Published in the June 2017 issue of Today’s Hospitalist
ALL TOO OFTEN, “ready, set, go!” has been the philosophy used to welcome new hospitalist hires. But faced with the high-stress, high-productivity environment that defines hospital medicine, programs are questioning whether such a grueling initiation is more likely to result in false starts, breakdowns and burnout.
An example can be found at Pacific Hospitalist Associates, a 52-person private group in Newport Beach, Calif. The group, which staffs several Hoag hospitals in Orange County, Calif., hires between three and six new hospitalists a year. All new hires go through a comprehensive month-long orientation program before working regular shifts and assuming a full patient load.
“You can’t take care of patients if you don’t know how to log onto the computer system, review medications, and be literate in the radiology platform and the e-prescribing system,” explains veteran hospitalist Wes Chandler, MD, the group’s founder and president.
“At the end of the day, it comes down to morale.”
New hires also need to know all the different call panels “so they know which consultant to call for patients in a particular health plan,” he says. “And there’s the fact that documentation and coding have to be clinically accurate so your mortality scores and your observed-over-expected readmissions rate are right.”
On top of that, hospitalists need to worry about patient satisfaction scores, learn to work with case managers and social workers, and absorb hospital-specific practice patterns.
“It’s way different than when I started 20 years ago,” Dr. Chandler says. In many ways, he adds, hospitalist practice today requires the opposite of the “trial-by-fire” approach he endured on his first job, in which he was expected to start generating as much revenue as fast as possible.
Instead, his group’s onboarding program includes shadowing, mentoring, freedom from weekend and night shifts, and reduced patient loads. The goal is to ensure “a comfortable experience” while inculcating new hires in “the group culture,” which he says celebrates a “yes, we can do it” and a “we will help one another” ethos.
Dr. Chandler’s organization is far from alone. A growing number of groups are recognizing the complexity of 21st-century hospitals and the very real financial consequences that hospitalists can have for health systems, physician groups and patients when they get things wrong.
Preventing early burnout
One thing that many onboarding programs share is the acknowledgment that new doctors often leave residency without solid training in essential skills. That can include everything from billing, coding and documentation to palliative care and the understanding that hospitalists’ jobs go far beyond admitting, rounding and discharging.
“You get one chance at a good first impression.”
There is also a very real concern about retaining hard-to-recruit hospitalists and preventing early burnout.
“Hospital medicine now has our own specialty designation, but there is no hospital medicine residency,” points out Michael Reitz, DO, vice president of medical affairs at Sentara Northern Virginia Hospital in Woodbridge, Va. While graduates come out knowing the clinical work, he says, “They don’t know the work of a hospitalist, which is not just seeing inpatients, but providing meaningful inpatient management.”
That’s a big gap, says Dr. Reitz. “We want certain performance out of our new hospitalists, and they don’t even know what the heck we are talking about. What is a DRG? What is case mix index? What is expected length of stay? Why are you consulting ID for nearly every patient with an infection?”
In his former position—at Banner Medical Group in Arizona—Dr. Reitz started an onboarding program for new hospitalists. The Banner Hospitalist Academy requires all new hires to attend four four-hour, off-site sessions (one each fiscal quarter throughout the 30 new hires’ first year). Topics covered include documentation and coding, understanding subsidies and risk, system-wide quality and safety initiatives, post-acute care, pain management, and hospice.
New hospitalists work reduced patient loads and receive shadowing, mentorship and orientation by local team leaders. The training period typically occurs at the beginning of hospitalists’ tenure, depending on their individual needs.
“The goal was to bring new graduates up to speed faster than usual,” Dr. Reitz says, “in a year, rather than three or five years.”
The most common hospitalist onboarding programs include shadowing (where a newbie follows an experienced provider, but doesn’t handle patients alone) or reduced patient panels for the first few days or weeks on the job. Some groups, like the one at Banner, add educational programs to fill in knowledge gaps.
Still others view onboarding as an opportunity to immerse hospitalists in the culture of their new group and build strong, collegial relationships so that people will not want to leave. La Quinta, Calif.-based hospital medicine consultant Leslie Flores makes the case that onboarding is most effective when it includes “acculturating newcomers and making them feel that they made a great choice to come here.”
A good onboarding program, says Ms. Flores, helps newcomers adjust to the nuts-and-bolts: When are switch days? What is the surge mechanism if you have too many patients? But it should also give new hires and those training them a chance to discuss the “why” behind those policy decisions. Good onboarding, for instance, covers questions like: Can I call my colleagues, or are they just going to tell me to suck it up? What’s my obligation to help others if I’m not busy today?
“The cultural stuff is more important and more difficult,” says Colin L. Findlay, MD, chief of hospital medicine for Sentara Medical Group. That’s especially true bringing new providers on board in a large multi-site group like his. “You have to be very intentional about that, starting with the hiring process,” Dr. Findlay says. “But then you have to solidify it during onboarding.”
Workshops and simulations
To that end, all of Sentara’s new hires now go through two programs designed to teach “providers about our highest priority—that they must be patient-centric,” Dr. Findlay says. (The project includes the entire 800-clinician medical group, not just the hospitalists.) The first program is a mandatory 90-minute workshop that focuses on patient experience and takes place during a new hire’s first two months on the job.
The second is a three-hour session in a simulation lab using standardized patients to practice communication skills, such as delivering bad news and managing handoffs from one hospitalist to another.
“It’s an expensive program,” Dr. Findlay admits. “But I like it to be part of the orientation program for new hires because it’s part of the cultural orientation to our group. It shows what the group values, and it sets the right tone from the beginning.”
Those sessions are provided in addition to local onboarding that occurs at each new hire’s hospital. Local onboarding is “specifically tailored by the site leader,” he says. Some new hires will shadow an experienced hospitalist for a few days and handle only a small patient census for the first week. Others, especially if they have worked elsewhere as a hospitalist, will be given a full patient load faster.
In Cleveland, The Martin Healthcare Group (MHG), with 110 providers, has created a structured onboarding program for new hires that includes two days away from the hospital.
Groups of between nine and 12 new hires come to the company’s headquarters to get to know one another, the company’s history, and the ins and outs of payroll, benefits and scheduling. New hires also take part in educational sessions and workshops on billing and coding, patient experience and palliative care, explains Ryan Carletti, MHG’s director of operations.
Their last afternoon is spent in the group’s simulation lab, where new hires practice procedures “that our hospitals particularly want our physicians to be well-versed in: central lines and intubations,” Mr. Carletti says. This off-site orientation takes place before a new hire starts or in the first few weeks or months. The other piece of MHG’s hospitalist orientation is a slow ramping up to full speed, which usually takes place over three or four days.
Other hospitalist groups have focused their onboarding less around special training and more around the idea of peer mentorship. Hospitalists joining HealthPartners’ eight Minnesota hospitals, for instance, have long participated in both a corporate orientation (for payroll, passwords, parking permits and EHR particulars, in part) and a hospitalist orientation. The latter entails working their first week alongside an experienced colleague on what the group calls a “half service.”
At the same time, explains Jerome Siy, MD, hospital medicine department chair, the group created a formal mentorship program two years ago. Each new person is paired with a current hospitalist who serves as a mentor for the first year.
The reasoning behind adding mentoring, Dr. Siy points out, is that no hospitalist can learn everything about a new system in one week. Newer hospitalists told him “how hard their first year was” and thought it would be helpful to include mentorship.
“It’s about getting people to feel engaged and supported,” says Dr. Siy, “so they don’t feel lost in a big crowd.” Mentors are expected to help colleagues with everything from answering questions about hospital peculiarities and living in Minnesota to work-life balance “and making sure that they are feeling healthy.”
The hospitalists at Spectrum Health Medical Group in Grand Rapids, Mich., created a similarly structured peer mentorship program for new hospitalist hires coming onboard its 71-FTE hospitalist group. The idea behind the program, says Muhammad Nabeel, MD, senior hospitalist at Spectrum Health’s Butterworth Hospital, was to standardize what had traditionally been a “very random” process of orienting new hires.
Now, each new physician is assigned a peer mentor to work alongside the first week on the job. Both doctors see a limited number of patients so they have enough time to engage in both the clinical and nonclinical nuances of starting up in a new system.
During the first two months, “the role of the mentor is to check in periodically” and cover all the points on a checklist that Dr. Nabeel designed. That checklist covers a wealth of topics, from how to apply for CME reimbursement to how to transfer patients to the ICU, as well as best practices for “high-yield patient satisfaction behaviors” during the first few months on the job.
In a letter published in the September 2016 issue of The Hospitalist about the program, Dr. Nabeel described how 100% of the new hires recommended that it be made permanent. Spectrum has decided to continue the program, even though the division sometimes must pay moonlighters to cover several shifts. That allows mentors to carry only half their usual patient census during new hires’ first week on the job.
“At the end of the day, it comes down to morale,” Dr. Nabeel says. “This is one of those important things that helps build morale, motivate providers and influence a transformation in the culture.”
In Sacramento, Calif., Thomas McIlraith, MD, is now a full-time hospitalist with Dignity Health’s Mercy Medical Group. But for the many years he was that group’s director, he considered onboarding to be so important that it was a task he refused to delegate.
Dr. McIlraith would work side-by-side with new hospitalists for their entire first seven-day week, helping them manage a small panel of patients that grew daily. He walked them through a checklist of introductions and orientations and would cover everything from how to get lunch and handle calls from the transfer center to EMR shortcuts and tips on how to improve patient satisfaction.
“My view is that you get one chance at a good first impression,” Dr. McIlraith says. “Hiring hospitalists is exceedingly competitive, and it is extremely important to have an edge on the competition.”
As Dr. McIlraith puts it, “Money only goes so far. If you can personally guarantee a good experience when a candidate starts with your group, you improve your chances of retaining them as a colleague.”
And given the intensity of hospitalist work, “my feeling is that if you can get new hires through the first week without getting them burned out, your chances of growing your program goes up substantially.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
• Spend the time and money to do it right. Hire moonlighters to pick up extra shifts, if necessary. Make sure that both the orienter and the orientee “aren’t distracted by too many patients and can take the time they need to get comfortable” in learning about the system, the culture and each other, says Wes Chandler, MD, of Pacific Hospitalist Associates in southern California.
• Fill in the “missing pieces” from the corporate or medical staff orientation programs that new hires go through, notes Muhammad Nabeel, MD, of Spectrum Health Medical Group in Grand Rapids, Mich. While you want to make sure new hires can access all the necessary electronic communications and medical records systems, you’ll also need to know what orientation topics the health system or medical staff office covers so you don’t duplicate those.
• Make monthly staff meetings “high-yield” by devoting time in each to orientation and wellness activities, says Jerome Siy, MD, of Minnesota’s HealthPartners. “If people start leaving the practice because they aren’t happy, it empowers other people to be unhappy,” Dr. Siy notes. “But we also know that happiness is contagious too.”
• Think about locums’ need for orientation. “We have seen groups offer a pretty good onboarding program for new permanent doctors, but they hire locums and throw them out there with nothing,” says hospital medicine consultant Leslie Flores of La Quinta, Calif. “Obviously, you can’t do an extensive onboarding for locums, but you can think about what locums need to work effectively in this environment.”
• A written policies-and-procedures document is no substitute for face time. Don’t hand newcomers a practice handbook—whether paper or online—and expect them to understand the nuances of practice procedures and standards. “People need to have a sense of what the culture is and how we operate,” says Thomas McIlraith, MD, of Mercy Medical Group in Sacramento.
• Offering everyone the same orientation isn’t cost- or time-effective. “One big mistake hospitalists make is to assume that everybody coming in needs the same thing,” Ms. Flores says. “If you are an experienced hospitalist, you will be bored to tears if you have to spend a week shadowing somebody.”
• Don’t expect one week or month to be enough to really integrate a newcomer into a group. “It’s a longer process than a week-long orientation to make someone feel they are well-entrenched in the group,” says Ms. Flores. Consider assigning mentors to newcomers for at least three or six months.