Creative Ancillary Staffing at DC Children’s Hospital
Dr. Arun Chopra trained at DC Children’s
Hospital from 2000-2003.
As ACGME work hours have become a reality, many programs have attempted to come into compliance by resorting to “creative scheduling” and having fewer residents cover the same work load. For many housestaff, this has unfortunately squeezed the educational and patient care activities we value the most. At DC Children’s hospital we found an effective, relatively low-cost solution to this problem by convincing the administration to hire new staff called “Patient Care Coordinators” to eliminate much of the time-consuming “scut” work contributing to excessive work hours.
Residents Evaluate Hours, Propose Solutions
As a CIR hospital, DC Children’s residents are able to re-negotiate a housestaff contract with the administration every three years. During the 2001 negotiation cycle, we decided to make work hours and quality of life issues our top priorities, rather than salary increases and economic benefits. We began by identifying what tasks kept us “trapped” in the hospital so long, and which tasks could be performed by non-physician staff without detracting from medical education or patient care.
For example, we found that repetitive IV placement and drawing labs and blood cultures kept most residents awake on overnight call duty, so we convinced the administration to hire an overnight phlebotomist. But we also looked at the inefficiencies that were built into the traditional housestaff work day. For example, after rounds, all the housestaff used to dive for the phones to call radiology and order the necessary tests. All of us would be put on hold, waiting in line for the radiology tech to answer our call and take our orders.
We heard about an innovative solution pioneered at John’s Hopkins Medical Center, where the hospital hired “patient care coordinators” to help the residents with these tasks. We realized that for coordinating radiologic studies, contacting primary care doctors, and scheduling outpatient follow-ups, one person could do the job of 12 residents better than 12 residents could do this one job.
During negotiations in 2001, we stressed to the administration that hiring PCCs would not only boost resident morale, but could also improve the hospital’s efficiency and possibly reduce the average length of stay. The hospital agreed with our arguments, and hired 2 PCCs during 2002.
Improvements in Efficiency
Current housestaff at Children’s say that the experience of working with PCCs has been overwhelmingly positive. Dr. Jamie Decker, a current PGY 3 says that the PCCs work closely with the housestaff on the floors:
“There are 2 Resident coordinators, 1 for each of the ward floors. The various teams will do work rounds, and afterwards the PCC will contact the interns, and interns will provide a list of things to be done … for example, this pt. Needs an ultrasound, can you schedule it and let me know what time it will be done. They can also coordinate studies for patients needing multiple studies, which is enormously helpful.”
Dr. Lewis Fermaglich, a PGY 2 resident, notes that PCCs are much more efficient at coordinating various hospital services than the residents ever could have been:
“The PCCs know the system and the people on the other end of the phone for each service, because they call radiology and MRI with scheduling requests every day,” says Lewis Fermaglich, a PGY 2 resident. “Before, I used to waste hours trying to coordinate outpatient radiologic studies, and being put on hold forever.”
Improvements in Patient Care
Housestaff say that more effective coordination also translates into more thorough follow-up care for patients. “At discharge, the PCC will contact the patient’s primary care physician about everything that needs to be done following the discharge. This has really improved patient care beyond what it was when I was an intern,” says Dr. Decker. “If I had six patients to discharge in a day, we’d end up just saying ‘follow up with your doctor.’ Now the PCC has the time to call the primary physician’s office, let them know the patient’s history, and give the patient’s family a specific appointment with their doctor.” Improved efficiency also means that residents can spend more time engaged in direct patient care, says Dr. Fermaglitch: “Instead of waiting on hold we can be in the room with patients or writing prescriptions and discharges, or seeing an ER patient instead of arguing with radiology about what time my patient can get a study.”
Easing the Way to ACGME Compliance
Because we started this initiative to reduce scut work and work hours in 2001, the new hours regulations were not as much of a shock for the DC Children’s program. When I cross-covered floors as a senior resident, I found that the PCCs eliminated a lot of the time-consuming tasks that made floors difficult during my internship. The lighter work load allows fewer residents to comfortably get the same job done, and eased many of our concerns about the decreased staffing necessary to comply with the ACGME guidelines.
And finally, Children’s residents are finding that the reduction in hours isn’t squeezing our educational time. Dr. Fermaglich reports that with the PCCs, “We absolutely are able to get to conferences and lectures more on time. I feel like we have more time to learn in general now that we’re not always doing secretarial work.”