Team Resident Playbook
- Team Resident is the Quarterback
You are the football quarterback, basketball point guard, or volleyball setter. You are primarily responsible for running the team and making sure that the workload among the interns and subintern is properly distributed.
- Responsible for informing the attending of all new admissions, all management issues. Works very closely with the attending. On day off, hands off all duties including scheduling to the attending.
- Runs work rounds and creates the daily rounding schedule each afternoon and provides this schedule to the Case Manager who notifies the nurses. Decides on teaching cases for each days rounds and assigns students to provide an instructive paper using Pubmed.
- Assigns cases to interns, and 4th year students
- Supervises the teaching of the 3rd year students, picks instructive cases for them to workup and follow
- Emphasizes constant horizontal communication and encourage collaborative management
- Plays a major role in teaching the students and interns
- Encourages consultations and orchestrates the information from consultations
- Supervises discharge planning and ordering of diagnostic tests
- Closely monitors the interns’ and 4th year subintern’s performance. Early in the year second checks and constant discussion are paramount.
- On the interns clinic day performs the admission work ups for the interns including dictations.
- On early admission days takes the team including the attending to the ER after work rounds. This assures that the team quickly fulfills the management needs of their new patients.
- Reviews the “To do” lists of each intern and redistributes the workload among the team members when one intern has a disproportionate amount of work.
- Informs the attending about consultants who mistreat the team members and do not demonstrate a positive customer supplier relationship.
- Monitors work hours and arranges days off. In general to assure continuity and proper management of the patients, no more than one team member at a time should be scheduled for a day off
- Orchestrates discharges and completes discharge dictations within 48 hours of discharge (vital for seamless handoffs, as well as accurate billing)
- Monitors patient concerns and satisfaction. Helps assure seamless communication between the team and the patients.
- Expects and provides the highest possible care for his/her patients
Suggestions: Your initial job is to reinforce the Attending’s emphasis on the fundamentals. Just as each football player needs to learn the basic passing motion, blocking technique, and the proper way to recover a fumble, or the basketball player needs to learn the proper shooting and passing techniques, you must learn and reinforce 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. Review what needs to be done for each patient after the progress summary is complete. Have each intern keep a running To Do list that they provide you and the attending at the end of rounds.
- Active involvement of the nurses. Nurses are accustomed to being ignored during work rounds, and are often hesitant to participate. You need to encourage their participation and should verbally reward them for their comments and suggestions. If the nurses 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: Unlike traditional residency models, 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. You, in collaboration with the attending, should encourage horizontal communication by asking questions of the interns, students and nurses. When possible defer to them, but after everyone has had their say, it is important for you to contribute your ideas.
- Teamwork: Emphasize that all patients belong to the team, not just a single intern. Everyone, that means both interns, is expected to know the basic history and active problems of all patients. You should help every member of the team to understand and contribute to the management strategies of the team’s patients. Make sure the interns pay attention on rounds and contribute to the management of all the patients (no wandering off). To emphasize teamwork, at the end of rounds you and the attending should review the To Do lists of the interns and divide up the work equitably. You and any intern with a light load should take over some of the tasks of the intern who has excessive work. In some cases the attending may agree to help. Emphasize we all sink or swim as a team.
Other important tasks:
- Focus on disposition: The day of admission, you and the attending should discuss with the team and specifically the PCRM the plans for discharge. Each afternoon prepare the discharges for the next morning. Dictate all discharges within 24-48 hrs.
- Set up the rounding schedule: At the same time as discharges are being planned, organize the next days rounding schedule, starting with the IMC patients on the 11th floor. Allot 5 minute blocks to each patient. Very complicated patients could take up to 15 min, but usually require 10 min. Simple or non-communicative patients may only take 5 minutes. On your day off make sure the attending takes over this task.
- Spend time at the bedside: Too often rounds are carried out in the hallway where it 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 ask questions or provide additional helpful details that can improve their care.
- Encourage completion of progress notes by 12 noon except on early admission days: Have the interns complete their notes before noon conference when possible and route them to the attending’s in basket.. This will allow the attending to review the notes and place them in the chart while you are at noon conference. On the early admission day the team should see the patients in the ER immediately following work rounds. This will assure that the team’s new patients receive timely management.
- Encourage frequent huddles to review patient progress and organize an afternoon huddle with the Case Manager. The attending should be present or use speakerphone to review potential discharges for the next morning and to also to appraise the attending of any significant changes in the condition and management of the team’s patients.
Utilize the Team Rounding Schedule and Utilize the Team Spread Sheet
Census for Care Prov: (12 patients)
8:45-9:00 AM Attending sees patients to be discharged before 10AM
9:00-11:00 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.
Example of a floor and hallway-based system
1. 9:00-9:20 IMC case
2. 9:20-9:30 Bed on 75
3. 9:30-10:10 Bed 6401-6426 (left hallway)
4. 10:10-10:50 Bed 6460-6436 (right hallway)
Example of a room-based schedule
1. 9:00-9:10 Bed 9410 IMC case 7. 10:00-10:10 Bed 6458
2. 9:10-9:20 Bed 9430 IMC case 8. 10:10-10:20 Bed 6454
3. 9:20-9:30 Bed 7501 9. 10:20-10:30 Bed 6450
4. 9:30-9:40 Bed 7505 10. 10:30-10:40 Bed 6448
5. 9:40-9:50 Bed 6515 11. 10:40-10:50 Bed 5510
6. 9:50-10:00 Bed 6423 (left hallway of 64) 12. 10:50-11:00 Bed 5540
On completion of rounds interns provide copies of their “To Do” list to you and you distribute the work evenly among the team members. The attending assists with any administrative impediments including resistant or delayed consultations. Intern makes calls for consultations, completes orders for diagnostic tests, and completes all progress notes adding changes in management decided on rounds and delivers them to the attending by 12 noon. The attending then writes his/her note and places the progress notes in the charts by 1PM.
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.