Published in the April 2018 issue of Today’s Hospitalist
WHEN ANDY ARWARI, MD, first started working as a hospitalist in 2004 at Carle Foundation Hospital in Urbana, Ill., “you would at the very most see patients spread across four floors.” But fast forward to 2014, and “we’d see patients scattered through 12 different floors. We actually measured how long it took to do those rounds, and we spent two hours a day walking.”
That’s when Dr. Arwari—who by then was medical director of hospital medicine—and his group started working to localize hospitalists in unit-based care. That innovation went live hospital-wide in August 2015, and the hospitalists haven’t looked back since.
Dr. Arwari, who is now Carle’s regional medical director, ticks off the many benefits of the model (and the whiteboard multidisciplinary rounds implemented at the same time): almost a half-day shaved off length of stay, team bonding, physicians’ more predictable workload, and not being hounded by pages in the parking lot at the end of a shift.
“Is our purity 100% as far as unit-based? The answer is ‘no.’ “
~ Andy Arwari, MD
Carle Foundation Hospital
Asked why his group has been successful with geographical localization when other groups have walked away from it, Dr. Arwari points to the need for what he calls “plasticity.” Put simply, his group doesn’t get bogged down in hard concepts of what geographic localization should look like.
“Is our purity 100% as far as unit-based?” he asks. “The answer is ‘no.’ We went from seeing patients on 12 floors to having patients on maybe four or five, and that’s a lot better.”
Such flexibility might have been viewed as heresy by some pioneers of unit-based care, but the reality is that for many groups, geographic rounding has proven tough to pull off. Instead of letting perfect be the enemy of pretty good, groups that have succeeded say they’re happy with “geographic-ish.”
But on top of being flexible, groups have also had to make some hard-and-fast, non-negotiable changes to get unit-based off the ground and sustain it. And given the many hospital variables—a complicated physical layout, limited telemetry, staffing shortages or chronic over capacity—some programs give geography a try only to give it up, and say they’re much happier for doing so.
The ideal layout
John Smith, DO, the director of the hospitalist service at MaineGeneral Medical Center in Augusta, Maine, points out that he and his group have the ideal hospital layout and organization for making unit-based care work.
The group moved into a brand new facility in 2013 that has hospital-wide telemetry. Group members also follow patients into and out of an open ICU, so they don’t have that additional handoff.
“With our physical plant and our ability to do most things on most floors, we don’t do much transferring inside the hospital.”
~ John Smith, DO
MaineGeneral Medical Center
Three of the floors in the hospital have three 12-bed pods, and the hospitalists “own” five of those pods, sharing the rest with other specialists and a family medicine residency program. During the day, five geographic-based hospitalists typically start with a daily census of between 12 and 14 patients across one of the pods and the ICU.
They also have some overflow patients “who tend to be in the pod right next to them,” Dr. Smith says. Hospitalists also follow some short-stay patients, while a sixth doctor serves as that day’s “floater.” The group has a dedicated person for admissions.
“There is some variability in how patients are assigned, depending on census and flow,” he points out. “But with our physical plant and our ability to do most things on most floors, we don’t do much transferring inside the hospital.” Because his group doesn’t need to wrestle with what he calls “patient drift” and movement, maintaining continuity with (largely) unit-based care isn’t a challenge.
“Not all units are created equal”
In 2015, when Paul Tesoriere, MD, the hospitalist director at Sentara Martha Jefferson Hospital in Charlottesville, Va., helped implement unit-based care, he thought he also had several key pieces in place. Case managers and pharmacists in the 176-bed hospital, for instance, were already assigned to specific units.
Moreover, hospitalists bought into geographic. They looked forward to fielding fewer pages, building better staff relationships, and being more present for patients and families.
Nevertheless, after two years, group members decided the model was unsustainable and they voted to move away from unit-based care, at least for the MDs. Physicians are now back to rounding throughout the hospital and are glad they made the move. They feel less isolated, Dr. Tesoriere reports, and they get to interact with their hospitalist colleagues more regularly throughout their rounding day.
“Unit-based is a very good idea. But in practice, it’s pretty difficult to achieve.”
~ Paul Tesoriere, MD
Sentara Martha Jefferson Hospital
Plus, “it’s much easier to distribute patients now, so people are willing to sacrifice a few more steps and pages to keep things simpler,” says Dr. Tesoriere. “Overall, unit-based is a very good idea. But in practice, it’s pretty difficult to achieve.”
One factor that hurt the model at Sentara Martha Jefferson: As a smaller hospital, it is very dependent on nurse staffing. “Beds may not be fully staffed if nurses call out,” he says, “so we couldn’t predictably give physicians an equal share of work.” Bed assignments were complicated, with many assignment delays. And patients kept moving around the hospital even after they were assigned, due to limited telemetry and specialty units.
“Not all units are created equal,” Dr. Tesoriere points out. “We couldn’t really staff the specialty units with our physician cohort because patients would be moved off once they no longer met certain criteria.” While the group always maintained that continuity was more important than geography, “when you have 20% or 25% of your patients off a unit, it defeats the purpose of geography.”
The need to staff up
Jyothi Kulkarni, MD, the director of the hospitalist program at The Valley Hospital in Ridgewood, N.J., however, points out that group members there typically have at most only 70% of their patients geographically located on one or two units, although there are weeks when it’s only 60%. Further, Dr. Kulkarni says she’s “pleasantly surprised” that the group can maintain that high of a percentage.
She agrees that covering specialty units is a challenge. But because her group works in a bigger hospital—451 beds—it can assign one hospitalist to cover a busier specialty unit such as neurology. (The group plans to expand single hospitalist coverage to the geriatrics unit as well.) Dr. Kulkarni also admits that while group members try to level load physicians’ census every day, that’s not always feasible because of the variable number of admissions to specialty units.
“We can usually level load within one or two patients,” Dr. Kulkarni says. Because the hospitalists rotate through all the units over the course of three months, daily census variations even out over time.
“We can usually level load within one or two patients.”
~ Jyothi Kulkarni, MD
The Valley Hospital
She also points out that this isn’t her group’s first attempt at unit-based care. Two earlier tries fell short due to suboptimal physician staffing levels. In fact, she credits the group’s ability to achieve its current success with localization to hiring eight new full-time physicians by October 2016.
“We needed to ensure the same number of rounders every day,” Dr. Kulkarni points out. “More FTEs made everyone’s load more manageable and patient distribution a lot easier.” Beefed-up staffing also allows one or two hospitalists a day to serve as floaters, which helps the other rounders stick more closely to one or two units.
But the third time has not been the charm for unit-based care at St. Joseph Medical Center, part of CHI Franciscan Health in Tacoma, Wash. Hospitalist site director Megha Shah, MD, says the program’s first attempt several years ago “was strictly geographic, with one provider on one floor.”
Her hospital, however, also has “different units, which are highly specialized in terms of nursing staff, equipment and protocols,” says Dr. Shah. “We make every effort to get patients to their desired bed, which results in increased patient movement.”
In addition, patients may need to be moved to an isolation room with a private bathroom, which isn’t possible on every unit, or a morbidly obese patient may need to be moved to a room that can accommodate a Hoyer lift. “Every time patients were moved to a different unit, they would have a new provider in charge of that unit,” she says. “We felt that was a big patient dissatisfier.”
“Unit-based care may not be the solution for us at this time until we improve our capacity issues.”
~ Megha Shah, MD
St. Joseph Medical Center
The hospitalists’ next attempt was to try localization on a smaller scale in a short-stay unit. “But the winter hit us, the census really blew up and we were just trying to keep up with it,” Dr. Shah recalls. “The hospital was constantly at 110% or 120% capacity, and we had to shift our focus to just getting patients seen.”
The group’s third and most recent effort, a unit-based pilot on only one floor, has gone much better. “We decided if patients had to move, we were not going to hand them off,” she says. That pilot was maintained long enough—four months— to give each hospitalist a chance to rotate through it.
Initial problems to solve
The pilot produced impressive results, with length of stay on that floor dropping about a day. The catch is that hospitalists don’t see any way to expand the model beyond the pilot. Even though the hospitalist group is better staffed this time around, the hospital continues operating at more than 100% capacity, so patient movement within the hospital can’t be easily resolved.
“When capacity is such an issue,” Dr. Shah says, “the hospital maintains 70 transition beds where patients go when they’re first admitted.” Those patients may not arrive on the right specialty floor for several days, being treated along the way by several providers. With so many temporary assignments, “unit-based care may not be the solution for us at this time until we improve our capacity issues.” The group continues, however, “to work toward it, and we’re designing a new workflow that would work for us.”
At Carle Foundation, Dr. Arwari didn’t need to solve capacity problems to launch unit-based care. But his group did need to completely overhaul its 100%-productivity-based compensation plan.
Under their previous plan, he explains, doctors were “hoarding RVUs” to maximize their income; as a result, they each ended up working the equivalent of a 1.8 FTE and burning out. To discharge patients efficiently and maintain uniform patient loads, the compensation plan had to be turned upside down to salary instead.
“A significant improvement in length of stay and case mix index pretty much sold the model to everybody.”
~ Matthew George, MD
Mississippi Baptist Medical Center
That so displeased a few high hospitalist producers that they left. But those who remained now have “more predictability in their day.” Further, having unit-based in place was a draw to other doctors, and the group was subsequently able to hire eight new physicians.
How to get buy-in
At Mississippi Baptist Medical Center in Jackson, Miss., Matthew George, MD, the hospitalist medical director, helped launch a successful geographic program across seven floors in 2016. Like other proponents of unit-based care, he’s not a stickler for total localization.
The physicians in his group typically start their block of seven days with a census of around 15 and the expectation that they will have between zero and two admissions a day. “The first day when they come on, team members are pretty much geographically assigned to one or two floors,” Dr. George points out. “But as the week progresses and doctors get new patients to fill in for the ones discharged, their geography gets diluted.”
One hurdle he had to clear was “convincing the group the effort was worth it,” he says. “They were used to roaming the hospital at their own pace, and they didn’t want to be tied down to one floor and put on a schedule, with interdisciplinary team rounds every day at 9:15 a.m.”
To help with buy-in, Dr. George gave doctors some leeway—starting rounds between 8:45 a.m. and 9:15 a.m.— rather than locking them into one set time. He also made a somewhat unusual addition to that multidisciplinary meeting every morning: including clinical documentation team coders. Incorporating coders led to an increase in the geometric mean length of stay and a 0.1 increase in the hospital’s case mix index, which boosted hospital reimbursement.
At the same time, absolute length of stay decreased, resulting in a reduction of more than 2,000 days in 2016. In 2017, Dr. George says, hospitalists’ average length of stay continued to steadily trend downward.
Even doctors who were reluctant to try the model ended up liking the more efficient workflow and the ability to run into consultants in the halls instead of waiting for reports. “When we were able to show a significant improvement in length of stay and case mix index,” says Dr. George, “that pretty much sold the model to everybody.”
Even a successful geographic program with a proven track record, like Dr. Smith’s at MaineGeneral, “takes some minding,” he says. “I have to continue to work with our nursing coordinators who make the bed assignments to get them to understand the importance of this. And we follow the numbers weekly, looking at our distributions and seeing how well we’re really doing.”
And even geographic efforts that crash and burn deliver some valuable lessons. While Dr. Shah in Tacoma can’t see a way clear to expand her group’s unit-based pilot, she and her colleagues were impressed by the multidisciplinary rounds that were part of the pilot.
“Geography right now can’t be our central concept,” she says. “But we want to take some of that standardized work—the checklists we created and the content of our discussions—and figure out how to apply those throughout the system.”
While Sentara Martha Jefferson’s hospitalists ended up abandoning unit-based care, Dr. Tesoriere says he and his group have since opted for “a middle road,” with doctors all floating but some advanced practice providers located geographically. One is based in the observation unit, while another does triage in the ED and a third rounds on specific units.
He also notes that group members might consider tackling unit-based care again, but only with certain key changes. For one, the hospital would have to expand its telemetry capacity and its number of cardiac and stroke beds, which are always in high demand.
And the nurses would need to be less specialized so more patients could be treated on any medical/surgical floor, not just specialized ones. “If we had more uniform nurse competencies, that would allow floors to take a potpourri of patients and eliminate some of the complexity we faced,” Dr. Tesoriere says.
Phyllis Maguire is Executive Editor of Today’s Hospitalist
How to handle interruptions
ONE BIG SELLING POINT of unit-based care is that, particularly when coupled with multidisciplinary rounds or meetings, doctors should end up with many fewer pages and interruptions.
But being physically present on primarily one unit can be “a double-edged sword,” says John Smith, DO, hospitalist director at MaineGeneral Medical Center in Augusta, Maine. “Staff know how to find you, so they bop in for every little thing.” Doctors there sometimes have to leave their unit and take refuge in the hospitalists’ office or close the door on their pod to do dictation.
At Mississippi Baptist Medical Center in Jackson, Miss., hospitalist director Matthew George, MD, says group members try to cut down on unit-based interruptions by reminding nurses to have any questions answered and orders processed during their multidisciplinary meetings. Beyond that, individual doctors try to set some limits.
“They’ll say, ‘I’ll make myself available at 10:30 a.m.’ or whatever time they pick,” says Dr. George. Still, some doctors are “so bothered by badgering or easy access that they sneak off the floor.”
Paul Tesoriere, MD, the hospitalist director at Sentara Martha Jefferson Hospital in Charlottesville, Va., identifies constant interruptions as one big reason why his group abandoned unit-based care after two years. “We didn’t really have an isolated work area,” he explains. “It was not uncommon to have several nurses lining up to talk to one physician.”
But at The Valley Hospital in Ridgewood, N.J., hospitalist director Jyothi Kulkarni, MD, says that many doctors—as in Dr. George’s group—set expectations, telling the charge nurse that she or he needs to get some discharges done first and will then be available. She also notes that doctors spend all seven days of a block located predominantly in one or two units.
“One hospitalist told me that the nurses end up knowing his workflow and how he does things,” says Dr. Kulkarni. “They don’t need to interrupt him because they know he’ll get back to them.”
First, don’t get hung up on some idea of geographic purity, say directors of hospitalist programs involved in such efforts. In terms of equal patient loads, some just let doctors’ daily census fluctuate like currency, figuring that patient loads will level out over time.
That’s not the case at Carle Foundation Hospital in Urbana, Ill., where the hospitalists do level load by looking at each doctor’s 24-hour patient distribution. While the group threw out a 100% productivity-based compensation plan, it does have a bonus mechanism to reward doctors for taking extra admissions.
Andy Arwari, MD, the previous director of hospital medicine services who is now Carle’s regional medical director, says clinicians take each colleague’s 24-hour distribution into account when dividing up overnight patients at 7 a.m. the next morning.
While all rounders are expected to take two admissions per day, doctors who take an additional admission not only reap a financial bonus, but that additional patient counts toward their 24-hour distribution. “It’s a double incentive,” Dr. Arwari says. “You’re going to be compensated, and you’ll also have one fewer patient distributed to you the next day.”
Many groups also institute interdisciplinary rounds—around a whiteboard, in a case manager’s office, in a conference room or at the bedside—at the same time that unit-based care goes live. But at The Valley Hospital in Ridgewood, N.J., hospitalist director Jyothi Kulkarni, MD, says that while the group implemented unit-based care in October 2016, they’re still waiting to implement interdisciplinary rounds, which should be launched later this year.
Why? “We wanted to see how unit-based worked and to make sure we could have at least 60% or 70% of our patients unit-based,” Dr. Kulkarni says. “Multidisciplinary rounds are the next step.”
At Carle, Dr. Arwari says, he and his group tried several different strategies for specialty floor coverage, including assigning one hospitalist (in rotation) for a set specialty floor. But many specialty units—he mentions heart failure and oncology—are always a challenge because of high intensity, high turnover or both.
He and his group tried several different strategies to cover specialty floors including assigning one hospitalist to each. But ultimately, the group decided to distribute the hospitalist patients on such services across two or three unit-based teams.
“That way,” he says, “all those patients aren’t on the back of one doctor, but among three.”