize a group, especially if it’s small, warns Schumacher’s Dr. Grace. If you have a four-physician practice, for example, but staff it with only three doctors with each moonlighting for a third of the fourth position, you have increased risk if one doctor leaves.
“Now you haven’t just lost one FTE,” says Dr. Grace. “You’ve lost 1.3 FTEs, which makes that physician more difficult to replace.”
Instead, he adds, look for other ways to find coverage during busy times. He offers this example: One hospital used a nocturnist to round in the early morning on patients admitted before midnight the night before as well as ICU patients. The nocturnist also rounded on patients on a rehab floor. “It didn’t matter if their diabetes was addressed at 7 a.m. or 7 p.m.,” Dr. Grace says.
Another idea is to ask the ED doctors to try to admit a patient first to a specialist if the hospitalists are overwhelmed. “Often, the specialists say ‘yes,’ ” he says.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
Seasonal surge tips
COPING WITH SEASONAL CENSUS SURGES? Here are some tips from Dean Dalili, MD, vice president of medical affairs in the hospitalist division of Hospital Physician Partners in Rockledge, Fla.:
- Have a back-up plan:
Set up an emergency coverage call system in which a community primary care physician will take unassigned patients from the ER. “Develop a network of part-time, overtime or primary care physicians with inpatient hospitalist admitting privileges who can be a resource to lean on,” Dr. Dalili advises. That network should include hospitalists who work at other sites but don’t have noncompete issues.
- Change shift-change days:
Consider switching the end of the seven-on/seven-off block of shifts to Saturday, not Monday. Mondays are typically busy discharge days; add in a new physician and it slows everything down. “You’ve increased the workload even if you haven’t increased the volume,” Dr. Dalili explains.
- Add a physician on shift-change days:
If higher volumes don’t justify adding a full physician shift throughout the week, consider adding an extra shift on the day when doctors change service. (Again, that’s typically on Monday.) “Change of service represents a high workload for incoming physicians,” Dr. Dalili points out. “Overlapping a physician from the previous week allows for a lower census and maintains continuity for patients awaiting discharge.”
- Add business:
Anticipating a slow season means an opportunity to solicit new business, he says. New service lines his group has added include surgical comanagement, inpatient psychiatric evaluations and admitting for primary care physicians with whom the group hasn’t partnered in the past. “The services we add in the slow season,” he says, “become permanent additions, a way to support our staffing levels and continue growth.” Dr. Dalili says he’s now getting feelers from a local ACO that’s taken note of the group’s low readmission rates, LOS and high quality.