John Nelson, MD

Burnout is influenced by a seemingly infinite combination of variables. An optimal schedule alone isn’t the key to preventing it, but maybe a good schedule can reduce your risk you’ll suffer from it.

Smart people who have spent years as hospitalists, working multiple different schedules, have formed a variety of conclusions about which work schedules best reduce the risk of burnout. There’s no meaningful research to settle the question, so everyone will have to reach their own conclusions, as I’ve done here.
 

Scheduling flexibility: Often overlooked?

Someone who typically works the same number of consecutive day shifts, each of which is the same duration, might suffer from the monotony and inexorable predictability. Schedules that vary the number of consecutive day shifts, the intensity or length of shifts, and the number of consecutive days off might result in lower rates of burnout. This is especially likely to be the case if each provider has some flexibility to control how her schedule varies over time.

shutteratakan/Thinkstock

Personal time goes on the calendar first

Those who have a regularly repeating work schedule tend to work hard arranging such important things as family vacations on days the schedule dictates. In other words, the first thing that goes on the personal calendar are the weeks of work; they’re “X-ed” out and personal events filled into the remaining days.

That’s fine for many personal activities, but it means the hospitalist might tend to set a pretty high bar for activities that are worth negotiating alterations to the usual schedule. For example, you might want to see U2 but decide to skip their concert in your town since it falls in the middle of your regularly scheduled week of work. Maybe that’s not a big deal (Isn’t U2 overplayed and out of date anyway?), but an accumulation of small sacrifices like this might increase resentment of work.

It’s possible to organize a hospitalist group schedule in which each provider’s personally requested days off, like the U2 concert, go on the work calendar first, and the clinical schedule is built around them. It can get pretty time consuming to manage, but might be a worthwhile investment to reduce burnout risk.

A paradox: Fewer shifts could increase burnout risk

I’m convinced many hospitalists make the mistake of seeking to maximize their number of days off with the idea that it will be good for happiness, career longevity, burnout, etc. While having more days off provides more time for nonwork activities and rest/recovery from work, it usually means the average workday is busier and more stressful to maintain expected levels of productivity. The net effect for some seems to be increased burnout.

Consider someone who has been working 182 hospitalist shifts and generating a total of 2,114 billed encounters annually (both are the most recent national medians available from surveys). This hospitalist successfully negotiates a reduction to 161 annual shifts. This would probably feel good to anyone at first, but keep in mind that it means the average number of daily encounters to maintain median annual productivity would increase 13% (from 11.6 to 13.1 in this example). That is, each day of work just got 13% busier.

I regularly encounter career hospitalists with more than 10 years of experience who say they still appreciate – or even are addicted to – having lots of days off. But the worked days often are so busy they don’t know how long they can keep doing it. It is possible some of them might be happier and less burned out if they work more shifts annually, and the average shift is meaningfully less busy.

The “right” number of shifts depends on a combination of personal and economic factors. Rather than focusing almost exclusively on the number of shifts worked annually, it may be better to think about the total amount of annual work measured in billed encounters, or wRVUs [work relative value units], and how it is titrated out on the calendar.

Other scheduling attributes and burnout

I think it’s really important to ensure the hospitalist group always has the target number of providers working each day. Many groups have experienced staffing deficits for so long that they’ve essentially given up on this goal, and staffing levels vary day to day. This means each provider has uncertainty regarding how often he will be scheduled on days with fewer than the targeted numbers of providers working.

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at john.nelson@nelsonflores.com.

Burnout is influenced by a seemingly infinite combination of variables. An optimal schedule alone isn’t the key to preventing it, but maybe a good schedule can reduce your risk you’ll suffer from it.

Smart people who have spent years as hospitalists, working multiple different schedules, have formed a variety of conclusions about which work schedules best reduce the risk of burnout. There’s no meaningful research to settle the question, so everyone will have to reach their own conclusions, as I’ve done here.
 

Scheduling flexibility: Often overlooked?

Someone who typically works the same number of consecutive day shifts, each of which is the same duration, might suffer from the monotony and inexorable predictability. Schedules that vary the number of consecutive day shifts, the intensity or length of shifts, and the number of consecutive days off might result in lower rates of burnout. This is especially likely to be the case if each provider has some flexibility to control how her schedule varies over time.

shutteratakan/Thinkstock

Personal time goes on the calendar first

Those who have a regularly repeating work schedule tend to work hard arranging such important things as family vacations on days the schedule dictates. In other words, the first thing that goes on the personal calendar are the weeks of work; they’re “X-ed” out and personal events filled into the remaining days.

That’s fine for many personal activities, but it means the hospitalist might tend to set a pretty high bar for activities that are worth negotiating alterations to the usual schedule. For example, you might want to see U2 but decide to skip their concert in your town since it falls in the middle of your regularly scheduled week of work. Maybe that’s not a big deal (Isn’t U2 overplayed and out of date anyway?), but an accumulation of small sacrifices like this might increase resentment of work.

It’s possible to organize a hospitalist group schedule in which each provider’s personally requested days off, like the U2 concert, go on the work calendar first, and the clinical schedule is built around them. It can get pretty time consuming to manage, but might be a worthwhile investment to reduce burnout risk.

A paradox: Fewer shifts could increase burnout risk

I’m convinced many hospitalists make the mistake of seeking to maximize their number of days off with the idea that it will be good for happiness, career longevity, burnout, etc. While having more days off provides more time for nonwork activities and rest/recovery from work, it usually means the average workday is busier and more stressful to maintain expected levels of productivity. The net effect for some seems to be increased burnout.

Consider someone who has been working 182 hospitalist shifts and generating a total of 2,114 billed encounters annually (both are the most recent national medians available from surveys). This hospitalist successfully negotiates a reduction to 161 annual shifts. This would probably feel good to anyone at first, but keep in mind that it means the average number of daily encounters to maintain median annual productivity would increase 13% (from 11.6 to 13.1 in this example). That is, each day of work just got 13% busier.

I regularly encounter career hospitalists with more than 10 years of experience who say they still appreciate – or even are addicted to – having lots of days off. But the worked days often are so busy they don’t know how long they can keep doing it. It is possible some of them might be happier and less burned out if they work more shifts annually, and the average shift is meaningfully less busy.

The “right” number of shifts depends on a combination of personal and economic factors. Rather than focusing almost exclusively on the number of shifts worked annually, it may be better to think about the total amount of annual work measured in billed encounters, or wRVUs [work relative value units], and how it is titrated out on the calendar.

Other scheduling attributes and burnout

I think it’s really important to ensure the hospitalist group always has the target number of providers working each day. Many groups have experienced staffing deficits for so long that they’ve essentially given up on this goal, and staffing levels vary day to day. This means each provider has uncertainty regarding how often he will be scheduled on days with fewer than the targeted numbers of providers working.

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at john.nelson@nelsonflores.com.

Burnout is influenced by a seemingly infinite combination of variables. An optimal schedule alone isn’t the key to preventing it, but maybe a good schedule can reduce your risk you’ll suffer from it.

Smart people who have spent years as hospitalists, working multiple different schedules, have formed a variety of conclusions about which work schedules best reduce the risk of burnout. There’s no meaningful research to settle the question, so everyone will have to reach their own conclusions, as I’ve done here.
 

Scheduling flexibility: Often overlooked?

Someone who typically works the same number of consecutive day shifts, each of which is the same duration, might suffer from the monotony and inexorable predictability. Schedules that vary the number of consecutive day shifts, the intensity or length of shifts, and the number of consecutive days off might result in lower rates of burnout. This is especially likely to be the case if each provider has some flexibility to control how her schedule varies over time.

shutteratakan/Thinkstock

Personal time goes on the calendar first

Those who have a regularly repeating work schedule tend to work hard arranging such important things as family vacations on days the schedule dictates. In other words, the first thing that goes on the personal calendar are the weeks of work; they’re “X-ed” out and personal events filled into the remaining days.

That’s fine for many personal activities, but it means the hospitalist might tend to set a pretty high bar for activities that are worth negotiating alterations to the usual schedule. For example, you might want to see U2 but decide to skip their concert in your town since it falls in the middle of your regularly scheduled week of work. Maybe that’s not a big deal (Isn’t U2 overplayed and out of date anyway?), but an accumulation of small sacrifices like this might increase resentment of work.

It’s possible to organize a hospitalist group schedule in which each provider’s personally requested days off, like the U2 concert, go on the work calendar first, and the clinical schedule is built around them. It can get pretty time consuming to manage, but might be a worthwhile investment to reduce burnout risk.

A paradox: Fewer shifts could increase burnout risk

I’m convinced many hospitalists make the mistake of seeking to maximize their number of days off with the idea that it will be good for happiness, career longevity, burnout, etc. While having more days off provides more time for nonwork activities and rest/recovery from work, it usually means the average workday is busier and more stressful to maintain expected levels of productivity. The net effect for some seems to be increased burnout.

Consider someone who has been working 182 hospitalist shifts and generating a total of 2,114 billed encounters annually (both are the most recent national medians available from surveys). This hospitalist successfully negotiates a reduction to 161 annual shifts. This would probably feel good to anyone at first, but keep in mind that it means the average number of daily encounters to maintain median annual productivity would increase 13% (from 11.6 to 13.1 in this example). That is, each day of work just got 13% busier.

I regularly encounter career hospitalists with more than 10 years of experience who say they still appreciate – or even are addicted to – having lots of days off. But the worked days often are so busy they don’t know how long they can keep doing it. It is possible some of them might be happier and less burned out if they work more shifts annually, and the average shift is meaningfully less busy.

The “right” number of shifts depends on a combination of personal and economic factors. Rather than focusing almost exclusively on the number of shifts worked annually, it may be better to think about the total amount of annual work measured in billed encounters, or wRVUs [work relative value units], and how it is titrated out on the calendar.

Other scheduling attributes and burnout

I think it’s really important to ensure the hospitalist group always has the target number of providers working each day. Many groups have experienced staffing deficits for so long that they’ve essentially given up on this goal, and staffing levels vary day to day. This means each provider has uncertainty regarding how often he will be scheduled on days with fewer than the targeted numbers of providers working.

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at john.nelson@nelsonflores.com.

I wrote about physician burnout and well-being in the July 2017 version of this column, and am still thinking a great deal about those issues. In the past 6 months, I can’t identify anything that strikes me as a real breakthrough in addressing these issues. However, the ever-increasing attention and resources directed at physician burnout and wellness, on both a local and national level, strike me as reason for cautious optimism.

A chief wellness officer

In summer 2017, Stanford University created a new physician executive role called chief wellness officer (CWO). As far as I am aware, this is the first such position connected with a hospital or medical school. It will be interesting to see if other organizations create similar positions, although I suspect that in places where it is explicitly recognized as a priority, responsibility for this work will be one of the many duties of a chief medical officer or other such executive, and not a position devoted solely to wellness. Interestingly, an Internet search revealed that some non–health care businesses have executive positions with that title, though the role seems focused more on physical health – as in exercise and smoking cessation – than emotional well-being and burnout.

According to a statement on the Stanford Medicine website, the new CWO will work with colleagues to continue “building on its innovative WellMD Center , which was established in 2016. The center has engaged more than 200 physicians through programs focusing on peer support, stress reduction, and ways to cultivate compassion and resilience, as well as a literature and a dinner series in which physicians explore the challenges and rewards of being a doctor. The center also aims to relieve some of the burden on physicians by improving efficiency and simplifying workplace systems, such as electronic medical records.”

A national conference

Over the last 2 or 3 years many, if not most, physician conferences, including the SHM annual conference, have added some content around physician burnout and well-being. But for the first time I’m aware of, an entire conference, the American Conference on Physician Health, addressed these topics in San Francisco in October 2017, and attracted 425 attendees along with an all-star faculty. I couldn’t attend myself, but found a reporter’s summary informative and I recommend it.

While the summary didn’t suggest the conference provided a cure or simple path to improvement, I’m encouraged that the topic has attracted the attention of some pretty smart people. If there is a second edition of this conference, I’ll try hard to attend.

Worthwhile web resources

The home page of Stanford’s WellMD Center provides a continuously updated list of recent research publications on physician health and links to many other resources, and is worth bookmarking.

Another great educational resource for physician wellness is the AMA’s STEPS Forward, a site devoted to practice improvement that provides guidance on patient care, work flow and process, leading change, technology and finance, as well as professional well-being. Of the five separate education modules in the latter category, I found the one on “Preventing Physician Burnout” especially informative. The site is free, doesn’t require an AMA membership, and can provide CME credit.

Making a difference locally: Individuals

Surveys, research, and the experience of experts available via the above resources and others are very valuable, but may be hard to translate into action for you and your fellow local caregivers. My sense is that many hospitalists address their own work-related distress by simply working less in total – reducing their full-time equivalents. That may be the most tangible and accessible intervention, and undeniably the right thing to do in some cases. But it isn’t an ideal approach for our field, which faces chronic staffing shortages. And it doesn’t do anything to change the average level of distress of a day of work. I worry that many people will find disappointment if working fewer shifts is their only burnout mitigation strategy.

Ensuring that you have some work-related interest outside of direct patient care, such as being the local electronic health record expert, or even the person leading formation of a support committee, can be really valuable. I first addressed this topic in the June 2011 issue of The Hospitalist, and there is a long list of things to consider: mindfulness, practicing “ self-compassion ,” cultivating deeper social connections in and out of the workplace, etc. Ultimately, each of us will have to choose our own path, and for some that should include professional help, e.g., from a mental health care provider.

But as a colleague once put it, a focus on changing ourselves is akin to just learning to take a punch better. A worthwhile endeavor, but it’s also necessary to try to decrease the number of punches thrown our way.

Making a difference locally: Medical staff

I’m part of the Provider Support Committee at my hospital, and I have concluded that nearly every hospital should have a group like this. Our own committee was modeled after the support committee at a hospital five miles away, and both groups see value in collaborating in our efforts. In fact, a person from each hospital’s committee serves on the committee at the other hospital.

These committees have popped up in other institutions, and many have been at it longer than at my hospital. But they all seem to share a mission of developing and implementing programs to position caregivers to thrive in their work, increase resilience, and reduce their risk of burnout. Some interventions are focused on making changes to an EHR, work schedules, work flows, or even staffing levels (i.e., reducing the “number of punches”). Other efforts are directed toward establishing groups that support personal reflection and/or social connections among providers.

A review of activities undertaken by seven different organizations is available at the AMA STEPS forward Preventing Physician Burnout website (click on “STEPS in practice.”)

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at john.nelson@nelsonflores.com

I wrote about physician burnout and well-being in the July 2017 version of this column, and am still thinking a great deal about those issues. In the past 6 months, I can’t identify anything that strikes me as a real breakthrough in addressing these issues. However, the ever-increasing attention and resources directed at physician burnout and wellness, on both a local and national level, strike me as reason for cautious optimism.

A chief wellness officer

In summer 2017, Stanford University created a new physician executive role called chief wellness officer (CWO). As far as I am aware, this is the first such position connected with a hospital or medical school. It will be interesting to see if other organizations create similar positions, although I suspect that in places where it is explicitly recognized as a priority, responsibility for this work will be one of the many duties of a chief medical officer or other such executive, and not a position devoted solely to wellness. Interestingly, an Internet search revealed that some non–health care businesses have executive positions with that title, though the role seems focused more on physical health – as in exercise and smoking cessation – than emotional well-being and burnout.

According to a statement on the Stanford Medicine website, the new CWO will work with colleagues to continue “building on its innovative WellMD Center , which was established in 2016. The center has engaged more than 200 physicians through programs focusing on peer support, stress reduction, and ways to cultivate compassion and resilience, as well as a literature and a dinner series in which physicians explore the challenges and rewards of being a doctor. The center also aims to relieve some of the burden on physicians by improving efficiency and simplifying workplace systems, such as electronic medical records.”

A national conference

Over the last 2 or 3 years many, if not most, physician conferences, including the SHM annual conference, have added some content around physician burnout and well-being. But for the first time I’m aware of, an entire conference, the American Conference on Physician Health, addressed these topics in San Francisco in October 2017, and attracted 425 attendees along with an all-star faculty. I couldn’t attend myself, but found a reporter’s summary informative and I recommend it.

While the summary didn’t suggest the conference provided a cure or simple path to improvement, I’m encouraged that the topic has attracted the attention of some pretty smart people. If there is a second edition of this conference, I’ll try hard to attend.

Worthwhile web resources

The home page of Stanford’s WellMD Center provides a continuously updated list of recent research publications on physician health and links to many other resources, and is worth bookmarking.

Another great educational resource for physician wellness is the AMA’s STEPS Forward, a site devoted to practice improvement that provides guidance on patient care, work flow and process, leading change, technology and finance, as well as professional well-being. Of the five separate education modules in the latter category, I found the one on “Preventing Physician Burnout” especially informative. The site is free, doesn’t require an AMA membership, and can provide CME credit.

Making a difference locally: Individuals

Surveys, research, and the experience of experts available via the above resources and others are very valuable, but may be hard to translate into action for you and your fellow local caregivers. My sense is that many hospitalists address their own work-related distress by simply working less in total – reducing their full-time equivalents. That may be the most tangible and accessible intervention, and undeniably the right thing to do in some cases. But it isn’t an ideal approach for our field, which faces chronic staffing shortages. And it doesn’t do anything to change the average level of distress of a day of work. I worry that many people will find disappointment if working fewer shifts is their only burnout mitigation strategy.

Ensuring that you have some work-related interest outside of direct patient care, such as being the local electronic health record expert, or even the person leading formation of a support committee, can be really valuable. I first addressed this topic in the June 2011 issue of The Hospitalist, and there is a long list of things to consider: mindfulness, practicing “ self-compassion ,” cultivating deeper social connections in and out of the workplace, etc. Ultimately, each of us will have to choose our own path, and for some that should include professional help, e.g., from a mental health care provider.

But as a colleague once put it, a focus on changing ourselves is akin to just learning to take a punch better. A worthwhile endeavor, but it’s also necessary to try to decrease the number of punches thrown our way.

Making a difference locally: Medical staff

I’m part of the Provider Support Committee at my hospital, and I have concluded that nearly every hospital should have a group like this. Our own committee was modeled after the support committee at a hospital five miles away, and both groups see value in collaborating in our efforts. In fact, a person from each hospital’s committee serves on the committee at the other hospital.

These committees have popped up in other institutions, and many have been at it longer than at my hospital. But they all seem to share a mission of developing and implementing programs to position caregivers to thrive in their work, increase resilience, and reduce their risk of burnout. Some interventions are focused on making changes to an EHR, work schedules, work flows, or even staffing levels (i.e., reducing the “number of punches”). Other efforts are directed toward establishing groups that support personal reflection and/or social connections among providers.

A review of activities undertaken by seven different organizations is available at the AMA STEPS forward Preventing Physician Burnout website (click on “STEPS in practice.”)

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at john.nelson@nelsonflores.com

I wrote about physician burnout and well-being in the July 2017 version of this column, and am still thinking a great deal about those issues. In the past 6 months, I can’t identify anything that strikes me as a real breakthrough in addressing these issues. However, the ever-increasing attention and resources directed at physician burnout and wellness, on both a local and national level, strike me as reason for cautious optimism.

A chief wellness officer

In summer 2017, Stanford University created a new physician executive role called chief wellness officer (CWO). As far as I am aware, this is the first such position connected with a hospital or medical school. It will be interesting to see if other organizations create similar positions, although I suspect that in places where it is explicitly recognized as a priority, responsibility for this work will be one of the many duties of a chief medical officer or other such executive, and not a position devoted solely to wellness. Interestingly, an Internet search revealed that some non–health care businesses have executive positions with that title, though the role seems focused more on physical health – as in exercise and smoking cessation – than emotional well-being and burnout.

According to a statement on the Stanford Medicine website, the new CWO will work with colleagues to continue “building on its innovative WellMD Center , which was established in 2016. The center has engaged more than 200 physicians through programs focusing on peer support, stress reduction, and ways to cultivate compassion and resilience, as well as a literature and a dinner series in which physicians explore the challenges and rewards of being a doctor. The center also aims to relieve some of the burden on physicians by improving efficiency and simplifying workplace systems, such as electronic medical records.”

A national conference

Over the last 2 or 3 years many, if not most, physician conferences, including the SHM annual conference, have added some content around physician burnout and well-being. But for the first time I’m aware of, an entire conference, the American Conference on Physician Health, addressed these topics in San Francisco in October 2017, and attracted 425 attendees along with an all-star faculty. I couldn’t attend myself, but found a reporter’s summary informative and I recommend it.

While the summary didn’t suggest the conference provided a cure or simple path to improvement, I’m encouraged that the topic has attracted the attention of some pretty smart people. If there is a second edition of this conference, I’ll try hard to attend.

Worthwhile web resources

The home page of Stanford’s WellMD Center provides a continuously updated list of recent research publications on physician health and links to many other resources, and is worth bookmarking.

Another great educational resource for physician wellness is the AMA’s STEPS Forward, a site devoted to practice improvement that provides guidance on patient care, work flow and process, leading change, technology and finance, as well as professional well-being. Of the five separate education modules in the latter category, I found the one on “Preventing Physician Burnout” especially informative. The site is free, doesn’t require an AMA membership, and can provide CME credit.

Making a difference locally: Individuals

Surveys, research, and the experience of experts available via the above resources and others are very valuable, but may be hard to translate into action for you and your fellow local caregivers. My sense is that many hospitalists address their own work-related distress by simply working less in total – reducing their full-time equivalents. That may be the most tangible and accessible intervention, and undeniably the right thing to do in some cases. But it isn’t an ideal approach for our field, which faces chronic staffing shortages. And it doesn’t do anything to change the average level of distress of a day of work. I worry that many people will find disappointment if working fewer shifts is their only burnout mitigation strategy.

Ensuring that you have some work-related interest outside of direct patient care, such as being the local electronic health record expert, or even the person leading formation of a support committee, can be really valuable. I first addressed this topic in the June 2011 issue of The Hospitalist, and there is a long list of things to consider: mindfulness, practicing “ self-compassion ,” cultivating deeper social connections in and out of the workplace, etc. Ultimately, each of us will have to choose our own path, and for some that should include professional help, e.g., from a mental health care provider.

But as a colleague once put it, a focus on changing ourselves is akin to just learning to take a punch better. A worthwhile endeavor, but it’s also necessary to try to decrease the number of punches thrown our way.

Making a difference locally: Medical staff

I’m part of the Provider Support Committee at my hospital, and I have concluded that nearly every hospital should have a group like this. Our own committee was modeled after the support committee at a hospital five miles away, and both groups see value in collaborating in our efforts. In fact, a person from each hospital’s committee serves on the committee at the other hospital.

These committees have popped up in other institutions, and many have been at it longer than at my hospital. But they all seem to share a mission of developing and implementing programs to position caregivers to thrive in their work, increase resilience, and reduce their risk of burnout. Some interventions are focused on making changes to an EHR, work schedules, work flows, or even staffing levels (i.e., reducing the “number of punches”). Other efforts are directed toward establishing groups that support personal reflection and/or social connections among providers.

A review of activities undertaken by seven different organizations is available at the AMA STEPS forward Preventing Physician Burnout website (click on “STEPS in practice.”)

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. Contact him at john.nelson@nelsonflores.com

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

The 2017 MGMA survey data on compensation and productivity were released last June. While the numbers aren’t surprising, reviewing them always gets me thinking about factors that influence reasonable expectations for compensation and productivity in any individual hospitalist group.

The data were collected in early 2017, reflecting work done in 2016, and show a national median hospitalist compensation for internal medicine physicians of $284,000, up from $278,500 the year before. Since MGMA added a hospitalist category to the survey, compensation has been growing significantly faster than inflation, even though productivity has been essentially flat. I’ve always thought that the high demand for hospitalists, which isn’t letting up much, in the face of a limited supply is probably the most significant force causing hospitalist compensation to rise faster than in most other specialties.

The survey shows a median of 2,114 billed encounters and 4,159 wRVUs (work relative value units) generated per internal medicine hospitalist annually (family medicine hospitalists are reported separately). These numbers have been pretty stable for many years.

Whether it is reasonable to expect hospitalists in your group to produce at this level is a question that can unspool into a lengthy conversation. Below are several assertions I regularly hear others make about productivity, and following each is my commentary.

“Surveys show only what is most typical, not what is optimal. Our field suffers from concerning levels of burnout, essentially proving that median levels of productivity shown in surveys is too high.”

I share this concern, but this is a complicated issue. You’ll have to make up your own mind regarding how significantly workload influences hospitalist burnout. But the modest amount of published research on this topic suggests that workload itself isn’t as strongly associated with burnout as you might think. I’m certain workload does play a role, but other factors such as “occupational solidarity” seem to matter more. Lowering workload in some settings might be appropriate, but without other interventions may not influence work-related stress and burnout as much as might be hoped.

“Surveys don’t capture unbillable activities (‘unbillable wRVUs’), so are a poor frame of reference when thinking about productivity expectations in our own group.”

It’s true that hospitalists do a lot of work that isn’t captured in wRVUs. My work with many groups around the country suggests the amount and difficulty of this unbillable work is reasonably similar across most groups. We all spend time with handoffs, managing paperwork such as charge capture and completing forms, responding to a rapid response call that doesn’t lead to a billable charge, etc. The average amount of this sort of work is built into the survey. Clearly some groups are outliers with meaningfully more unbillable work than elsewhere, but that can be a difficult or impossible thing to prove.

“My hospital has unique barriers to efficiency/productivity, so it’s more difficult to achieve levels of productivity shown in surveys.”

This is another way of expressing the previous issue. To support this assertion hospitalists will mention that it is tougher to be productive at their hospital because they’re a referral center with unusually sick and complicated patients; they teach trainees in addition to clinical care; and/or their patients and families are unusually demanding, so they take much more time than at other places.

Yet for each of these issues I also hear the reverse argument regularly. Hospitalists point out that because they’re a small hospital (not a referral center) they lack the support of other specialties so must manage all aspects of care themselves; they don’t have residents to help do some of the work; and their patients are unsophisticated and lack social support. For these reasons, the argument goes, they shouldn’t be expected to achieve levels of productivity shown in surveys.

I have worked with hospitalist groups that I am convinced do face unusual barriers to efficiency that are meaningful enough that unless the barriers can be addressed, I think productivity expectations should be lower than survey benchmarks. For example, in most academic medical centers and a very small number of nonacademic hospitals, only the attending physician writes orders; consulting doctors don’t. This means that the attending hospitalist must check a patient’s chart repeatedly through the day just to see if the consultant proposed even small things like ordering a routine lab test, advancing the diet, etc., that the hospitalist must order.

A separate daytime admitter shift is a modest barrier to efficiency that is so common it is clearly factored into survey results. Most hospitalist groups with more than about five doctors working daily have one doctor (or more than one in large groups) manage admissions while the rest round and are protected from admissions. While this may have a number of benefits, overall hospitalist efficiency isn’t one of them. It means that all patients, not just those admitted at night, will have a handoff from the admitting provider to a new attending for the first rounding visit. This new attending will spend additional time becoming familiar with the patient – time that wouldn’t be necessary had that doctor performed the admission visit herself.

“Our hospitalist group is always being asked to take on more duties, such as managing med reconciliation, taking referrals from an additional PCP group, or serving as admitting and attending physician for patients previously admitted by a different specialty (which now serves in the consultant role). For this reason, it’s necessary to steadily lower hospitalist productivity expectations over time.”

A hospitalist today probably spends a quarter of the day doing things I didn’t have to do at the outset of my career in the 1980s. So my impulse is to agree that as the breadth of our responsibilities expands, expected wRVU productivity should fall. But surveys over the last 15-20 years don’t show this happening, and the pressure to maintain productivity levels isn’t likely to let up. Rather than generating fewer wRVUs (seeing fewer patients), hospital medicine, like health care as a whole, faces the challenge of continually improving our efficiency.

“Surveys are only one frame of reference for determining expectations at my particular hospitalist group. There are other factors to consider as well.”

This is absolutely true. There may be many reasons for your group to set expectations that are meaningfully different from survey figures. Just make sure your rationale for doing so is well considered and effectively communicated to other stakeholders, such as those in finance and organizational leadership at your organization.
 

Dr. Nelson has had a career in clinical practice as a hospitalist starting in 1988. He is cofounder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice management courses. John.nelson@nelsonflores.com

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at john.nelson@nelsonflores.com

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at john.nelson@nelsonflores.com

It’s very unusual for hospitalists to achieve top quartile performance on the Physician Communication domain of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This is the story of a group that did just that for patients on one unit of a large hospital.

I’m not sure how reproducible this would be at other hospitals, or even on other units in the same hospital, and wonder whether performance will stay at this remarkably high level much longer than the current 5-month track record of success. Even so, five months of success suggests they’re on to something.

There is another hospitalist group at that hospital, but I’m discussing work done only by MedOne hospitalists, who together with hospital personnel, developed what they call the Comprehensive Medical Unit (CMU). Their goal was to involve multiple disciplines and use Lean principles to design a new approach to care on 5-Orange, a 20-bed unit in OhioHealth’s Riverside Methodist Hospital in Columbus. The CMU model went live in October 2016.

MedOne Hospital Physicians is a private hospitalist group of 35 physicians and 12 advanced practice clinicians, which comprise nurse practitioners (NPs) and physician assistants (PAs), constituting 46 full-time–equivalent clinical staffing. The group contracts with Riverside, which has approximately 710 staffed beds. MedOne also works in area skilled nursing facilities, helps a long-term acute care and rehabilitation hospital, and provides support to two other hospitals that are not part of OhioHealth.
 

Features of the model

At its core, this model is a variation of the increasingly common combination of geographically assigned hospitalists (who in this case don’t have patients elsewhere in the hospital) and multidisciplinary rounds (that is, the physician and NP hospitalists make bedside rounds with a nurse and pharmacist). But their model also incorporates a few less-common features.

Only 4 of the 35 MedOne hospitalists are eligible to provide care on the CMU, and each still spends a significant portion of time in the regular hospitalist rotation working in the rest of the hospital. These doctors weren’t selected as the highest performers or because they had the best patient satisfaction track record. Instead, five MedOne doctors volunteered to work on the unit, and four were chosen. A MedOne hospitalist NP also works on the unit, since any NP in the group is eligible to work there.

This is a hospitalist-only unit; no non–hospitalist patients are placed on the unit. There is no deliberate attempt to assign patients to the unit based on how sick they are or complicated their cases are. All are general medicine patients, including up to six intermediate care patients (e.g., “ICU step-down” patients requiring mask ventilation, etc.). While configured for 20 patients, the unit can flex to as many as 24 patients and has done so numerous times. The hospitalists (physician and NP combined) have averaged 18.9 daily encounters since the CMU opened.

Nurse staffing on the unit was reconfigured to comprise bedside nurses – known as Clinical Nurses (CNs) – and more experienced RNs – in the role of Comprehensive Charge Nurses (CCNs), who attend rounds and coordinate the patients’ hospitalizations rather than doing bedside care. 5-Orange has one more Charge Nurse than is typical for other units in the hospital, so total RN-to-patient staffing levels and nurse staffing costs are higher. But the CNs care for the same number of patients as do their counterparts in other hospital units.

In order to try to discharge patients early in the day, the NP sees only the patients who are being discharged, while the physician makes all other visits. When possible, I think it’s best to minimize the incidence of a provider’s first visit with a patient being a discharge visit; this may increase the risk of misunderstandings and errors. Instead, in this model, the physician working on the CMU will already know the patient from the preceding days and will be on the unit and readily accessible to the NP all day, which might mitigate some of these concerns.
 

Outcomes

I think the most notable outcome is the top quartile patient satisfaction scores from the 37 patients cared for on the unit who returned a survey, some of whom have asked to return to the CMU if they’re hospitalized again. Specifically, 86% of responses were “top box,” which places the hospitalists at the 84th percentile of performance for all hospitals. Physician Communication scores on the HCAHPS survey for hospitalists on other units at this hospital are in the bottom deciles, which is more typical for hospitalists.

Length of stay is half a day shorter than comparable units with similar readmission rates, and more patients are discharged earlier in the day. The four hospitalists who work on the unit report higher satisfaction, in part because they get an average of only 1 page a day – compared with the typical 15-40 pages their colleagues get working elsewhere in the hospital.
 

Cautions

I’m not sure why the MedOne model has yielded such impressive patient satisfaction and other results. While there are some relatively unique features of their model – only four hospitalists are eligible to work there and nursing roles have been reconfigured – I wouldn’t expect these to yield such remarkable results. So far, they have roughly 5 months of data and just 37 returned patient satisfaction surveys, so it’s possible that random variation and/or the Hawthorne effect are playing a meaningful role. It will be really informative to see their outcomes a year or 2 from now and to gauge how they fare if and when they implement the same model in other units of the hospital.

I suspect MedOne’s precise configuration for staffing and roles of nurses, NPs, and physicians is important, but I’m guessing the most valuable thing they implemented was the creation of a powerful sense of teamwork and shared purpose among those working on the unit. The interpersonal bonding and feeling of shared purpose that likely occurred as they worked to devise and go live with the model, as well as the tremendous satisfaction at seeing their early results, have probably led to terrific enthusiasm within their team.

That enthusiasm may be the key ingredient contributing to their early success.
 

Dr. Nelson has been working in clinical practice as a hospitalist since 1988. He is a cofounder and past president of Society of Hospital Medicine and a principal in Nelson Flores Hospital Medicine Consultants. He is codirector for SHM’s practice-management courses. Contact him at john.nelson@nelsonflores.com