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4 Strategies for Managing Hospitalists

Joe Cantlupe, for HealthLeaders Media, May 6, 2013

Some hospitals are also looking to expand the role of hospitalists who do double duty, working in clinics and in hospitals. These hospitalists are known as extensivists. In a 2011 study of patients treated by extensivists in California, the Agency for Healthcare Research and Quality found a length of stay of 4.5 days compared to the average 5.6 in Medicare patients.

The University of Chicago Medical Center has initiated a study of 2,000 patients in a program known as Comprehensive Care, says David Meltzer, MD, PhD, chief of the section of hospital medicine at the University of Chicago. The project is focusing on patients with chronic conditions who are likely to need frequent hospital care. "Many people think that the doctor-patient relationship is the key to better health," he says. "If that is true, patients who are often in the hospital might get better care if they could see the same doctor in clinic and in the hospital," Meltzer says.

Success key No. 3: Unit scheduling
A few years ago, at St. Mary's Health Center, the hospitalists were in the building, but they were scattered all over, "having patients in 13 different units," Vaidyan recalls. Indeed, hospitalists were often assigned patients on different floors and in different units, wasting time and resources, as hospital officials saw it. "It wasn't productive," says Vaidyan.

"We redesigned our program in which a hospitalist would have 80% of their patients in one unit," Vaidyan says. "The idea is that the hospitalist can stay in that unit for an extended time to build a relationship with the nursing staff and multidisciplinary team members. The process has led to improved patient satisfaction."

At St. Mary's, an internal report compared patient satisfaction in hospitalist cases to nonhospitalist ones. The use of hospitalists increased patient satisfaction from 41% in 2008 to 55% in 2010 under a HCAHPS survey, according to St. Mary's. During that same period, a nonhospitalist unit improved only from 41% to 49%.

The hospital is continuing to strive for improvement in patient satisfaction scores, Vaidyan says. Overall, the hospital received 81% patient satisfaction scores, similar to scores in the rest of Missouri as well as the rest of the United States, according to Hospital Compare.

Although the dilemma seemed simple, the location of the hospitalists had a cascading impact from efficiency to patient satisfaction. Moving the hospitalists to be nearer the patients had a psychological advantage: Suddenly patients saw the hospitalists as physicians who were right there, caregivers who would be mindful of their needs. To resolve the problem, St. Mary's assigned hospitalists to a specific unit, including a special 20-bed area specifically reserved for them and RNs.

Banner Baywood also uses a so-called "unit-based assignment model, says Spratling, who praises the model. "Instead of rounding on patients scattered throughout the hospital in multiple units, the hospitalist is assigned to round on all the patients in a convenient 26-bed unit. The new model creates a new rounding priority that enables the hospitalist to discharge patients earlier in the day, resulting in improved patient flow," he adds.

"There was a basic dysfunction that was overcome," Spratling says. "Patients were waiting to go home, and they'd wait and wait, and before you knew it, it was 4 p.m. Often, it was then too late to arrange for home healthcare if they needed it or to get them to a skilled nursing facility if needed. We made the changes so the patients could be discharged in the morning, and we didn't have 'rush hour' discharges at the hospital at 5 p.m."

 With its revised scheduling, the hospital was able to receive an average of 40 more patients for inpatient procedures. The hospital did not merely set the stage for efficiency but it also improved relationships among the case managers, social workers, "as well as face-to-face time, having a true interdisciplinary team working with the family and patient," Spratling says.

At Banner Baywood, patient satisfaction scores for the unit are 99%, about 15 percentage points higher than the 84% for the rest of the facility, according to the hospital. Both St. Mary's and Banner Baywood Medical Center credited the rounding changes to improved patient satisfaction scores.

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