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Rehabbing your hospitalist practice

November 2007

Published in the November 2007 issue of Today’s Hospitalist

When she was brought in to shore up a failing hospitalist program in southern Oregon last summer, Sandra Hartline, MD, knew she would have her hands full. But it wasn’t until she arrived on the scene at Three Rivers Community Hospital in Grants Pass that she realized the full extent of the damage.

For one, the program was understaffed. Schedules were patched together with locum tenens, a situation that often led to high turnover and coverage mayhem.

And the program was burdened with “special coverage arrangements” with certain doctors, fostering unrealistic expectations from the medical staff. It all added up to hospitalists not even being able to meet the program’s primary objective: taking care of unassigned patients.

Such intractable problems called for drastic action. “We had to stand down the program and restart it,” recalls Dr. Hartline, who works with Sound Inpatient Physicians. That company operates more than two dozen hospitalist programs in the western U.S. and took over management of the Three Rivers group last April. “No one was particularly happy about that, but it was the only way to deal with the situation.”

Terminating a hospitalist group and then reviving it is only one of several strategies being tried to rehabilitate hospitalist groups nationwide. While resuscitation may be the most extreme example of how to reconfigure a hospital medicine program, many groups are finding that their programs need a significant overhaul, one that may involve switching employment models, replacing program leadership or scaling back over-reaching services.

The reasons behind the need to reconfigure are many, but often boil down to this: Many hospitalist programs grow so rapidly that they encounter organizational troubles or dead ends. While some groups can accommodate for growth, others find that a program overhaul “rehabilitation, reconfiguration or resuscitation “is in order.

Figuring out what works and what doesn’t

Industry observers say that cost pressures and anemic levels of financial support are common factors that edge hospitalist groups into “rehab.” Without the right level of funding, programs get bogged down by problems that can’t be addressed without going back to the drawing board and finding more cash.

Or programs are forced to address the after-effects of bad leadership or of not having enough organizational infrastructure in place “a range of “bad habits programs developed along the way that are difficult to turn around,” says hospitalist industry consultant Steve Nahm, vice president of The Camden Group in El Segundo, Calif. “That’s fairly common with programs that have been in place from three to five years.”

One of those bad habits, saying “yes” to every request for a new service, is forcing a growing number of programs into a “major remodel,” Mr. Nahm says. “When you have design flaws and you build on the volume, you have problems.”

Some design problems, like unworkable hospitalist schedules or patient loads, have a trickle-down effect on both group and individual-physician performance “and on a program’s ability to recruit. In some cases, the only way to deal with the overload is to take the program down to the foundation and start over.

“There is a lot more knowledge now about what works and what doesn’t,” Mr. Nahm says. “Some programs are undergoing remodeling to get rid of practices or staffing structures that we know don’t work.”

Management model switch

When pressed to cite his primary reasons for reconfiguring his hospitalist program at Baptist Hospital of Miami, Tomas Villanueva, DO, MBA, quickly lists his “top three.”

“I couldn’t maintain doctor-patient ratios of less than one-to-20 and keep the doors open,” he recalls. “Our salaries and our schedules weren’t competitive. I ended up with a lot of frustrated, exhausted physicians.”

With his group working a grueling schedule of 14-on/seven-off, length of stay and patient satisfaction were starting to suffer. “Most of the reasons a hospital would want a hospitalist program weren’t there,” he points out. “We weren’t producing the deliverables.”

Behind the high volume and the low pay was the fact that Dr. Villanueva’s private group wasn’t getting the financial support it needed from the hospital. During contract negotiations last spring, when he was about to ask for better support for the 13-physician group, he realized it would take more than cash to fix what ailed the program.

He needed more hospitalists, better information and communication systems, and more nursing and administrative support. He also needed to lower individual physicians’ patient volume to deliver better quality.

He was able to convince the CEO that with better staffing, the hospitalist group would be able to deliver the quality and financial improvements that the hospital needed to see. But the hospital CEO was worried about providing more extensive support, given the laws governing independent-group subsidies from nonprofit hospitals.

The solution was for the group itself to make a change. “The entrepreneur part of me was not all that interested in working that hard for an organization that might barely break even,” he recalls. “I said, ‘Why don’t we consider having the hospital employ the group?’ and the CEO agreed. In our case, that switch was what we needed to ‘rehab’ our program. We all like working at the hospital and wanted to stay, so it came down to a business decision.”

First order of business: burnout

The first problem to address under the new model was physician burnout. Dr. Villanueva brought in two more hospitalists and converted to a seven-on/seven-off schedule. The employed arrangement also gave the group access to Baptist’s roving nurse practitioners, who now help with the hospitalists’ “code rescues” and further lighten physician load.

While the hospitalists were pleased with those changes, the medical staff was not, at least initially. Staff physicians were concerned that the administration might interfere with referral patterns, Dr. Villanueva explains, or reduce the autonomy of hospitalists’ decision-making.

“I knew there would be some anxiety because our group handles all of the unassigned, so I have had to go out of my way to nip that in the bud,” he says. As part of the new contract, the hospitalist group retains its previous clinical autonomy and its consulting pool relationships.

The second hitch “which, in hindsight, Dr. Villanueva says he would change if he could “is the bonus structure, which is based entirely on quality measures. With more hospitalists on board and with the employed-physician model, productivity is lagging a bit more than he might like.

“In retrospect,” says Dr. Villanueva, “I would have made the bonus structure a hybrid of quality and productivity.”

Dwindling primary care referrals

While the Baptist Hospital program is revamping, Erik DeLue, MD, at Virtua Memorial Hospital in Mt. Holly, N.J., is wrestling with what he terms “a combination of reconfiguration and rehabilitation.” The hospitalist program he took over this August was plagued by high turnover, exceeding 80% a few years ago. The program was also in dire need of standardized staffing, sign-outs, handoffs and general communication, especially with referring doctors.

An even more basic problem: Due to the program’s many iterations “first as a subcontracted private practice, then as a nationally operated staff-model program that utilized a large number of “PRN” staff and a night-time house-doctor system “the program had lost much of its referring primary care physician (PCP) base.

“I was brought in primarily to stabilize the program, provide on-site leadership and bring back the PCPs,” Dr. DeLue explains. The hospitalist census, which was once around 110, was hovering at 70. “We’re trying to repackage and re-brand to show the PCPs that we’re serious about making this a great program.”

While Dr. DeLue had previously headed up two programs, including one startup, he admits that trying to steer an existing program in new directions is the hardest job he’s taken on.

“When you grow a program organically, I think it’s a lot easier,” he explains. “You’re not dealing with the habits” that predecessors developed.

Increased hospital commitment

In rehabilitating the Virtua program, Dr. DeLue points out, the hospital is making a substantial commitment.

It brought a highly experienced hospitalist-medicine consultant in-house to help direct the program overhaul, and it is converting the program to an employed model. The hospital also is trying to address recruitment issues by revising its seven-on/seven-off schedule to allow for 160 paid-vacation hours and more CME time a year for the group’s 13 hospitalists.

“That is a major restructuring in terms of making the program more attractive and making sure people don’t feel burned out,” says Dr. DeLue.

The hospital has also put new infrastructure elements in place, including an electronic sign-out process and discharge communication protocols. And to streamline communications with primary care physicians, as well as with subspecialists and ED doctors, Dr. DeLue is switching from pagers to personal cell phones.

“Once people start communicating more by phone, they’ll realize that the channels are open,” he says. “It will be better than having me go around beating the drum and telling people to communicate.”

Patterns of patient volume

The good news is that Dr. DeLue has been able to recruit some new physicians. But he says he still has a ways to go before he actively markets the program. The current patient volume is derived primarily from unassigned patients, he says, a practice that will continue.

However, the program also preferentially admits nursing home patients, a practice that has thwarted initial attempts to manage length of stay. The group also needs to clarify the roles of both the house doctors and the hospitalists at night, to make it clear that the hospitalists have an autonomous practice.

Nonetheless, he is optimistic about the program’s prospects and heartened by the gains he has seen. Dr. DeLue says he is also encouraged by the reception he’s received from nurses and case managers.

“Now that we work for the same organization, we’re part of the same team,” he explains. “Everyone is buying into that.”

Misalignment prompts a remodel

For the Saint Luke’s Hospitalist Group in Kansas City, Mo., the key issue that drove the group’s recent reconfiguration was the misalignment between the program’s management and its clinical objectives.

The group was managed and operated by the same team that commandeered the Saint Luke’s Health System’s outpatient practices. “Inherently, the goals of managing an outpatient group are different from those of an inpatient group,” says Anthony Fangman, MD, the group’s newly elected director. “Incentives for high productivity, sometimes seen in outpatient settings, are not always the best fit for an inpatient hospitalist practice.”

Because the hospitalists were being managed like an outpatient program, Dr. Fangman recalls, physicians were seeing too many patients and working every other weekend. “The high patient volume was detrimental to our group and making patient care more difficult.”

The group insisted on a different management structure and is now managed by the hospital, not the outpatient management team, although both are under the Saint Luke’s system. (According to Dr. Fangman, the group enjoyed “a great relationship” with the outpatient physicians and medical staff during and after the transition.) The 19-physician group, which now provides services at three Saint Luke’s campuses, also reconfigured its staffing and scheduling.

Data to support more staffing

The hospitalists now work about 23 days a month, down from a peak of 28 under the previous arrangement. Still, each hospitalist works three full weeks of night shifts annually.

As the program continues to grow, one main challenge has been communicating to the hospital administrators why having more hospitalists “the group is asking for a staffing increase in 2008 “is in the best interests of both the patients and the hospitals.

“We are presenting data to management about length of stay and other important benefits since the program’s inception,” Dr. Fangman explains. The group hopes the data will make the case that a lower length of stay not only provides a financial benefit, but better quality of care.

“The faster we diagnose and treat our patients, the better their outcomes,” he says. “We are not simply getting them ‘out the door.’ ”

Complete resuscitation

In Oregon, the Three Rivers hospitalist program that was suspended in April was resuscitated by Sound at the beginning of September.

Dr. Hartline says she has been encouraged by the way her five-member hospitalist team “most of them new “has learned to roll with the changes. “They’re young and energetic, and they apparently enjoy the challenge,” she points out.

The tough nut has been convincing the medical staff that dispensing with locums, using Sound’s more hospitalist-friendly scheduling model, and focusing on the unassigned coverage rather than individual arrangements are in everyone’s best interests.

“The deals that were made with private physicians have had lasting effects,” she says, citing conflicts among physicians who would like the group to take on hospitalized patients.

“I find that I’m constantly managing expectations and then coming up with back-up plans, and reminding people that the program’s primary goal is to take care of the unassigned patients.”

Now 12 weeks into the new effort, the conflicts are fewer and the medical staff is happier. But Dr. Hartline still faces some fallout from the previous “just-say-yes” era.

“I have to remind them why the previous program failed,” she says, “that if you overwork hospitalists, they’ll leave.”

Bonnie Darves is a freelance writer specializing in health care. She is based in Chadds Ford, Pa.

What’s driving the “re-dos”?

In many cases where hospitalist groups are being “rehabbed,” the physicians themselves have decided that it’s time for a change.

But increasingly, it’s hospitals that drive re-do initiatives. That may occur when a new CEO comes on board or when operational or patient-satisfaction problems loom large enough to get administration’s attention.

As hospital medicine matures, administrators are now more aware of the financial potential of well functioning and integrated programs. They also see the quality and patient-satisfaction gains that some of their colleagues are making.

“We’re moving into the era of demonstrable improvement and demonstrable efficiency, and that’s driving some of the revamping of programs,” observes Scot Smith, MD, medical director for Sound Inpatient Physicians’ Pacific region. “They’re not asking, ‘Should there be a hospitalist program?’ They’re saying, ‘Should it be this particular program?’ There is a push to retool programs that never got off on the right foot.”

According to Dr. Smith, the me-too mentality that drove many hospitals to adopt a program has undergone a fundamental shift. Today, hospitals want to have hospitalist programs not only for competitive reasons; they want programs that actually deliver the goods.

“Hospitals now have increased access to good data and interpretive ability of those data,” he says. “There is a clearer sense of the potential return on investment.”

Dr. Smith points out that many factors now driving “rehab” within the Tacoma, Wash.-based company’s programs are data related, especially since Medicare launched its core measures program. Hospitals are either asking for or compiling breakout data on inpatient costs and charges, as well as diagnosis and drug-utilization figures for the hospitalist program, sometimes down to the individual-physician level.

“There’s much more integration between hospitals and hospitalist programs in data, and sharing of actual metrics,” Dr. Smith explains. “That’s requiring a higher level of sophistication among physicians to see the hospitalization through the eyes of the hospital.”

Today’s Hospitalist blog debuts

Want to read more about “and discuss “rehabbing practice basics? Erik DeLue, MD, one of the physicians featured in this month’s cover story, has started blogging about practice redesign and hospital medicine. Tune in and sound off at the Today’s Hospitalist Web site.