Operations

Why 7 On/7 Off Doesn’t Meet the Needs of Long-Stay Hospital Patients

by Lauren Doctoroff, MD
By: Lauren Doctoroff, MD Much has been written about the loss of the perspective of the primary care doctor for hospitalized patients and the impact on their hospitalization. However, few have reflected on the challenges posed by the 7 on/7 off hospitalist schedule for complicated long-stay patients. I have been a hospitalist for more than 10 years, and, for the past 3, I have been responsible for a complex patient strategy for my hospital. Having looked at the charts of hundreds of patients with long and complicated hospital stays, it is clear that there is an incompatibility between the on again/off again hospitalist schedule and the needs of these patients. With frequently changing providers, patients suffer not only from their own medical fluctuations, but also the changing plans of their providers. These are not the patients awaiting guardianship or insurance to allow for an adequate discharge plan. These are the…
Dr. Lauren Doctoroff is a hospitalist at the Beth Israel Deaconess Medical Center in Boston, Massachusetts. She completed medical school at the University of California at San Francisco in 2003, and a primary care internal medicine internship and residency at Massachusetts General Hospital in 2006. Her clinical responsibilities include hospitalist work on a teaching and a non-teaching service at the BIDMC. In addition, she was the founding medical director of the Healthcare Associates Post Discharge Clinic, a hospitalist-staffed, primary care-based post hospitalization clinic from 2009-2015. She also serves as the medical director of the PACT Transitional Care Program. As of 2015, she serves as the Medical Director for Utilization Management for the BIDMC, and chairs the Utilization Review Committee, and leads multiple initiatives on hospital utilization. She is a fellow of the Society of Hospital Medicine and serves on the SHM Public Policy Committee. She is an Assistant Professor at Harvard Medical School. Her academic interests include transitions in care and post discharge care, as well as hospital utilization particularly among patients with prolonged stays. She has published on post discharge care and outlier patients and has spoken locally and nationally on topics of transitions of care and post discharge care.

You Have Lowered Length of Stay. Congratulations. You’re Fired.

For several decades, providers working within hospitals have had incentives to reduce stay durations and keep patient flow tip-top. DRG-based and capitated payments expedited that shift. Accompanying the change, physicians became more aware of the potential repercussions of sicker and quicker discharges. They began to monitor their care and as best as possible, use what measures they could ascertain as a proxy for quality (readmissions and hospital acquired conditions). Providers balanced the harms of a continued stay over the benefits of added days, not to mention the need for cost savings. However, the narrow focus on the hospital stay, the first three to seven days of illness, distracted us from the out weeks after discharge. With the acceleration of inpatient episodes, we cast patients to post-acute settings unprepared for the hardship they would face. By the latter, I mean, frailty risk, more reliance on others for help, and a greater need…

George Carlin Predicts Hospital Planning Strategy

My wife and I are planning to add square footage to our house. We want more space. We are considering an office expansion, a guest room, and making the master bedroom more master and less bedroom. The kids are growing, the family is always visiting, and we have no plans to relocate. We also need more space for our stuff. "Everybody's gotta have a little place for their stuff. That's all life is about.  Trying to find a place for your stuff." — George Carlin We added a shed, stuffed the closets, and overloaded the garage. How did we get so much stuff? The average US household has 300,000 things in it. In addition, houses in the US have tripled in size since the 1950s, yet fewer people live inside these homes. We're one of the 25% of American households that have a two-car garage but don't put both cars in there.…

The Essentials of QI Leadership: A Conversation with Dr. Eric Howell, Part 2

My last blog post, featuring my Q and A with Dr. Eric Howell, Division Director, Collaborative Inpatient Medicine Service (CIMS) at Johns Hopkins Bayview Medical Center in Baltimore, MD, and SHM's Senior Physician Advisor, focused on his early days in Quality Improvement (QI) and advice for training in QI. This next post discusses the Center’s role within SHM and how hospitalists can become involved in quality improvement. How did you get involved in The Center, and can you explain your role in The Center today? It was a lot of luck, good timing and being prepared. I’ve been in The Center for two years. Before that, I was involved with a number of The Center’s successful QI projects. I was reasonably well known in the Project BOOST (SHM's program for improving care transitions) community. Along with Mark Williams and Jeff Greenwald, I was one of the original three who pitched Project…

From SXSW to SHM: Our Tour to Promote Value Conversations Between Doctors & Patients

By Chris Moriates, MD, SFHM and Vineet Arora, MD, MAPP, SFHM At a movie premiere for the new Terrence Malick flick, “Song to Song”, Ryan Gosling, Michael Fassbender, and Rooney Mara walked the red carpet to flashing cameras and screaming fans in front of the famous Paramount Theatre in Austin. The next day, down the street, to a lot less fanfare, our Costs of Care team – Neel Shah and both of us – took the stage at the annual SXSW festival for own version of a premiere. We were about to step out of the normal medical conference crowd (i.e. no screaming fans but some with #pinksocks on) and see for the first time if videos we made depicting scenarios of doctors and patients confronting healthcare costs would translate to the real world. Would it work, or would the critics, like with the “Song to Song” premier, give us…
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