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Four-day blocks match hospitalists' and patients' schedules

From the June ACP Hospitalist, copyright © 2012 by the American College of Physicians

By Stacey Butterfield

Sidebar: Another new way to schedule

Where: Johns Hopkins Bayview Medical Center, a 335-bed academic medical center in Baltimore.

The issue: Changing hospitalist schedules to improve physician satisfaction and continuity of care.

Background

In early 2009, the Johns Hopkins hospitalists had schedules that were very busy and very haphazard. They worked blocks of anywhere from one to five days, and took new patients every day they were below their caps.

“For 80% of our patients, length of stay is four days or less, so they get the same doc the whole time.” —Eric E. Howell, MD, FACP

“Working faster meant more work,” said hospitalist Shalini Chandra, MD, during a session at Hospital Medicine 2012 in April. “Providers felt they were being punished for discharging patients, because they would get new patients the next morning.”

Another disadvantage of the scheduling system was the number of handoffs. “Some were saying the length of stay was too long. Some were saying there were too many handoffs,” said Dr. Chandra. So in the summer of 2009, the hospitalists went on a retreat and developed a new scheduling model, known formally as Creating Incentives and Continuity Leading to Efficiency (CICLE) and informally as “slam and dwindle.”

How it works

The slam comes on the first day of the new four-day blocks developed by the hospitalist group. During his first day on, a hospitalist takes only new admissions, up to a cap of 12 patients. If he doesn't get 12 patients during the first day shift, admissions that come in overnight will bring him up to the cap by the morning of Day 2. “The Day 2 or Slam Day is a long day because that's the day they're focused on learning about all their patients and getting all the nitty-gritty,” said Dr. Chandra.

But then, the hospitalist is done taking new patients. The rest of the four days is devoted to treating, and ideally discharging, those patients. “It's to your advantage and your patients' advantage to try and discharge your patients as soon as it is medically appropriate,” said Dr. Chandra. “The sicker patients who still need to be in the hospital get more attention. Discharged ones don't have to be handed off.”

The length of the block was specifically chosen to reduce the frequency of handoffs, according to hospitalist division director Eric E. Howell, MD, FACP. “For 80% of our patients, length of stay is four days or less, so they get the same doc the whole time,” he said, also during a lecture at Hospital Medicine 2012.

Results

A reduction in handoffs was the most dramatic effect of the new schedule, according to results published in the April 2012 Mayo Clinic Proceedings. The percentage of patients cared for by a single hospitalist almost doubled, from 17.3% under the old schedule to 28.2% under CICLE. Length of stay also changed significantly, from 2.92 days to 2.7.

The new system was good for satisfaction, too. “Not only were the patients happier because they had one doctor, but it became a huge satisfier for the docs as well,” said Dr. Howell, noting that the “dwindle” part of the block carried some appealing benefits. “If they can discharge their patients, they can go home when they're done.”

There was also a benefit for the hospital administration—a decrease in charges per admission and per day. “A lot of these charges fell because by not changing the providers, they were making [fewer] medication charges [and] lab charges,” said Dr. Chandra.

Challenges

The CICLE study did have one result that would not be so pleasing to administrators, if it is confirmed to be an effect of the new schedule. The change was not statistically significant, but 30-day readmission rates went up from 15% to 17.3%. “One of the unintended consequences of this might be that you have higher readmission rates,” said Dr. Howell.

Next steps

To combat this possibility, the Johns Hopkins hospitalists' next project is an improvement effort targeting readmissions.

The CICLE model is also currently being expanded to affiliated hospitalist programs in community hospitals. The model won't necessarily be appropriate for every hospital, Dr. Chandra noted. “It is an FTE-intensive model. It's probably not going to work in a small group of 10 providers,” she said.

Words of wisdom

Whether or not CICLE works for one's hospital, its convenience and popularity may be an indication that seven on/seven off is not the only solution to hospitalist scheduling.

“I hear a lot of people saying they're stuck in this [seven on/seven off] schedule because it's easy and it's a good recruiting tool,” said Dr. Howell.

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Another new way to schedule

The Johns Hopkins doctors weren't the only hospitalists proposing scheduling innovations at Hospital Medicine 2012. During a session on surge capacity, hospitalist and consultant John R. Nelson, MD, FACP, described the benefits of working many days of varying length instead of traditional blocks of 12-hour shifts.

“Our field tends to value so much the days off, we try to cram our years of work into the fewest number of shifts,” said Dr. Nelson, who is medical director of the hospitalist service at Overlake Hospital in Bellevue, Wash. “The problem is the lower you go in the number of shifts, the busier you're going to be on each shift, and the less capacity you have when it's really busy.”

One solution to this problem, he said, is to have shifts of variable, somewhat unspecified length. “You just say you have to work however long is required for that day,” said Dr. Nelson.

The system is not quite the free-for-all that it might at first sound. All of the hospitalists on a given day shift would have their pagers on for a full 12 hours. At least one of them would be assigned in advance to stay in the hospital for at least 12 hours; this hospitalist works from 7 a.m. until 7 p.m. or whenever the night doctor is no longer overwhelmed by evening admissions (even if that's after 7).

The other hospitalists on during that day would each take an equal share of new admissions and treat their existing patients. When they have completed the admissions and their patients are stable, they can leave the hospital. “On the busiest day of the year, all of these hospitalists are working 12 hours or more. On the slowest day of the year, some of them are leaving around lunchtime,” said Dr. Nelson.

“It's a method to more closely match daily manpower to unpredictable workload,” he explained. Hospitalists would take turns being the one who has to stay late, and the frequent opportunities to leave early could make busy shifts that run extra long more tolerable.

Also, hospitalists on this schedule might be more able and willing to take work more than seven days at a stretch, he added, because they're not burned out from seven long days. It's also possible to do something other than work and sleep during one's week in the hospital. “I was able to mesh my personal life and my work life. I did personal and work stuff nearly every day,” said Dr. Nelson.

Because the shifts are volume-based, it's not necessarily possible to plan this personal time in advance, however, which is one of the limitations of this schedule. It demands an acceptance of unpredictability and makes it more difficult to draw up a calendar. It also requires accurately judging the stability of patients. Otherwise, a hospitalist who has left for the day will have to run back in response to a page or ask a colleague to deal with the problem.

Despite these disadvantages, Dr. Nelson is convinced of the overall value of this alternative schedule. “I'm suggesting that we take the same annual volume of work and titrate it out over more shifts for each of us,” he said, noting that this concept is not currently popular with hospitalists, both in his audience and the field as a whole. “I'm going to come ask you again in 20 years if you really believe in working the fewest days possible,” he said.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated