Is it time for a real office?

Published in the February 2013 issue of Today’s Hospitalist

A few years ago, Greta Boynton, MD, chief of the hospitalist service at Eastern Connecticut Health Network, invited senior leaders from the hospital to join her team for signout in the hospitalists’ office. As the secretary sat at one of two desks managing patient assignments, nine of the group’s 15 hospitalists came in.

Some leaned on a laundry basket to give verbal signoffs as others tried to push their way into the room, their legs literally dangling out of the doorway. When the administrators arrived, they poked their heads in the cramped office and scurried away. The hospital leaders quickly got the point: The hospitalists needed more space.

Fortunately, that meeting came at a time when the 250-bed hospital in Manchester, Conn., was redesigning its ICU. That opened up precious physical space in the hospital, conveniently down the hall from the “closet” the hospitalists were using as their office. Although the space they ended up receiving had been originally designated for somebody else, hospital leadership gave it to the hospitalists.

And at CentraCare Health System’s St. Cloud Hospital in St. Cloud, Minn., years of lobbying by hospitalists for more space has finally paid off. Eric McFarling, MD, one of the group’s co-leaders, notes that the hospitalists recently got the go-ahead to quadruple their space in the hospital.

Until that space is ready in June, the 28 hospitalists and five nurse practitioners there struggle for privacy “and inches “in a space allotted to them 12 years ago, when the group had only six members. The green light for a space that Dr. McFarling says should survive a decade of staff growth came courtesy of a hospital expansion. The hospitalist group will move into the space vacated by the coronary care unit.

The “why does a hospitalist need an office at all?” view has given way to the recognition that the specialty needs a space of its own. But groups often end up with little more than a broom closet with two computer terminals. That setup still smacks of “glorified resident” status, an image completely at odds with the responsibilities of expanding and maturing hospitalist groups.

Although some hospitals can’t or won’t give hospitalists the square footage they’re asking for, many administrators are realizing the importance of allowing hospitalists dedicated space. More space gives doctors the potential to be more efficient, increase patient satisfaction, shorten length of stay (LOS), and boost retention and recruitment.

“Hospitals are becoming open to requests for more dedicated space, especially if we’re helping them meet their goals and initiatives,” says Glenn Appelbaum, senior vice president of operations for the St. Louis region of IPC The Hospitalist Company Inc., the nation’s largest hospitalist physician group practice company.

But faced with tight budgets, limited real estate and still-evolving views of hospital medicine, it’s often up to hospitalists to make noise about what they need.

“While people talk about office health and ergonomics, doctors are hunched over computers in the dark,” Dr. McFarling says. “We didn’t choose this job for the wow of a big office. But it is time for a little respect.”

What office space says
What worked for hospitalists a decade ago just doesn’t cut it any more. Groups are larger and need space to access electronic health records, discharge notes and online literature, as well as conduct the growing administrative parts of their jobs in IT and quality improvement.

The lack of formal office space may not only turn off younger doctors, but older, more experienced hospitalists interviewing for jobs. At this point in their careers, they know what they need and want “and that includes more workspace. Potential recruits may question how a dark, makeshift office reflects the hospital’s view of its hospitalists.

“A cramped office says that we’re taking care of half the patients in the hospital and we still have a crummy hole in the wall,” says Joseph Ming Wah Li, MD, section chief of hospital medicine at Beth Israel Deaconess in Boston. “Someone at an interview may look and say, ‘This hospital may not really like its hospitalists.’ ”

Dr. Boynton agrees that office space speaks volumes about how a hospital values its hospitalists. “The challenge with hospital medicine is not being seen as a super-resident,” she says, “but to be taken seriously as a profession.”

And space sends a message about how well that challenge is being met. “If hospitalists have private space that identifies them and treats them as professionals,” says IPC’s Mr. Appelbaum, “that shows they are as important to that hospital as the department of case management or radiology. It validates their importance.”

Out of the closet
While a good working environment may help retain hospitalists, there’s no doubt that first impressions count, says William Ford, MD, regional medical director at Abington Health in Pennsylvania. “It’s like buying a car. You can’t tell until you drive it, but if you see it in a showroom and it’s painted nicely and looks good, it makes a good impression.”

Two and a half years after Dr. Boynton got the attention of her hospital’s leadership, the group’s redesigned space is now making that good first impression, something that helps during recruiting.

The 20 full-time employees at Eastern Connecticut now share a space equal to four patient rooms. There’s room for everyone to work on signouts. Afterwards, some physicians hit the floor, while others migrate to work stations, each with its own computer and telephone and drawers to keep journals and order sets. Care managers are invited in for 10-minute huddles to discuss workflow and multidisciplinary issues. The secretary is now at her own desk doing patient assignments. Doctors have lockers to store keys, purses and prescription pads, and a centralized coat rack.

“The space shows that the hospital really supports this group in all aspects,” says Dr. Boynton. “We’re treated like professionals and not relegated to the closet down the hall.”

Square feet vs. location
How much space is enough? While one office may be too small for several physicians, that doesn’t mean that hospitalists need the traditional breakdown of one office per physician. “I’m not a believer that you have to have a big house and never use some rooms,” Dr. Li says. “Some traditionalists, however, would say that’s an absolute must.”

In Dr. Li’s mind, location is more important than sheer volume. “It sounds silly,” he adds, “but plenty of programs have offices in a building down the street. That’s useless.”

Dr. Ford can speak from experience. While his current space at Abington Health is not ideal “the 28 hospitalists on two medical campuses have modular desks in shared office space, with access to conference rooms for monthly staff meetings “it beats the set-up he had at Temple University Health System in Philadelphia.

When the hospitalists there asked for more space five years ago, they got it “but it was across the street from the hospital. “The doctors liked it, but not in the winter,” says Dr. Ford, who was section chief at Temple. “They ended up using nursing lockers at the hospital “and rarely came back across the street except for team meetings.”

Sometimes there’s a happier tradeoff. Paul J. Tesoriere, MD, ultimately chose a ground floor location for his hospitalist group’s office during construction of the new Martha Jefferson Hospital in Charlottesville, Va. The new location is a step up from the two side-by-side offices the group’s 16 hospitalists had been using in the old hospital. The open space was centrally located with easy access to patients, but not on a patient floor.

“My goal was to be as close to patients as possible, preferably on a patient floor,” he says, “but the office would have been too small. The cost difference per square foot on clinical space vs. nonclinical space was significant.”

While some of the hospitalists had a mixed response to the windowless space, they’ve adjusted over the past year and half, now that each has his or her own open cubicle, computer, phone, storage, kitchenette and bathroom. And the large space shows well when recruiting, says Dr. Tesoriere, director of hospital medicine.

Critical elements
Ideally, once you figure out what you need the space to do, you design around those needs. But the reality of tight hospital space and budgets often dictates what hospitalists get. The trick is figuring out how to maximize what you have to create a productive and positive atmosphere.

Dr. Boynton worked with an architect and designer to work out what she needed. She ended up with eight cubicles, each with a computer, telephone, desk, filing cabinet and shelving; an area for coats; lockers; a kitchenette with a refrigerator, microwave and sink; two closed-off areas, each with a physical door, one for her and one for the assistant chief; a conference table that can seat 10 for lectures, staff meetings and “lunch ‘n learns”; and a large, flat screen TV mounted nearby.

Dr. Boynton had a voice in the details, choosing easy-to-clean flooring over carpet and stretching the budget by choosing new-looking used furniture. It was more important, she says, to have a light, airy, well-organized space.

Dr. McFarling just finalized plans with his architects for his $1 million budget at CentraCare. He points to ideas that he says reflect the latest in office trends that improve productivity within the 5,500-square-foot space, such as having lights high on the wall with as much natural light as possible. To address the need for a quiet atmosphere, each desk space will have 4 feet by 6 feet-high frosted glass dividers with doors that close (spaces are assigned but flexible), and white noise piped in the central area from the ceiling.

“Distraction is rampant in the hospital “beepers, families in hallways, nurses waving at you,” he says. “Finally, there will be one place where we can sit down and concentrate.”

Having a common area is critical to foster relationships and information exchange. At CentraCare, the hospitalists’ office, will include a 46-inch monitor to show X-rays, a table with connections for electronic devices such as iPhones and iPads, an electronic message board to give alerts on occupancy, and computer stations for quick dictations as an alternative to the cubicles. And at some IPC practices, wall-mounted TVs make signouts easier and are also used for orientation, training, and compliance and coding video conferencing.

Group unity
Common space is also a great way to foster team unity. Before his hospitalist group upgraded its space, Dr. Li says that everybody ate in his or her own office. Now, physicians see each other in the office during the day to share ideas and bounce questions off each other. The area also fosters mentoring, Dr. Li adds, something that’s relatively new to the maturing field of hospital medicine.

“I don’t want people holed away in a dark office on another floor. I want them here. I want to eat lunch with them,” Dr. Li says. The office layout makes that easy. “We’re constantly bumping into each other,” he adds, “but in a good way.”

Even small practices need a table to conduct business, maintains Mr. Appelbaum. IPC’s groups can range from four to 25 hospitalists. Every group needs a table that can accommodate all of the group members “they have weekly business meetings “as well as case managers and other hospital personnel who might need to join meetings. If space is very tight, they’ll ask to use a conference room in an auditorium. All of this is outlined in each IPC contract, he says.

Dr. Li strongly advocates for decorating the common area with team-building items. For example, he includes electronic picture frames with photos from personal and professional events, and posters from CME meetings. He also displays the group’s annual group photos, which reflect the growth of the group to newcomers.

“I’m not naive enough to believe that hanging pictures on the wall is going to get people to get along,” he says. “But it sure helps.” (See “Redesign must-haves.”)

The hospitalist vibe
A well-designed hospitalist office space reflects the specialty’s values: functional without the bells and whistles of other specialties’ space. Dr. Li likens it to a well-tuned Honda Civic instead of a Cadillac.

“There’s no show involved because we don’t have family or patients coming in,” Dr. McFarling says. “We’re all about getting stuff done.”

That vibe is reflected in how the space functions. At Eastern Connecticut, it’s more utilitarian than ostentatious. Among the plants, there’s also a bulletin board with the group’s quality and efficiency metrics.

Dr. Tesoriere, who notes that hospitalists’ space doesn’t need “fluff” like fancy artwork, can’t say enough about the small things in his new space that can make a difference in how physicians feel about their jobs.

“What are the items that will allow you to perform your job better in a practical sense and add to satisfaction?” he asks. “A kitchenette may be a small thing, but it’s nice to know I can grab coffee whenever I want. Cumulatively it adds to satisfaction. It has added to ours.”

Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.

Negotiating tips

IN 2007, when it became clear that the hospitalist group at Boston’s Beth Israel Deaconess Medical Center needed more (and a more cohesive) office area, space was at a premium. Joseph Ming Wah Li, MD, section chief of hospital medicine, took the initiative and started talking to people he thought could help make something happen.

The strategy worked. While he wasn’t able to design his own space, he was given options: get more space but outside of the hospital; have multiple offices in several different areas of the hospital; or occupy a suite of seven shared offices with a central conference area and a separate kitchen with a refrigerator and microwave. That third option was the one he wanted.

If you’re negotiating for more or better space, Dr. Li suggests the following:

• Don’t be afraid to ask for a lot, but be sure to prioritize what is most important to you. Include a request for a common meeting area.
• Identify the decision-maker, such as the head of the planning committee.
• Be prepared to answer this question: “You guys are hospitalists. Why do you need space?” with a clear discussion of, for example, how your teaching leaders have to meet with residents or students, how many are working on research and research grants, and why someone who does quality improvement or medication safety might need a private office.
• Use data, including the number of full-time employees and administrative assistants, to explain why you need a change.
• And expect those data to be checked. After Dr. Li presented his proposal, he got a visit from administrators. That visit not only verified his numbers, but also gave a visual that packed a punch.

“They saw all those doctors crammed here and how it was adversely affecting their work,” he says. “They’re paying them a lot of money. They realized that giving doctors more space may make them more productive.” The hospital has since given the group more offices as the staff has grown to 45 physicians.

Redesign must-haves

IN ADDITION TO the obligatory telephones and computer monitors, hospitalists say that the following are must-have elements in an office redesign:

• A central conference area for meetings and lunches. Include a table and/or couch to encourage people to face each other.
• Auditory and visual privacy to do dictating and paperwork.
• Sufficient wall space or screen to project a PowerPoint presentation.
• Team-fostering items for the walls: electronic picture frames, bulletin boards and CME posters.
• Cabinets to store everything from stethoscopes and pens to a bottle of aspirin.
• A place to keep valuables.
• Shelves.
• An area for food and beverages.
• WiFi for laptop use.
• Easy access to printers, Xerox machines and fax machines.
• One empty private office that people can reserve for interviews.
• Unisex bathroom(s).
• A lock. The suite should be locked in off hours with access available by ID badge for nocturnists.