Organizers and Facilitators: Sara Westergaard, Gopi Astik, Khoosh Dayton, Angela Keniston, Anne Linker, Anna Maw, Kendall Rogers, Marisha Burden

Background: Hospital medicine staffing models are increasingly complex with various roles and responsibilities in the hospital. This is due in part to overall growth of the field as well as growth in utilization of hospital medicine services by other specialty services.

On our 6/14 call, we discussed hospitalist clinician perceptions around these care delivery models as it relates to cognitive workload and continuity of care to better understand how staffing decisions are made at various institutions across the HOMERuN collaborative.

Benefits to Staffing Models

• Variety in service lines: Hospitalists enjoy variety in the work they do, and many have flexibility to work between direct care, academic, specialty, and co-management services.  
• Career growth: Becoming an expert or leader of a specialty service line provides career satisfaction and opportunities for career development.
• Improved quality and safety: Hospitalists are known to improve quality of care for inpatients. If hospitalists can focus on a particular service line, they will develop a skillset for those patients and can manage them more effectively and efficiently. Patients are also likely to benefit if seen by the same set of providers.
• Outpatient specialty access: With hospitalists covering the inpatient workload for specialty services, it can improve patient access by allowing specialists to go back to clinic.

"In general, most faculty like to have some variety and it can provide a little bit of systole and diastole. If you're on direct care and then you go to like an APP service or something where you're not first call, that can help reduce burnout for folks who have high clinical responsibilities."

Challenges to Staffing Models

• Intensity/acuity of various services: Recognizing different service lines may require different workloads and figuring out how to balance.
• Staffing limitations: As hospital medicine groups cover more service lines in the hospital, it can be challenging to have adequate staffing that is dedicated to covering all service lines.
• Niche specialization: Certain service lines are more specialized and may have a specific culture and expectations that can be hard for someone who is new to the service or covering rarely. This becomes particularly challenging for clinicians with lower clinical FTE and when considering jeopardy coverage for these specialized service lines.
• Scope of practice: While hospitalists are often thought of as problem-solvers and fixers in the inpatient setting, they may not have a skillset for everything in the hospital and need to be able to recognize and voice this limitation.
• Lack of community/belonging: With a smaller number of people rotating on a particular service line, it can be difficult to grow and maintain a sense of community for those individuals in the larger group.

"When people have more than a certain amount of jobs, they feel like they are switching too often and they're not as good at any one role as they would like to be or as familiar with the sort of SOPs [scope of practice] in that role. So I think there is a fine line and that is not the same for every person."

Factors Influencing Staffing Models

• Need-based: Models have evolved out of need — from duty hour restrictions for house-staff and related to house-staff unionization to specialty providers needed in the outpatient setting to increasing medical complexity requiring internal medicine expertise.
• External factors: Requests coming from outside of the hospital medicine group and at the hospital/system level are driven largely by the need to manage medical complexity and capacity.
• COVID: Increased asks to hospital medicine groups and increased patient volumes during and following the pandemic.
• Decision making: Variability in how decisions are made within the hospital medicine groups. Some utilize a democratic approach while others have a top-down approach with decisions coming exclusively from group leadership.
• Financial priorities: Understanding who is benefiting financially from the creation of new service lines covered by hospitalists and how hospitalists can use this when negotiating.

"I think for us, in general, people are not seeking out careers as a co-management hospitalist. So the reason we launched these services, or at least justified them, is they had to generate a margin for our division through the funds flow model. We wouldn't be able to survive on RVUs and finances are tight I think everywhere."

Ideal Staffing Models

• Workloads: Staffing to a patient census that meets patient and family needs given increasing patient complexity while still remaining financially viable.
• Schedule structure and ownership: Determining the right duration on service and handoff structure that accommodates work-life balance while maintaining patient care continuity. Hospitalists also want to have some ownership over their schedule and the ability to self-select for certain service lines.
• Intentional hiring practices: Hiring specifically for certain service lines as groups become more specialized.

"The culture has always been that hospitalists do what the hospital and patients need and what the health care system needs but I think it is of huge importance to have some amount of autonomy over your work and over your schedules."

Key Takeaways

1. Hospitalists enjoy variety in their work, but also find value and satisfaction from becoming an expert of a specific service (e.g., specialty service, geographic unit cohorting).
2. As hospitalists cover more service lines, this can become increasingly difficult to staff and to maintain jeopardy or back-up coverage and may also lead to less sense of community or belonging.
3. Staffing models have largely evolved out of need and increasing medical complexity of hospitalized patients with most requests coming from outside of the hospital medicine group.
4. Hospitalists want the autonomy to make decisions around their work and schedules (e.g., number of different services covered).

Our next meeting will be on August 9, 2024.