Published in the June 2013 issue of Today’s Hospitalist
AS PRESIDENT DWIGHT EISENHOWER once observed, “The search for a scapegoat is the easiest of all hunting expeditions.” In today’s ACO-driven and value-based purchasing environment, the health care industry serves as a good demonstration of that principle. With public reporting of various performance metrics and associated financial penalties hitting thin bottom lines, there is plenty of potential finger-pointing to go around.
Many progressive health systems are responding by reexamining clinician roles and redesigning acute care processes to improve efficiency and quality. But other less forward-thinking hospitals are taking the path of least resistance and finding someone to blame. And with hospitalists now the single largest specialty in many acute care settings, they have become an easy target.
In the blame-game playbook being used by some shortsighted administrators, the following strategies are often used to target hospitalists:
- Length of stay (LOS):
Blame the aggregate variance compared to the geometric mean LOS for an isolated month on the hospitalists ex post facto and urge them to improve. (Geometric mean LOS is a way to calculate LOS that the CMS uses to minimize the impact of outliers.)
Ignore the delays often caused in transferring patients out to an LTAC or SNF or because of patients’ complicated, deteriorating health status. Overlook the fact that some patients have no family or social support “or that patients may have been admitted by a primary care physician, suffered surgical complications or picked up a hospital-acquired infection. Attribute the inability to remove obvious outliers from LOS reports on “lack of reporting functionality” and make IT backlog the fall guy for the hospital’s inability to provide information about geometric mean LOS in the electronic medical record in real time.
- Patient satisfaction:
Hold hospitalists responsible for the hospital’s faltering “doctor communication” score, as if the emergency physicians or specialists never made any negative contribution.
Do point out, however, that the surgery department has higher satisfaction scores than the medicine department. But don’t mention studies showing that patients admitted through the ED have lower satisfaction than those admitted directly.
Discount any negative impact that hospitalist short-staffing may have on satisfaction scores. And when discussing how low HCAHPS scores may lead to steeper value-based purchasing penalties, leave unsaid the fact that among the eight “patient experience of care” dimensions that together make up 30% of the value-based purchasing total performance score, only one (doctor communication) partially applies to the hospitalists.
- Core measures:
Make a big deal about overall core measure scores, but don’t mention that small sample sizes often leave no room for error, thereby creating a (too) thin line between perfection and failure.
Beat the drum about hospitalists’ lack of accountability, but leave out the fact that hospitalists can sustainably meet core-measure requirements only if many other systems are in place to help them. Make sure, for instance, to deflect any discussion about implementing automated tools for medicine reconciliation, core measure alerts, and CPOE; education at all staff levels; resources to support processes enabled by checklists and order sets; concurrent monitoring; and daily reporting.
Vilify the hospitalists for high readmission rates and point to the poor quality of their discharge summaries, based on feedback from primary care physicians.
Pooh-pooh any systematic approach to analyzing readmitted patients and identifying those at higher risk for readmission at the outset of care. Give only lip service to combining efforts to improve treatment guidelines, after-care partnerships and intensive patient education. Push back against any recommendation to create a dedicated post-discharge team to collaborate with primary care physicians, SNFs and hospice.
Start a throughput committee and rename it “Lean” without ever defining how to measure and report throughput. Put ED physicians in charge, even if they often make throughput worse via unnecessary admissions.
Blame any bottlenecks on late rounding by hospitalists and their unwillingness to write discharge orders earlier in the day. Promise to look into why it takes hours between discharge orders and patients leaving, and act surprised when staffed bed shortage is brought up as the possible root cause.
And despite evidence that hospitalists respond promptly to ED admissions, blame them for the ED’s long length of stay. Write off as excuses untimely lab or imaging reports, case-manager workload or lack of weekend availability.
Lies, damned lies and statistics
As Mark Twain once put it, “Facts are stubborn, but statistics are more pliable.” Progressive hospital systems and facilities would do well to nurture a culture of fact-based problem-solving rather than finger-pointing.
It may be a sign of the times that the AMA has seen fit to adopt principles for physician employment that remind us: “In any situation where the economic or other interests of the employer are in conflict with patient welfare, patient welfare must take priority.”
Practicing evidence-based management should be just as important as practicing evidence-based medicine. But hospitalists would do well to recognize that while they are in the business of medicine, they trained only in the “medicine” part of that business.
Hospitalists need to understand key performance metrics to avoid becoming modern-day whipping boys and girls. And because averages lie, hospitalists need to learn how to drill down into data and conduct data-driven analyses to compare apples to apples.
They also need proper representation to help specialists, who often control the agenda of the medical executive committee, realize what hospitalists bring in terms of value to the hospital. And doctors need to develop a comprehensive, meaningful hospitalist-specific scorecard to curtail random, one-off scapegoating. Happy hunting!
Abhay Padgaonkar, an expert in hospitalist practice management, is president of Innovative Solutions Consulting (www.innovativesolutions.org), which is based in Phoenix. He advises clients of all sizes on challenges related to performance improvement and can be reached via e-mail at email@example.com.