A few years ago, Virginia Mason patients who were admitted from the ED would face long wait times for admission, especially if they arrived as hospitalist day shifts were ending. In addition to affecting patients, the delays contributed to burnout among the night staff, according to Evan Coates, MD, section head of the hospital medicine and neurohospitalist teams.
In response, hospital leaders decided to redesign hospitalists' schedules and admitting duties. They began by mapping out the average timing of admissions, and the graphs showed that patients came in faster in the late afternoons and early evenings, when fewer physicians were available to admit them. “Our plan to accept admissions did not fit well with our demand for admissions,” Dr. Coates said.
They also found that the service needed to accommodate 29 admissions per day at peak volume, but the existing hospitalist staffing model had an admitting capacity of only 22 patients. So Dr. Coates put forward a challenge to his physicians: “We'll consider running our service [on] any schedule model you want, but we have to cover this demand.”
How it works
The doctors presented ideas for a few different staffing models, and then the team used historical data points, Legos, and video to simulate the models, said Dr. Coates. “You could see over about 12 minutes: Did your system work, or did delays happen?” he said. Once a system worked most of the time in simulation, the team made real changes to the doctors' shifts, which were tweaked over time in a series of reassessments.
Ultimately, the most successful strategies were spreading out admissions over the whole team (rather than having half the physicians round while the other half admitted) and staggering shift start times, Dr. Coates said. “Having everybody start at 7 a.m. didn't work as well as having some people start at 7 and some people start at 9,” he said.
From baseline to implementation of the final staffing system in 2015, mean ED patient wait times for admission decreased by 35%, from 66 minutes to 43 minutes, according to results published online in August 2017 by BMJ Open Quality. In addition, daily admitting capacity increased to 30 patients. “As we found these solutions, we had more capacity to see patients than we did prior to doing this work,” said Dr. Coates. “And with that additional capacity, more patients just kept coming.”
Fixing the capacity problem created a growth opportunity. The group now discharges 700 patients a month, compared to 350 per month in 2013, Dr. Coates said. “We've just grown really rapidly, and hiring and adding services has become a bigger part of the solution recently,” he said. Another surprising effect was decreased costs, he said, as cost per discharge decreased from $367 to $187 during the study period, even after accounting for hiring costs.
Changing the work schedules proved to be a “huge challenge” because doctors had to adjust to new shift start times, commuting times, and, in some cases, admitting duties they didn't have before, said Dr. Coates. But the hospital's culture encourages clinicians to embrace change, he said. “What's normal is thinking ahead, group conversation, trying new things,” Dr. Coates said. “That expectation is, I think, what made it easier to take on bigger work.”
Other challenges went beyond the hospitalists themselves. Because half of the teams are teaching teams, Dr. Coates said he also had to make sure residents were engaged and involved in the solution. Plus, getting the necessary data to map the admissions required new partnerships with analytics and other hospital departments.
With operations now running smoothly, Dr. Coates is more focused on “the stuff that is really more why you might become a hospitalist,” such as improving education and quality of care. The hospital service's current initiatives include improving consultations with other hospital groups and training advanced practice providers to be hospitalists through a new fellowship program.
Words of wisdom
“The specific solutions that we found here may or may not apply in other groups, but what is really important is a culture of . . . being comfortable trying stuff,” said Dr. Coates.