THE HOSPITALISTS WITH Virginia Mason Franciscan Health (VMFH) in Tacoma, Wash., have been working to understand their workflow. That’s the only way, they find, to maintain adequate staffing and sustainable workloads.
With 160 hospitalists, the group staffs six separate hospitals in the same system. Day providers used to work a combination of shorter dedicated rounding days and longer ones (12 or 13 hours) to cover late afternoon admissions. But now, group members are transitioning to consistent 12-hour shifts instead.
Why? As Ishmael Ching, MD, one of the system’s associate medical directors of hospital medicine, explains, “we wanted some equivalence across shifts and the ability to track our work more easily.”
Instead of variable shifts, the flexibility that group members have worked to achieve is to ensure—at short notice—enough staffing across their six hospitals to maintain sustainable workloads. As Dr. Ching notes, that entails “really understanding our workflow. A lot of what we’ve done over the past few months is trying to understand when new patients come in and adjust the time for when physicians are available to provide timely care.”
“It’s demoralizing to have work that you’ve identified as insurmountable.”
Ishmael Ching, MD
Virginia Mason Franciscan Health
To do so, the group monitored its number of admissions, based on admit orders, as well as how many consults they have and how many patients are admitted to their service from critical care. While the group used to track those encounters manually, “we’ve now moved to an electronic process so everyone can see when patients are coming in.”
What they’ve found, says Dr. Ching, is that admissions peak between 3 p.m. and 5 p.m., lasting until 10 p.m. or even midnight. To accommodate that predictable surge, one swing shift admitter—who used to come in at noon or at 2 p.m.—now starts at 11 a.m. And one of the nocturnists who used to start at 8 or even 8:30 p.m. now starts at 6 p.m.
Adjusting shift start times has significantly improved workflow. “Patients are not being held as long, waiting to be seen,” Dr. Ching says. “Instead of overwhelmed providers having to hand off patients, there’s now less pent-up work.”
Level-loading across sites
As Thérèse Franco, MD, the group’s other associate medical director, explains, rightsizing staffing to demand to ensure consistent workloads also entails “understanding the best use case for per diems and locums.” Right now, locums cover shifts until the growing group can hire new full-time physicians. Per diems fill in scheduled absences such as vacations and family and parental leave.
“We have taken an interest in the relationship between staffing and wellbeing.”
Thérèse Franco, MD
Virginia Mason Franciscan Health
Float physicians are another key set of providers. “Several sites end up needing a fraction of an FTE, too small to justify hiring a new hospitalist,” Dr. Franco points out. “Instead, we have a float role, with hospitalists floating between sites to round out these small but significant staffing needs.”
Float physicians are full-time employed hospitalists, dedicated to a standard clinical role with variable locations.
“They tend to stick to two or three of our hospitals, almost as if they’re loosely regionalized,” Dr. Franco adds, “working a 0.1FTE to 0.5 FTE at any given site, depending on our needs.” The combination of locums and float and per diem providers “have proven to be an invaluable resource in flexing our staff to meet predictable volume fluctuations and staff availability.”
At the same time, “all of Washington state is really in crisis mode” in terms of hospital volumes, she says, particularly in EDs where patients are waiting hours to be seen and admitted.
To accommodate such situations, which are not as reliably predictable, “we may relocate regularly scheduled providers between sites to level load,” says Dr. Franco. Early each morning, when patient lists across all six hospitals are finalized, the team uses a structured decision-making tool and process (other recent innovations) to decide if it needs to relocate any providers. If such a move can decompress a team, then a site-based hospitalist may be assigned to another facility for the day.
Such strategic assignments have, Dr. Franco adds, “reduced the number of ‘panic mode’ times when we had to rely on a lot of high-touch, manual processes and favors to find coverage.” It has also, says Dr. Ching, ended what was often “a contentious process, trying to figure out who needs backup. That used to become a very emotional and personal decision rather than just looking at objective numbers.”
Making the best use of flexible staffing has definitely reduced burnout. “It’s demoralizing to have work that you’ve identified as insurmountable,” Dr. Ching says. “Now, we’ve identified objective markers of where we need to staff up, and we’ve made that process visible.”
Dr. Franco agrees. “We have taken an interest in the relationship between staffing and wellbeing,” she says. “We’re trying to identify how those relate and what are best staffing practices.”
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Phyllis Maguire is Executive Editor of Today’s Hospitalist.
