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.
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.
“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.
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.
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.
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.