Published in the January 2011 issue of Today’s Hospitalist
When it comes to hospitalist programs, practice consultants and management company executives say they’ve heard it all.
They’ve dealt with hospitalists complaining that they see too many patients for too little money. They’ve talked to hospital administrators worried about the level of financial support they give hospitalist groups. And they’ve seen everything in between.
During a presentation at the University of California, San Francisco annual meeting on treating hospitalized patients last fall, two veterans of the specialty addressed some of the more common problems and the best innovations they’ve seen in hospitalist practices. Here’s a look at the four cases they presented, and the solutions that were adopted by the hospitals and hospitalist groups.
CASE 1: Is the grass really greener?
The first case study was offered up by John Nelson, MD, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., and a hospitalist consultant.
The 22 hospitalists who were employed by a multispecialty clinic were unhappy about nearly everything. They complained that their workload was too high, their compensation was too low, they received zero vacation days and they got no respect from the surgeons they worked with.
Why were they so sure they had it so bad? They’d heard that the physicians at the hospitalist group across town were capped at 18 patients per shift, were paid significantly more, got three weeks of vacation a year “and had a good working relationship with their hospital’s surgeons.
Dr. Nelson said that the physicians’ unhappiness had reached a breaking point, and some were threatening to quit. That led him to ask the audience a question: What’s a reasonable response by the physicians in this group?
According to Dr. Nelson, the key to navigating this type of conflict is to compare global measures like work over a long period of time. “The fact that the other group has a patient volume cap doesn’t really tell you that much,” he explained. “You still don’t know who works harder over the course of a year.”
The other doctors receiving three weeks of paid vacation doesn’t mean much either, he added. “They might still end up working more shifts annually, despite that.”
To get to the bottom of the complaints, Dr. Nelson called the other practice. He found that while those hospitalists were indeed being paid more, they were also working harder. Still, he concluded that the physicians at the first group were underpaid, which led the group to raise its compensation.
While Dr. Nelson said that the pay raise seemed to satisfy the physicians “all but one remained with the group “he took issue with threatening to quit as a tactic to get what you want.
“I’ve worked with a lot of hospitalist practices and a lot of hospitalists who threatened to quit,” he explained. “Very rarely do those physicians actually follow through with their threat, so it’s not a good idea to threaten to quit. Making the threat usually just creates problems, so you should just decide if you’re going to quit and then do it.”
Making threats is not only ineffective, but it can create a negative work environment for everyone. “You don’t want to get into a victim mentality,” Dr. Nelson said. “I see that a lot, and I think people actually harm themselves. Bellyaching about how you work too hard and aren’t paid enough will rarely galvanize your employer to make a change.” Instead of complaints, he urged, show up with compensation and workload data to make your case.
CASE 2: You want us to do what?
The five-physician private hospitalist group was stunned at the long “and growing “wish list of administrators at a large community-based teaching hospital where they worked.
Administrators wanted the hospitalists to improve communication between the hospitalist group and just about everyone else, reduce the hospital’s readmission rate and improve its length of stay. And for good measure, they also asked the hospitalists to improve patient satisfaction and start a hospitalist teaching service.
Adam D. Singer, MD, founder and CEO of IPC-The Hospitalist Company Inc. in North Hollywood, Calif., said that the situation is a good example of how hospitalist practices must sometimes “take half a step back” to move forward. In this case, that meant that the hospitalists and administrators had to take a hard look at many of the things they were already doing. The hospital formed a committee with representation from just about every department and took the drastic step of re-engineering how care was delivered.
To tackle length of stay and readmissions, grand rounds are now held every day at 9 a.m. with doctors, nurses, social workers and case managers sitting down to review patient cases. Multidisciplinary rounds are held twice a week, and the team does walking rounds on the floor. In addition, the hospitalists converted from a seven-on/seven-off schedule and now work a more traditional Monday through Friday schedule.
Hospital administrators also put their money where their mouths were and built a 20-bed unit to be used only by hospitalists. “From the way the architects designed the rooms to the way lab data are delivered in the morning to the way the chairs are set up,” Dr. Singer said, “this floor was built from the ground up for hospitalists only. There is literally no patient on this floor unless it’s being managed by this care team.”
All of these changes produced a dramatic reduction in the number of daily pages doctors receive. The changes also led to a 22% reduction in readmissions, a 36% improvement in patient satisfaction and a 4% reduction in length of stay. And the changes allowed the hospitalists to get a teaching service off the ground.
Dr. Singer acknowledged that the hospital’s solution is far from typical. “The hospital had an enlightened administration, including a vice president of medical affairs and a case manager who were open to change. We also had a hospitalist leader who understands that hospital medicine is not just the art of delivering medicine, but how the delivery system is structured and how operational issues affect the delivery of care.”
CASE 3: Can’t we all get along?
Dr. Nelson’s next case was a hospital plagued by poor coordination of care. The hospitalists and administrators responded by setting themselves ambitious goals: a positive return on investment, fewer errors, higher quality care and improved patient satisfaction.
To reach those goals, the eight-physician hospitalist group moved to a new model of care that put a premium on collaborating with other clinicians. Like the example presented by Dr. Singer, the hospital in this case spearheaded the effort to reinvent how patients are cared for.
Under the new collaborative care model, physicians, nurses and pharmacists all work closely with a care manager, a position that Dr. Nelson said is part social worker and part discharge planner. The model is also being used by several physician specialists at the hospital, not just hospitalists.
“They meet when there’s a patient to be admitted,” he explained. “They walk into the patient’s room together and do the admission together and develop a single plan of care. It’s a remarkable thing to see.”
The hospital has tackled patient safety issues as well, putting stops in place that cease all activity when patients aren’t getting appropriate therapy. “If clinicians don’t meet an antibiotic deadline for pneumonia, they will stop,” Dr. Nelson said. “They don’t continue to treat the next patient. They don’t dictate an admission note. They stop everything to get patients their antibiotic.”
Dr. Nelson said that the hospital also made physical changes to make care more efficient. “They installed cabinets in each patient room that have 80% of the supplies a nurse will need to take care of the patient,” he explained. “Nurses don’t have to waste time running down the hall to the supply cabinet.”
The results have been impressive. Length of stay and costs dropped, saving the hospital $300 per medical case and $1,000 each for surgery cases. “This system cost an arm and a leg,” Dr. Nelson said, “but the hospital is convinced that it pays for itself.”
The hospital also found that the number of adverse events dropped after the system was introduced, and that fewer patients were calling the hospital after discharge with questions about medications.
But while the new system of care presents clear benefits, Dr. Nelson wonders about the impact on physicians.
“It’s complicated,” he pointed out. “Are you willing to say that every time there’s an admission, you’ll listen to the nurse talk about things like skin care that aren’t necessarily germane to your role in this patient’s stay? Is that really a good thing?”
When Dr. Nelson asked the hospitalists there for their views, he heard a range of responses. When he visited the hospital, it was still using a more traditional model of patient care in some units. That gave hospitalists a unique opportunity to compare the new care model to the more traditional system. While they had some ambivalence about which care model they preferred to work in, they were convinced the extra effort in the collaborative care model paid dividends for patients.
CASE 4: The nuclear option?
The final case focused on frustration, but this time it was hospital administrators, not physicians, who were unhappy.
Dr. Singer highlighted the case of a 375-bed hospital that employed 14 hospitalists. The physicians were paid straight salary and worked a seven-on/seven-off schedule.
Hospital administrators were unhappy that their length of stay was above the national norm, and that patient satisfaction and medical staff satisfaction scores were low. To make matters worse, the hospital was paying the hospitalists a subsidy of nearly $3 million a year.
“The hospital could not afford that,” Dr. Singer said. That left administrators with a difficult choice: Should they try to restructure the program, or should they simply take the nuclear approach and kill the program and start from scratch?
In analyzing the situation, Dr. Singer said a big problem was that the hospitalist program didn’t have the full attention of its physicians. Many lived near the hospital only when they were working, and they left town during their week off.
To engage the hospitalists, Dr. Singer said the hospital changed two key elements: their compensation and their work schedules.
The hospital added a productivity element to its compensation plan. And instead of assigning all physicians to work seven-on/seven-off, the hospital adopted a hybrid system. Some physicians now work Monday through Friday, while others work seven-on/ seven-off. The program also hired a nocturnist. “The program ended up decreasing the number of doctors,” Dr. Singer said, “but increasing the manpower available to see patients on any given day.”
The hospital saw results almost immediately. It was able to reduce the subsidy it paid the hospitalist group by $1 million a year. It also reduced the number of hospitalists from 14 to 10, so the daily census per physician went up from nine patients per day to 14. Hospitalists also saw their compensation increase by 35% due to the productivity incentive.
What was the impact on the original physicians in the group? Dr. Singer said that unfortunately, all 14 of the original physicians had left within year. “Whenever you take a half step back to reengineer a practice,” he explained, “there will be doctors who have trouble in the new world.”
Edward Doyle is Editor of Today’s Hospitalist.