Published in the January 2006 issue of Today’s Hospitalist
Like many U.S. hospitals, Providence St. Vincent Medical Center in Portland, Ore., has put emergency-preparedness planning on the fast track. The 450-bed facility is intensifying efforts to make sure it can respond to a natural or human-fueled disaster, a fl u epidemic or a SARS outbreak that erupts before the surveillance radar detects it.
Unlike most of its counterparts around the country, however, Providence St. Vincent has tapped into its hospitalist group to lead its disaster preparedness committee. “In most places, the main doctor sitting in that committee would be the chief of staff,” says Woody English, MD, lead physician and co-founder of Providence St. Vincent Hospitalists. “But there’s a recognition here that you really need professionals who know the hospital, and who better than hospitalists?”
In terms of hospital hierarchy, the 16-physician hospitalist group was a shoe-in for the position because of its reputation for tackling and resolving thorny systems issues. From streamlining DNR orders to slashing length of stay, the hospitalists at Providence St. Vincent have made a name for themselves in tackling these kinds of complex systems issues.
It’s because of that reputation that the hospital not only encourages the group to identify quality improvement projects, but compensates its physicians to pursue these initiatives. And when those projects get results, the group is eligible for additional financial incentives.
“It’s part of our job description,” Dr. English says of quality improvement projects, “and the hospital gives us both time and a salary incentive to do these things.”
The hospitalists at Providence St. Vincent have spent years earning their reputation. Initially, hospitalist-initiated projects were “driven by the doctors” without any financial support from St. Vincent. It took some time, Dr. English says, before the administration realized how systems improvements ultimately improved the facility’s bottom line.
Over time, however, the hospitalists have worked to show the executive team exactly how their efforts help the hospital’s bottom line. When budget concerns or political issues have landed hospitalist program funding in the limelight, Dr. English says, that relationship has helped immensely.
“Providence has developed a way to justify financially what we call our value proposition,” he explains. “We come up with all the ways that we deliver value to the hospital and ascribe a dollar figure to it. Then we do what the financial people do: convert that to a return on investment.”
For example, Dr. English, who is board certified in infectious disease, and his group have participated in several initiatives to reduce infection rates and associated costly complications.
Whether the return on investment of the hospitalist-led initiatives is 5:1 or 7:1 “the group is seeing the latter level of returns these days “the hospital “is happy,” Dr. English says, “and it gives us a way to talk in a financial manner about our program” without simply focusing on clinical issues. “It took a while to develop that trust, but I can say that we have always had the ability to talk with one another.”
An even more unusual aspect of the hospitalists’ relationship with the administration is the extent to which the group’s counsel “and direct assistance “is sought in addressing long-range objectives that affect the entire hospital, not just the wards.
Each year, for example, the hospitalists are asked to review the organization’s strategic plan to identify ways they can help the administration meet goals. “We know what the high the priorities are,” Dr. English says, “and we design our activities around those.”
The group launched its first project in 1998, the year after a large local medical group contracted with Dr. English and two infectious disease colleagues to review its utilization and then later to cover its inpatients. (The program was later converted to a hospital-employed model.) The hospitalists rewrote Providence St. Vincent’s DNR orders to make them easier to use and implement.
At about the same time, the group began holding daily late-morning meetings with discharge planners that have become legendary for their effectiveness in improving continuity of care. These 30-minute breakneck-paced sessions, which have included not only traditional social workers and hospitalists but physical therapists, hospice nurses and even health plan representatives, are largely responsible for the hospitalist group’s noteworthy lengths of stay.
“Month after month, with statistical significance,” Dr. English says, “our length of stay is better than the top 15 percent” of hospitals that participate in the national Wharton-designed CareScience database.
Within three months of start-up, the group had reduced length of stay 30 percent “and it had the data to prove it. Dr. English notes that achievement “enabled us to start having ‘credible’ conversations with the hospital” about future expansion and potential support of the program.
Discharge summaries and EMR
On the heels of that early initiative, the group next managed to move discharge summaries from the bottom of the transcription department’s priority list to near-STAT status. That led to four-hour turnarounds, obviating the infamous “black hole” that often occurs after patients are discharged.
“Early on,” Dr. English says, “we recognized that the most important transcription done in the hospital was the discharge summary, which historically was put at the end of the queue.”
The group’s success in achieving rapid turnaround of discharge summaries and smoother handoffs not only got the attention of the hospital administration, but it became a key marketing tool the hospitalists used to grow their referral base.
In an unusual twist that is also intended to improve care continuity, the hospitalist group has established the requirement that all medical groups whose patients it accepts must either have an electronic medical record (EMR) in place or promise to install one within a certain time period.
“The idea is that if there isn’t already enough of a financial incentive for [referring groups] to invest in this,” Dr. English says, “we’re enough of a carrot that a number of groups have gone ahead and purchased EMRs so they can use our services.”
A rocky period
As Dr. English is quick to point out, the picture for the hospitalists at Providence St. Vincent, which is the flagship hospital of the 18-hospital Providence Health System, has not always been so rosy.
Dr. English recalls the period in 2000 and 2001 when the group, in an effort to cope with rapidly increasing volume, made the transition from a part-time “outside-supported” group to a full-time, 24-hour coverage model. While the group had hoped the hospital would fund the expansion, there was a change in administration that forced the hospitalists to prove their value all over again.
“When we made that transition to full-time,” Dr. English recalls, “we had new leadership who needed to learn how our group functioned and the depth to which it supported hospital operations. They didn’t want to take this on and suddenly sink the commitment of a whole lot of FTE doctors into a new program.”
But because the hospitalists had already committed to taking on more patients from community physicians, they ended up facing an overload of patients with no promise of help. “We did what a lot of programs did,” Dr. English says. “We fried.”
The group survived that hectic time by hiring physician assistants, enlisting support from medical staff colleagues who were willing to be on call for a stipend, and trying to negotiate support from the hospital to employ more full time hospitalists. The effort was eventually successful, but the period was painful for all concerned.
“We were able to pull it off without too much bloodshed,” Dr. English says, “but there was some.”
Bouncing back with performance measures
Since that rocky period, the hospitalists have once again been able to focus on the systems improvements that have become their hallmark. Most recently, the hospitalists developed and implemented a heart failure discharge checklist that not only standardizes heart failure care, but also helps the hospital gather the data it needs to meet performance measures.
As is the case with many hospitals, meeting the measures of Medicare and other payers and “scoring well” has also become a top priority for St. Vincent Medical Center.
“It’s all about looking for opportunities to make the systems work for you and deliver some value to the hospital,” Dr. English says, “by making a safer passage for patients and enhancing the reputation of the hospital as the best place to practice and the best place to be a patient. Improving the design of care also reduces many of the frustrations that lead to burnout and professional dissatisfaction.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.