The COVID-19 pandemic placed incredible stress on the entire U.S. healthcare system—the need to care for patients hospitalized with a novel infectious disease, displacing elective surgical patients, and keeping “regular” medical patients’ home—creating workforce and capacity mismatches. Limited personal protective equipment at the outset of the pandemic also necessitated changes in how clinicians were deployed. Although hospitalists across the country have long been involved in addressing healthcare systems challenges, COVID-19 suddenly placed them at the fore of a rapidly evolving pandemic response, including being tasked with developing workforce plans involving clinicians both within and outside of hospital medicine. We aim to describe what we learned from engaging with hospitalists nationwide.
Given the persistent strains on the acute care system, we believe the hospitalist operational and clinical skillset is instrumental to the agile and continuous development of hospital workforce plans. We propose a conceptual framework illustrating the relationships among skillset, innovation, and system constraints that should be considered when anticipating needs for workforce planning, deployment, and adaptation.
The Hospital Medicine Reengineering Network (HOMERuN), a collaborative research network of academic hospitalists, quickly mobilized at the outset of the pandemic to focus on dissemination of knowledge and learnings regarding effective pandemic responses. Several workgroups were formed, including groups focused on discharge criteria, physician and advanced practice provider wellness and support, medical education, clinical pathways, and workforce adaptations among others. Our workgroup, composed of 11 hospitalists from eight U.S. academic medical centers, surveyed colleagues nationwide to learn what inpatient workforce adaptations were being implemented and compiled surge plans and training manuals disseminated to non-hospitalist clinicians newly working in the inpatient setting. Follow-up focus groups and surveys also permitted tracking of staffing changes and operational practices as cases surged and receded. Virtual meetings, newsletters, and publications were used to share findings with hospitalists registered with HOMERuN.1
Through this work, we saw some commonalities in responses to the first wave of patients, such as patient cohorting and hospitalist supervision of specialists and advanced care providers who were newly working in an inpatient general medicine clinical setting. Although there were similar workforce adaptations deployed by hospitals across the country, we saw however even greater evidence of the need for unique planning in each health system. Contextual differences in factors including clinical staff availability, regulations around involvement of learners in COVID-19 care, and the physical environment across hospitals limited the wholesale application of uniform effective solutions from one institution to another without significant local adaptation.
Regardless of the adaptations put in place by a given institution, we observed that hospitalists were integral to making operational decisions, serving as leaders of workgroups, and overseeing daily communication and collaboration across complex health system networks. These observations reinforced the importance of hospitalists and their skillsets, balancing dual roles as front-line clinicians and operational leaders. Systems knowledge and systems process improvement have always been central to hospitalist work.2-4 Hospitalists were uniquely positioned to lead the response to COVID-19 due to a deeply embedded understanding of the inpatient clinical context, navigating the inpatient setting to deliver care efficiently and safely to patients, accessing and utilizing system-wide resources, engaging in real-time, rapid process improvement, collaborating across clinical roles, and navigating communication channels.
The importance of well-established contextual knowledge in a time of rapid change was also apparent. Having a pre-existing, deeply rooted understanding of the system mitigated the uncertainty inherent in delivering clinical care to a surge of patients with a novel disease. In addition to process knowledge, hospitalists are among a small group of clinicians who interact frequently with almost all other inpatient services and have rich local networks. Hospitalists are often asked to create order and workflows that bridge multiple disciplines, and coordinate care in complex social and clinical situations. In rapidly evolving, high uncertainty situations, relationships provide the basis for effective communication, sense-making, and learning.5 Hospitalists uniquely possess the relational networks and operational knowledge in the inpatient setting to be most effective under the conditions of unprecedented hospital capacity strain.
The rapidity of dynamic change tested hospitalist ability to effectively navigate systems change. Participants discussed the challenge of continued changes on a workforce experiencing burnout. With the first surges, workforce planning relied on goodwill that was hard to maintain over time. Hospitalists’ abilities to navigate complex systems and their skill in utilizing networks again enabled them to mitigate and overcome barriers. Hospitalists leveraged local, regional, and national networks to share information and solve local problems, with HOMERuN was an example.
With both the unique skillset of the hospitalist and the system in which hospitalists work in mind, we propose a conceptual framework for hospital medicine workforce planning, deployment, and adaptation that elucidates the iterative relationship between adaptation and context in the setting of system constraints (see figure). This framework illustrates that the hospitalists’ expertise lies in the overlap of skills in both the clinical and operational domains, including patient safety, quality improvement, multidisciplinary communication and collaboration, and systems navigation. This dynamic interplay between clinical and operational expertise is the basis for the innovations necessary for meeting the demands of high-capacity scenarios. Communication and collaboration within clinical and operational domains, which are inherent in the hospitalist skill set, enables innovations to be attempted. These responses are shaped by local systems constraints, such as number of available hospital beds and ratios of other clinical staff. The outcomes that emerge from these new ways of organizing our clinical work, at both the patient and workforce levels, in turn shape future innovations.
Additionally, this framework provides examples of innovations, including the adaptations made in response to surges of patients, both COVID-19 patients and non-COVID-19 surgical, procedural, and medical patients. Our colleagues nationwide have described system/resource constraints including insufficient beds or ICU capacity, shortages in nursing and other ancillary staff like respiratory therapists, and a lack of redundancy in provider staffing. Navigating these system constraints to deploy adaptations that maximize patient outcomes (e.g., being discharged from the acute care setting as early as safely possible and reducing return to the hospital) and minimize workforce burnout was a challenge common across hospitals. Adaptations continue to be necessary as hospitals contend with both the evolving nature of the COVID-19 pandemic and pre-existing hospital capacity strain, particularly at academic medical centers.
Learning to adapt in dynamic environments is applicable beyond the COVID-19 pandemic. Hospitalists have an indispensable generalist clinical and operational expertise and skillset that enhances communication and collaboration and provides the necessary foundation for innovation across healthcare settings and situations. Our framework explicitly illustrates hospitalists’ skillsets, showing how hospitalists can effectively lead and navigate rapid systems change.
Authors’ Note and Acknowledgement: The authors are members of the Workforce Planning workgroup of the Hospital Medicine Reengineering Network (HOMERuN) COVID-19 Collaborative. Support for the COVID-19 Collaborative was provided by the Gordon and Betty Moore Foundation. We thank contributor Tiffany Lee, MA, with HOMERuN of the University of California, San Francisco School of Medicine.
Disclaimer: The views expressed do not represent the position of the Department of Veterans Affairs or other organizations affiliated with the authors.