Published in the August 2009 issue of Today’s Hospitalist
PLENTY OF HOSPITALIST PROGRAMS pay lip service to improving quality and developing physicians’ leadership skills. But when push comes to shove “a sky-high census meets barebones staffing, for example “such “extracurricular” activities often take a back seat.
But that isn’t the case at the hospitalist program at the University of New Mexico Health Sciences Center in Albuquerque. Consider these first-year objectives for all new hospitalist hires: Finish leadership boot camp. Learn quality-improvement principles and engage in quality-improvement efforts. Select a project you’ll individually “own” and document results. Give regular progress reports on that project, as well as quarterly presentations, to the entire hospitalist group.
To meet those goals, the program gives its 14 physicians not only financial incentives, but also time away from their clinical work. At least 10% of physicians’ scheduled work hours are set aside to pursue quality- and leadership-related activities.
“Our goal is to develop leadership and quality skills in all of our hospitalists, and we hire with those in mind,” says Kendall Rogers, MD, chief of hospital medicine at the academic center. “We believe hospitalists must have this basis of leadership skills because whether they want to be or not, they are team leaders in the hospital and positioned to drive change.”
To kick off their orientation, hospitalists start with comprehensive leadership training through in-house programs and presentations, with periodic, refresher training thereafter. Physicians who demonstrate a special affinity for leadership are encouraged “and funded “to pursue more training through the leadership academy of the Society of Hospital Medicine (SHM) or the American College of Physician Executives.
Hospitalists must then put those skills to work. Each hospitalist adopts some aspect of the care cycle “admission, discharge, protocol-driven care or ward service, for example ” or some element of the program’s overall academic mission. One hospitalist might “own” resident education, while another might take on hospitalist retention or serve as the group’s liaison to other clinical services in the hospital.
Ditto on developing quality-improvement skills. Every hospitalist, Dr. Rogers contends, should be able to look at a process of providing care, recognize its deficiencies and start proposing solutions.
“In our program, we want people who are not content with the status quo,” he says. “Health care needs a vast amount of effort and improvement. Physicians have to be engaged in that, and hospitalists are perfectly suited to the task.”
While the hospitalist program was started in 1999, it really began focusing on the value of hospitalists as leaders in 2006. Since then, the scope of the group’s quality initiatives and of physician leadership has evolved.
In part, that’s because the program grew from six hospitalists to 14 over a two-year period. That expansion allowed individual hospitalists to more tightly focus their sphere of responsibility on an area like medication reconciliation upon admission, rather than the entire admissions process.
“As we add more hospitalists, we have sectioned off these spheres of ownership into more bite-sized pieces,” Dr. Rogers explains. “That helps prevent the bystander effect, where everyone knows a certain aspect of care is suffering but no one wants to take the initiative to try to fix it.”
The results have been impressive. Hospitalist-led projects have increased DVT prophylaxis from 60% to more than 90%, established mortality reviews on all deaths occurring on medicine services, launched a post-hospitalization discharge clinic, developed numerous order sets and protocols, and instituted nursing sepsis screening and bundled-care protocols, among many others.
Hospitalists have also taken lead roles in CPOE implementation, core-measure improvement, discharge-planning projects and medication safety. They’ve also been able to take advantage of SHM mentoring projects like the VTE Prevention Collaborative and Project BOOST.
According to Dr. Rogers, individual physicians schedule and implement their own quality-improvement projects. Each hospitalist with 10% time protection should be spending about four hours a week on quality improvement. But no one monitors that time, and hospitalists are free to complete that work while on clinical service or to come in on non-clinical days for committee or project meetings.
The group also tries to accommodate both those hospitalists who would rather do more clinical work in lieu of devoting a full 10% of their time to quality improvement and those who want more time for quality projects. In such cases, hospitalists might “swap” chunks of time, allowing some physicians to devote more time to research or education.
“My goal is to help our hospitalists develop a sustainable career, which I think means no more than 70% clinical work,” Dr. Rogers says. “To prevent burnout, our goal is to align that other 30% with gratifying non-clinical activities.”
The issue of incentives
Dr. Rogers has also taken the grand-rounds concept and modified. What once were typical grand rounds on cutting-edge treatments have instead become “hospital medicine best practices” meetings, with hospitalists delivering evidence from a project such as VTE prevention or glycemic control.
At these sessions, hospitalists discuss how they individually approach a particular issue. The idea is to identify practice variations, of which there are always many, and to “come up with a group guideline” by the end of the meeting, Dr. Rogers says. “Even where evidence is lacking, we work to develop a standardized approach until evidence can provide better guidance.”
The group recently tackled standardizing consult recommendations for postop hip-replacement care to include osteoporosis treatment recommendations at discharge. Past sessions have covered influenza screening and post-stroke hypertension management.
Compensation incentives make up 25% of hospitalists’ income and are based almost entirely on performance on quality activities and other measures that support the service and educational missions.
The next step, Dr. Rogers says, is to reconfigure the incentive plan so hospitalists can provide outcomes data to substantiate their individual impact on quality, although that methodology is still in development. Incentives are also based on performance in leadership and project ownership and on less concrete factors, such as citizenship, education and teamwork.
Sticking to the mission
To safeguard physicians’ quality-improvement time, Dr. Rogers has worked to limit growth that doesn’t fit its mission statement. The group wants to avoid the mission creep that has beset hospital medicine by, for example, not taking on surgery or neurology admissions.
“Hospital medicine still hasn’t perfected the care of internal medicine patients,” Dr. Rogers maintains. “Until we have best practices and reliable processes for our patient population, I do not feel we should be taking primary ownership of patients outside of our training. We still have a long way to go.”
That doesn’t mean the group limits its leadership role in the hospital. In fact, the hospitalists are directly accountable for quality throughout the facility, Dr. Rogers explains.
The forms and processes they developed to admit and discharge medicine patients, for example, are now used by all adult specialties in the hospital. “We don’t try to fix processes just for medicine patients,” says Dr. Rogers. “That is the vital role a hospitalist group should be providing to its institution and its patients.”
Bonnie Darves is a freelance health care writer based in Seattle.