I’ve been a non-academic, community hospitalist for most of my career, so I keep an eye on the rapid rise of community hospitalist programs and their challenges.
Establishing the initial program and making it stable is the first step, and that can take months or years. But with growth, you start feeling inevitable pressure to provide 24/7 in-house coverage.
This is a big decision, and not one to take lightly. Typically, the move takes additional resources and a fundamental re-structuring of a program.
Why should groups switch to 24/7? Reasons vary and can include:
● pressure from the ED or medical staff to expedite admissions and avoid holding orders;
● an increasing call burden on hospitalists taking call from home;
● the need for an in-house physician to provide code coverage or to head a rapid response team; and
● help for specialists, especially surgeons, with admissions, consults or preop clearances.
The timing of this move is important, and you need to plan well in advance to avoid stressing a hospitalist program that is stressed already from rapid growth.
If you’re leading the charge for around-the clock-coverage, realize that your hospital administration can be a tough nut to crack. Knowing that administrators are from varying backgrounds will help you pitch the move to a new–and much more expensive–program structure.
CMOs and CNOs are from the clinical side and will respond to information on patient satisfaction, quality and safety.
Your CFO (or as we like to call him/her, the CF”NO”) will want all the pros and cons as this new model will require much more financial support. To get over that financial hump, the hospital needs to realize that 24/7 coverage brings many intangible benefits–and that the move may never be justified strictly on finances.
Make sure you presentation to the administration is well thought out and delivered in a way that shows you’re aware of the costs. At the same time, highlight the “value-add” and the potential impact the new model may have on the whole hospital in terms of patient safety, patient satisfaction and throughput.
Patient safety is a real benefit to stress. Physicians can obviously respond more quickly (with or without a rapid response team) and personally to the bedside, allowing for a more complete, first-hand evaluation and better judgment in determining treatment protocols. In the facilities where we’ve moved to 24/7 coverage, we’ve seen a marked reduction in the number of code blues, especially since we implemented the IHI’s recommendations on rapid response teams.
Hospitalists have also had a big impact on patient satisfaction; many would say negatively. However, the patients I’ve seen who have been the biggest naysayers and who complain the loudest that their primary physician no longer practices in the hospital can be swayed quickly when they or a loved one needs a doctor in the middle of the night, and the hospitalist arrives. When highlighting the intangibles of 24/7 coverage, be sure to stress to administrators that having a physician on-site can only improve patient satisfaction scores.
To justify moving to a 24/7 model, you may want to track your number of admissions between 7 p.m. and 7 a.m. for several months. You should also get data on other key night-time services like code coverage and rapid response teams.
If you’re averaging between six and eight admissions a night, you’re getting close to breaking even on the cost of a dedicated nocturnist. Be sure to also mention the number of consults that you could do on surgical patients, allowing them to go more quickly to the OR. (That argument always gets the CF”NO’s” attention!)
We get a fair number of orthopedic consults for patients who need medical clearance for surgery. Under the old system, we’d see and clear these patients on hospital day 1, and they’d go to surgery on hospital day 2. With 24/7 coverage, they can be evaluated and cleared on hospital day 0 with surgery on hospital day 1–a full day less in terms of overall length of stay.
Finally, in a competitive recruiting environment, a program that has dedicated night coverage tends to fare better than one that requires beeper call from home. That’s another argument to make.
When you’re considering your needs assessment, include manpower; you’ll need two additional FTEs to staff all nights. You’ll also need hospital space (which, if your hospital is like ours, will be the toughest commodity to acquire) for a call room or modified office where the doc can get a break.
Consider piloting a program like this first to make the concept easier for the bean counters to swallow. Rather than hiring additional staff, look for a source of additional staffing such as a locum tenens firm or a community pool of physicians. That can supplement your full-time staff until buy-in occurs. Be sure to set expectations upfront with these physicians to ensure that your pilot goals are met, and the doctors are not just “sleeping for dollars.”
The day when 24/7 coverage will be the norm is coming even for hospitalists in small community programs, so get ready. The more thought you put into planning, the less stress you’ll cause your program and staff, and the smoother your transition to a 24/7 model will be.