Attending Playbook

You are the coach or conductor and you are ultimately responsible.

• Performance Measures – The coach cares for the patients through the members of the team, and his or her performance is assessed using 6 scoring elements (score 1 lowest 5 highest). The top score is 30. Attendings who fail to achieve a score above 15 are not following the Gatorounds system. We have found that those who score below 15 have longer patient lengths of stay and higher percentages of patients readmitted within 30 days.  Ideally residents and case managers should evaluate these 6 categories of attending performance with the goal of providing you with objective feedback that will allow you to continually improve your performance:
  1. Horizontal communication (acts as a discussion leader,
     encourages everyone to participate).
  2. Trouble shoots (when the team encounters a
     a problem the attending tries to solve by contacting
     the appropriate person or people)
  3. Involves nurses and case manager in the care of
     each patient. (Asks their opinions and listens
     to their suggestions.)
  4. Follows a rounding schedule (with the help of
     the resident sets up a daily schedule that
     predicts when the team will be at each room.)
  5. Encourages work sharing (when one intern has
     excessive work the attending redistributes the work to
     other members of the team to assure efficiency)
  6. Knows the patients prior to rounds (has read the
     electronic records of all patients prior to rounds,
     allowing the residents and students to discuss
     management issues rather than spend the majority
     of the time updating the attending)(Scores will be 5 best to 1 worst for each category, best total score = 30)

Other Suggestions:

Remember you are the coach, and your initial job is to teach the team the fundamentals. Just as the football coach teaches the passing motion, blocking technique, and the proper way to recover a fumble, or the basketball coach teaches the proper shooting and passing techniques, you must teach your team the fundamentals.

• Succinct and efficient presentations: Expect and encourage the interns and students to speak confidently and efficiently. No mumbling! Make sure they are following the communication protocols exactly. Remember efficient communication is a key fundamental (See Communication protocols)
• Active involvement of the nurses. Nurses are accustomed to being ignored during work rounds, and are often hesitant to participate. They need encouragement and should be verbally rewarded for their comments and suggestions. If they contribute to and understand the management plans care will be more efficient and less error prone. Also the number of pages to the house staff will decrease.
• Horizontal communication: Emphasize that this is not a top-down structure. Each person has unique roles and makes unique contributions. It is important that everyone feel empowered to contribute during rounds. The attending encourages horizontal communication by asking questions of every member of the team. The attending is the discussion facilitator. After the intern or student presents the progress report on each case, the attending should ask for the team resident’s input and then other members of the team before providing his or her ideas. This will encourage active participation by the residents and students. The Attending should speak last and summarize the conclusions of the group.
• Teamwork: Emphasize that all patients belong to the team not just a single intern. Everyone should know the basic history and active problems of all patients. Every member of the team should understand and contribute to the management strategies of the team’s patients. To emphasize this principle, at the end of rounds the attending and team resident should review the To Do lists of the interns and divide up the work equitably. In some cases the attending may agree to call a consult or perform one or more tasks. The team resident and any intern with a light load should also pitch in. The team should huddle with the case manager each day between 3-4 PM to review patient progress, potential AM discharges, and any issues that have arisen during the day. This allows the team to have a shared mental model.

Other important tasks:

• Sees all admissions in ER as soon as possible (usually within 1 hour): Determine the severity of illness and if the triage to general medicine is appropriate. See all other admissions within 6 hours.
• Focus on disposition: The day of admission, the attending should discuss with the team and specifically with the PCRM and team resident the plans for discharge.
• Contact the primary physician: As part of disposition the attending should contact the primary care attending to notify him/her of the patients condition, and inquire about potential medication changes, as well as disposition. This behavior should be modeled to the house staff.
• Serve as the second order problem solver: You need to run interference for the team. If a consultation is delayed you should call the attending or training director to encourage prompt service.
• Spend time at the bedside: Too often rounds are carried out in the hallway which is extremely noisy. Most patients enjoy hearing the team discuss their case. This creates increased trust between the team and the patient and emphasizes transparency. Furthermore, patients often asked questions or provide additional helpful details that can improve their care. This also allows you to quickly examine your patients.

Follows the Rounding Schedule
Census for Care Prov: (12 patients). See Game Plan
8:45-9:00 AM Attending sees patients to be discharged before 10AM
9:00-11:00 AM Bedside Rounds (average 5-10 minutes per patient) Schedule is created by the Team resident the afternoon before rounds. The case manager relays the schedule to the nurses.
11:00-11:30 Teaching session in the room. Students presents a case in detail. Emphasis on pathogenesis, clinical manifestations, diagnosis (differential diagnosis whenever possible), and treatment. Alternatively start bedside rounds at 9AM and devote 10-15 minutes to teaching at the bedside of 2-3 selected patients.

On completion of rounds interns provide copies of their “To Do” list to the team resident who with your help distributes the work evenly among the team members. The attending assists with any administrative impediments including resistant or delayed consultations. Interns makes calls for consultations, completes orders for diagnostic tests, and with the exception of early admission days when the team sees the new patients immediately following work rounds, completes all electronic progress notes adding changes in management decided on rounds by 12 noon, allowing the attending to complete his/her addendum notes and signatures by 1 PM.

Progress notes
Computerized templates are preferred. Once these templates are created the intern can update progress prior to rounds. Expect the interns to write new impressions and plans each day (they should not just copy and paste the same note day after day) and these should reflect the discussion on work rounds.  With the exception of the early admission days (should see new admissions immediately following work rounds) the Interns should try to complete progress notes before noon conference and route them to the attending. From 12-1PM the attending can review all progress notes, write their electronic notes. On return from conference the attending can communicate with the team any new ideas or suggested changes in management.

Expectations for Subspecialty Consultations
High quality systems of care dictate that communication be respectful and that members of the healthcare team trust each other. Without trust and respect there can be no teamwork and the care of our patients will suffer. Disagreements among physicians are quickly detected by patients and can lead to distrust of the healthcare system and of the physicians.

Obligations of the Consultant

• Act as a supplier of a service and make every effort to please the customer (consulting team).
• Respond within 24 hours of a request, and in a true emergency within one hour (example: ER consults).
• Communicate with the attending directly, in addition to the house staff responsible for the patient’s care. Provide contact information that will enhance attending-to-attending communication
• Recommendations need to be logical, practical, and based on an accurate assessment of the data.
• Respond quickly to any concerns or questions by the team
• Follow-up visits on all cases in which problems remain active and are evolving

Obligations of the Consulting Physician

• Clearly define the question you are asking of the consultant and/or clearly define the specific service you are requesting.
• Consult early in the day and early in the hospitalization. Whenever possible make the request before 12 noon to allow the consultation team to efficiently manage their consultations. Consultations early in the hospitalization lead to more efficient and higher quality care.
• Follow the recommendations of the expert consultant. Failure to do so conveys a lack of trust and disrespect for the consultant.
• If the team does not agree with the consultant’s recommendations, the attending is obligated to immediately contact the consultant and discuss the reasons for this disagreement.
• Respectful behavior and constructive communication are vital. When a disagreement persists, a compromise should be established. There should never be a “chart war”.
• Constructive feedback is vital in order to improve our systems of care. If after discussing the case with the consultant, the attending is unhappy with a specific consultation because of delay, inappropriate recommendation, or disrespectful communication, he or she should immediately contact the Chief of the Division or Department responsible for providing this service.