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Hospital Medicine: Flexible Schedule for Better Patient Care

By Shannon Firth, Contributing Writer, MedPage Today  
   April 02, 2015

By having hospitalists admit a disproportionate number of patients at the start of their work week, they can then taper off admissions in their last 2 days and prevent patients from transitioning among more providers than is necessary.

Want to improve satisfaction ratings among hospitalized patients? Try this: limit the number of hospitalists that a patient sees on any given day.

Rather than considering hospitalists as interchangeable cogs in the healthcare system, this approach allows the hospitalist to establish a relationship with the patient.

"What percentage of patients at your hospital see only one daytime hospitalist?" asked John Nelson, MD, a consultant at Nelson Flores Hospital Medicine Consultants, medical director at the Overlake Hospital Medicine Center in Bellevue, Wash., and co-founder of the Society of Hospital Medicine. Nelson spoke at a Hospital Medicine conference here.

Hospitalists variable schedules often force patients to transition between more providers than is necessary, he said. Having hospitalists work as many consecutive day shifts as possible is one way to avoid multiple hand-offs. Yet, even hospitalists working 7 days on and 7 days off shifts will admit new patients on their last day.

What if hospitals could avoid this dilemma? "What if you could exempt doctors on their last day from taking on the care of any new patients?" Nelson asked.

By having hospitalists admit a disproportionate number of patients at the start of their work week, they can then taper off their admissions in their last 2 days. So, that at noon on the second from last day of their work that provider will stop taking any new patients, he said.

Nelson's colleague, Eric Howell, MD, immediate past president of the Society for Hospital Medicine, refers to this pattern of front-loading patient assignment as "slam and dwindle."

"We hand off about six patients, usually because we've been able to whittle our list down," Nelson said. Using this method of assignment, roughly 71% of patients will see the same daytime provider throughout their stay, he said.

In addition to better continuity of care, the incoming provider will pick up a lighter load of patients because on the last day of the outgoing provider's shift, he or she will have more time to "tee up" patients, writing appropriate off-service notes, talking to families and doing the discharge work for individuals expected to leave the following day.

The obvious challenge here is that on the last day of one provider's shift, all of the other providers will be that much busier. This is why it's important to stagger providers' work schedules. "You can't rotate your whole team [on one day]," he said.

Nelson said his site is generously staffed.

"We have it organized so that someone has to stay all day for emergencies, but others can get released when their work is done," he said.

Aside from the 7-days-on/7-days-off model, Nelson said a flexible schedule can also achieve the one-patient, one-hospitalist goal by encouraging physicians to work in the way they work best, even if it means a move away from rigid schedules.

For example, not everyone has to start and finish work at the same time each day, he said.

Besides rigid shifts, Nelson also wishes hospitalists could forget about "load-leveling." The daily half-hour meeting of four or more physicians to evenly distribute patients wastes money and wastes time. "[L]etting it fall randomly, it will be level, or really close to it, over the course of say, a year."

From our partners at MedPage Today.

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