Published in the August 2006 issue of Today’s Hospitalist
What’s the best staffing model for hospital medicine programs? How many patient encounters per day is appropriate? How can hospitalists prove their value to the hospitals where they work?
When it comes to running a hospitalist program, these are just a few of the questions that hospitalists must grapple with. And while the range of opinion about what constitutes “best practices” within hospital medicine is wide, there is a growing consensus that hospitalists cannot afford to ignore certain strategies.
At a preconference session held before the Society of Hospital Medicine’s annual meeting in Washington earlier this year, several veterans of the hospitalist movement attempted to define best practices for the specialty. They focused on high-profile areas like scheduling, compensation, communication with referring physicians and demonstrating value.
During the meeting, many of the speakers “and some physicians in the audience “said that if hospital medicine is going to continue its meteoric growth, its practitioners need to begin embracing new strategies and technologies. Along those lines, they called on hospitalist programs to do everything from using a new breed of patient-tracking software to collecting data to benchmark their program.
Here’s a look at some of the recommendations speakers and hospitalists at the meeting made in areas includÂ¬ing scheduling and staffing, patient volume and compensation, and strategies to communicate with clinicians and administrators.
In the decade since hospitalists arrived on the inpatient scene, programs have tried nearly every conceivable staffÂ¬ing and scheduling arrangement under the sun. While there are still plenty of scheduling models to choose from, several speakers at the meeting agreed that one of those models is concerning.
John Nelson, MD, director of the hospitalist group at Overlake Hospital in Bellevue, Wash., urged his colleagues to seriously consider alternatives to a one-week-on, one-week-off schedule. Although that model is popular, he said that experience has shown that it may be more stressful than many realize. It may also paradoxically increase burnout.
“It can be difficult for people to organize their personal lives around the seven-on, seven-off schedule,” Dr. Nelson, a co-founder of the Society of Hospital Medicine, told participants. “That week off may feel nice, but putting your personal life on hold for the seven consecutive days of work can prove difficult every other week, year after year.”
He cited the difficulties of making plans for attending conferences or taking a vacation of more than seven days. He also explained that the scheduling model reduces the number of days physicians work in a given year, which means they end up being very busy during each of the relatively few days they work.
Put differently, doctors may have compressed a reasonable annual work load into an unreasonably small number of days. “If you work seven on, seven off, you’ll work only 183 days,” he said. “That’s far fewer than the 210 or 220 many hospitalists work.”
Because of these concerns, Dr. Nelson advises hospitalist programs to “titrate out the workload over more days so that the typical work day is less busy, and to strive for variation in scheduling.” Both of those strategies, he said, will help support a healthier lifestyle for hospitalists.
Night and weekend staffing
As most hospitalists have learned the hard way, nights and weekends aren’t necessarily any “lighter” than the rest of the week. In fact, physician workload can actually increase during those shifts because of understaffing “fewer nurses are working, for example “and because it’s more difficult to obtain ancillary services in other parts of the hospital.
Because of these problems, Dr. Nelson said that lighter staffing on weekends can compromise care and overwork hospitalists. Other speakers concurred, citing trends in and emerging thinking about hospital medicine staffing.
“What we’re seeing is that as programs grow, weekends will become standard staffing,” explained Roger Heroux, MHA, PhD, a co-founder of the San Diego-based consulting firm Hospitalist Management Resources LLC. “But the bigger issue is ensuring that your hospitalists have the resources they need, that they can get CT scans and X-rays done. Determining if your hospital is a seven-day operation will drive a lot of other issues.”
What are some successful strategies to staff nights and weekends? During a question-and-answer session, some participants said their programs pay shift differentials, giving physicians an extra $1,000 for weekend shifts. Others said their programs used dedicated moonlighting staff, or that they ramped up staffing by adding physician assistants to the care team when fewer hospitalists are in the house.
Winthrop Whitcomb, MD, of Mercy Inpatient Medical Services in Springfield, Mass., and a co-founder of the Society of Hospital Medicine, agreed that shift differentials for hospitalists working the weekend are reasonable, but he said that he asks for something in return.
“If you’re paying a differential,” he explained, “make sure you give those hospitalists some tasks that will help decompress the week a bit.”
In setting patient loads for physicians, the consensus was that hospitalist programs need to move carefully and keep an eye on the big picture and balance volume with length-of-stay considerations. According to Dr. Whitcomb, hospitals that push their hospitalist programs to increase their per-physician patient volumes may hurt their efficiency “and the hospital’s revenues “in the long run.
He said that if a hospitalist group increases its volume from 15 to 20 patients per hospitalist per day, for example, it can expect to see length of stay rise. “Data suggest that length of stay goes up by about one-third of a day when volumes get that high,” Dr. Whitcomb explained. “If you do the math, the total cost to the hospital of going from 15 to 20 patients per day is about $450,000 a year.”
It’s true that the group may reap additional revenues from seeing more patients. At an additional $50 per patient, Dr. Whitcomb said, the additional encounter per hospitalist could come to $365,000 a year. But he added that any gain in revenue will be more than offset by an increased length of stay.
“How busy you are as a physician has a lot to do with how effective and efficient you can be for the hospital,” Dr. Whitcomb said. “Those two issues are joined at the hip.”
How can hospitalists deal with pressure from hospital administrators to see more patients? He advised citing not only the potential revenue drain, but other costly issues like burnout, turnover and reduced quality of care.
And when it comes to discussing hospitalist workloads with hospital administrators, Dr. Nelson said that hospitalists need to make sure to distinguish between patient census numbers and patient encounters. It is nearly always better to think in terms of daily encounters than census, as the latter simply shows a snapshot of patient volume at any one time during the day. It doesn’t take into account the number of patients that are discharged and admitted over the course of the day.
Dr. Nelson explained that a hospitalist who starts the day with a census of 11 to 15 patients but who must take on two admissions and do two “double visits” on a single patient is suddenly up to 17 patient encounters “a full load by any account.
How can hospitalist programs reward their physicians for increasing productivity or quality “and do it without dipping into their existing pay? Speakers said the key is to engineer a system that allays the fears of physicians, and also provides incentives that are large enough to get physicians’ attention.
When hospitalist programs attempt to introduce productivity or quality incentives “or both “where none existed before, physicians often worry that money for those bonuses will be taken from their base pay and returned to them, but only if they meet new performance thresholds. Physicians worry that they’ll in effect be working harder for the same pay.
While Drs. Nelson and Whitcomb said they understand those concerns, they explained that hospitalist programs can make the shift to incentive programs without financially penalizing their physicians or compromising the program’s financial underpinnings.
The key, according to Dr. Nelson, who is a proponent of productivity-based compensation systems, is to acknowledge that physicians “attach a lot of symbolism” to base salary. As a result, it’s important to assure hospitalists that there will almost surely be an upside in earning potential.
“I think it’s reasonable to connect the doctor to the financial health of the practice and to pay physicians something “whether it’s based on RVUs or some other variable component “that reflects how hard they work,” Dr. Nelson said. As a rule of thumb, he maintained, it takes at least 5 percent to 10 percent of overall pay to change behavior, which is the usual objective of an incentive arrangement.
That’s just a minimum, he added, noting that he personÂ¬ally thinks that incentive-based compensation should be far higher, in the 40 percent range. He also believes that it should incorporate performance on identified quality measures. And finally, whatever percentage or arrangement is settled on, both Dr. Nelson and Dr. Whitcomb agreed that “extremely complex” incentive programs should be avoided.
Despite all of the attention that discharge planning communiÂ¬cations and care continuity have received in recent years, the speakers agreed that many hospitalist programs still aren’t doing enough in these all-important areas.
One strategy that received a fair amount of attention at the presentation was daily meetings and cross-disciplinary communication to maximize productivity, communicate expectations and identify problems. Early-morning multi-disciplinary meetings, for example, can do far more than improve camaraderie among care-team members.
Besides helping to set clear discharge and admission priorities, the meeting’s timing enables hospitalists and other personnel to identify and address issues that could complicate or delay discharges “patient transfer problems and pharmacy backlogs, for example.
“We have found that if the patient isn’t transferred to a post-acute care center by 3 p.m., it doesn’t happen,” explained Martin Buser, MPH, co-founder of the San Diego-based consulting firm Hospitalist Management Resources LLC. “So make sure the morning meeting and rounds are geared to the entire discharge process. And it’s smart to coordinate the operational issues with the team manager so you can minimize constant interruptions during the day.”
Speakers at the meeting also urged hospitalists to do a better job of real-time patient communication, both during hospitalization and at discharge.
Dr. Whitcomb, for example, stressed the importance of transmitting the history and physical and discharge document in a manner that ensures the receiving party “the hospitalist or community physician “has it on hand when needed.
He also stressed the importance of requiring primary care physicians to deliver patient records to hospitalists, so that it’s not a one-sided situation. “I think the PCP has equal responsibility for communicating,” Dr. Whitcomb explained, “and in a well-functioning system, the PCP should have a way of getting records to the hospitalist.”
In Dr. Whitcomb’s program, for example, the hospitalist’s transmission of the history and physical to the primary care physician is supposed to prompt the outpatient physician to send key records to the hospitalist. In turn, the hospitalist agrees to communicate key events that occur during hospitalization to primary care physicians to make sure they know about the situation before discharge.
One of the best ways for hospitalists to approach continuity communications is to put themselves in the position of the “receiving” party at the next juncture, whether that’s a primary care physician, skilled nursing facility medical director or the patient’s family member. “I simply put myself in the PCP’s place and ask myself what event I would want to know about before the patient came in?” Dr. Whitcomb said.
When hospitalist programs first get off the ground, many are quickly able to reduce length of stay and costs per patient. While that’s a good start, the reality is that most administrators will want evidence that the program is continuing to help the hospital meet its goals.
A key to demonstrating a hospitalist program’s value to hospital administrators, speakers at the meeting agreed, is to generate complete financial reports frequently “and then communicate those results to hospital administrators.
“You want to develop a return-on-investment strategy that’s driven by DRGs, costs per discharge and readmission rates,” Mr. Buser said. He added that business plans and the ability to produce detailed financial reports are pre-requisites.
A key to proving value, however, is using the hospitalist program’s own systems and not relying on the hospital’s systems for financial data generation and retrieval. Mr. Buser said that the arrival on the market of hospitalist-specific software programs will give groups the ability to capture and report data.
These newer-generation packages can help groups maximize their reimbursement, report performance and automatically transfer patient information and demographics directly to billing companies. “These software programs are essential to the success of your program,” Mr. Buser said.
Another area that should not be overlooked is performance reporting. Because hospitals are turning to hospitalists to help them qualify for incentive payments from payers like Medicare, it’s in hospitalist programs’ best interest to involve themselves proactively in hospitals’ quality improvement efforts. It’s also critical to make administrators aware of hospitalists’ role in securing that bonus money.
Finally, hospitalist groups can do more than just send reports to build relationships. They should establish active relationships not only with referring physicians and medical staff, but hospital administrators and medical leadership, urged Dr. Whitcomb and Mr. Buser.
“It’s a good idea to take the hospital CEO, the medical director and other senior leaders on rounds with you once in awhile- “and hospitalists should even insist on it,” Dr. Whitcomb said. “There’s no substitute for letting them see firsthand what your life is like. You want to ensure your program receives their full support.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.