Home Cover Story Growing pains?

Growing pains?

October 2010

Published in the October 2010 issue of Today’s Hospitalist

IN 1992, WHEN HE HELPED FOUND the hospital medicine program at Beth Israel Deaconess Medical Center in Boston, Joseph Li, MD, was one of only a handful of hospitalists. Because everyone in that small group knew how everything in the hospital worked, management was a breeze.

“In the beginning, all five or six of us had all the information in our heads,” Dr. Li recalls. “We knew intimately how things worked.” But as the group grew, its institutional memory became diffused by newcomers who didn’t completely understand the group’s policies and procedures. When the number of daily e-mails between group members began to skyrocket, Dr. Li made what he now says was the big mistake of trying to shoehorn the group’s history and culture into a written program manual.

As he recalls, that document topped out at 120 pages, but size was only part of the problem. “It was always out-of-date,” Dr. Li says. “It was cumbersome and clunky and not at all usable.”

While large and small hospitalist groups alike have many of the same goals “solid financial planning, strategic personnel management and attention to quality “the challenges of running a big group are exponentially greater than running a small group. For groups that top 20 or more physicians, even finding physical space for everyone can be a problem, while communication gaps (as Dr. Li found out) can hurt morale and sabotage retention. All of that comes on top of ballooning bottom lines and increasingly complex budgets.

“As a group gets larger, you have to change your model,” says Peter Short, MD, senior vice president of medical affairs at Beverly Hospital in Beverly, Mass., who oversees a 27-physician hospitalist group. “You have to move from the mindset of a small mom-and-pop business to a large business. If you have 20 doctors, you are in a multimillion dollar company, and you have to think like a multimillion dollar company.”

Expect to grow
For many groups, the problems that come with growth are a surprise because big programs are still relatively new in hospital medicine. Groups as large as Dr. Li’s, which now has 34 physicians and will reach 40 next summer, are in the minority.

But that may be changing. Up to one-quarter of hospitalists now work in groups of more than 10 physicians, according to the 2010 Today’s Hospitalist Compensation & Career Survey. The mean size of a hospitalist group today, that survey says, is 10.58 fulltime equivalent physicians, plus 3.41 FTE clinical non- MD providers.

Consultants claim that the trend toward larger groups is likely to accelerate as hospitalists take on new areas of comanagement. And experts predict that hospitalist groups will grow as hospitals look for help navigating the many payment changes expected under health care reform.

The bottom line is that for many programs, getting big isn’t a matter of choice. Consultants say that if groups can’t accommodate their hospitals’ demands for new service lines, administrators and referring physicians will look for someone else to fill the need.

That leaves some industry veterans warning hospitalist groups to expect to deal with growing pains sooner or later. Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC, a national consulting and management services company based in San Diego and Colorado Springs, Colo., says hospitalist groups should start thinking about how to deal with the complications of growth when they reach eight physicians.

“Eight is not unwieldy yet, but it’s probably a sign that your group is going to keep growing,” Mr. Buser says. “It’s a good time to get ready, and that starts with recognizing that the skill set you need to manage five physicians is different than what you need to manage 25.”

A new mindset
The challenges posed by growth come in many flavors. Wendy J. Miller, MD, lead physician of the Abbott Northwestern Hospitalist Service in Minneapolis and one of its 57 physicians, says she was surprised to discover that her group didn’t have enough call rooms.

“For a group our size, if it’s a crazy night, we need three call rooms,” Dr. Miller says. “That’s hard for the hospital to understand. We need more call rooms if people have to spend the night.”

Other concerns that may seem minor to small hospitalist groups can be critical for larger ones. That was the case when Pacific Hospitalist Associates in Newport Beach, Calif., a group with almost 40 physicians, was choosing an electronic health record system.

“We had multiple options, but we ended up choosing a system that is used by some of the larger medical groups in our area,” explains Weston Chandler, MD, the group’s president and founder. “Rather than select a product that was less expensive or more interesting to us, we realized that connectivity and growth potential was more important.” Size becomes, Dr. Chandler adds, a factor in any critical decision. “You have to ask if this is something that is going to allow us to continue to grow.”

The biggest problem: communication
But the biggest adjustment larger programs say they face is how to keep the lines of communication open among group members. At some point, the old ways of sharing information within the practice ” let alone with the growing roster of referring doctors, specialists and nurses “no longer work.

In Boston, Dr. Li says that his colleagues came up with a much better communication tool than his doomed program manual: an electronic Wiki Web site for group members.

While all the information contained already exists in a paper manual, staff meeting minutes or forwarded e-mails, Dr. Li says that the Wiki gives everyone not only the same information, but a forum for comments. That interactivity, he notes, has been a double-edged sword.

On the plus side, Dr. Li notes, the Wiki is readily accessible on PDAs and the Internet. The downside? “It gives an instant soapbox for people to share their views with others in the group,” views that can be controversial.

At the same time, the Wiki breaks down barriers between group veterans and new recruits, helping newcomers feel like they belong. “It allows people who have been in the group a long time and those who are new to the group the same size soapbox, so to speak,” Dr. Li points out.

Maintaining a democracy
At Minneapolis’ Abbott Northwestern Hospitalist Service, Dr. Miller devotes nearly all of her half-time position as administrator to communication issues. That includes not only talking to group members, but hospital administrators and physicians in the multispecialty medical group that employs the hospitalists.

Dr. Miller makes liberal use of SurveyMonkey-type online surveys and weekly e-mail updates, as well as regular monthly meetings of both the group’s subcommittees and all physicians. Her goal is to keep group governance as democratic as possible, despite its large size.

Over the years, Dr. Miller says she’s learned the value of building consensus. If schedules are imposed without first being preceded by surveys, trial periods, debate and group decisions, she notes, “it turns into chaos.” That’s why nothing goes on the agenda for the monthly meeting of the full group without first being vetted by one of the group’s subcommittees.

Consensus-building may make meetings run smoothly, but it doesn’t address another challenge faced by large groups: finding ways to make sure that everyone can attend group meetings. One of the biggest problems is covering shifts in a 24/7 environment.

Brian Bossard, MD, founder and CEO of Inpatient Physician Associates, a group of 20 hospitalists that serves two hospitals in Lincoln, Neb., arranges coverage through local primary care physicians for his two-hour quarterly group meetings. Because meetings are now held only quarterly, says Dr. Bossard, “attendance is very good.”

At Virtua Memorial in Mt. Holly, N.J., Erik DeLue, MD, MBA, now oversees a hospitalist program that has grown to 28 physicians in two hospitals. Dr. DeLue has made hour-long group meetings, held every seven weeks, a requirement of the job and arranges a call-in phone connection.

Others who head up big groups “such as Thomas McIlraith, MD, chair of the 51-physician hospital medicine group at Sacramento’s three Catholic Healthcare West hospitals “tie bonus money to meeting attendance. “In a large organization,” Dr. McIlraith says, “you have to have face time.”

Group culture and uniformity
Because creating a sense of identity in large groups is so tough, Mr. Buser recommends splintering the group into smaller teams as it grows, creating clusters of hospitalists who tend to work together. In Minneapolis, Dr. Miller’s group has done just that in response to physician complaints that the small-group feeling can’t be maintained as the group has grown.

Most individual hospitalists are scheduled to work shifts with the same 12 physicians. “You can trade in and out, but you mostly work with that same team,” Dr. Miller says. “It helps build a feeling that you’re in the trenches together.”

Another challenge that large programs face, says Dr. McIlraith, is standardizing how the group works, which applies to everything from shift start-times ” in the case of his group, across three hospitals “to handing off patients. That kind of standardization, he explains, helps people “buy into the fact that they are part of one organization.”

Having individual members of a group work in synch also helps standardize clinical care. That’s particularly important as larger groups try to replicate their success at multiple hospitals in health care systems. This month, for instance, Dr. DeLue is rolling out a new hospitalist program at another hospital in his southern New Jersey health system. Administrators have told him that they want the new group to be “indistinguishable” from his.

While the two hospitals may be vastly different in terms of culture, patient population, staffing levels and histories, the health system wants “uniformity,” Dr. DeLue points out, “not just from a branding standpoint but also from a quality standpoint.”

Growing expectations
While that might seem daunting, leaders of big groups point out that they have an advantage in terms of standardizing care because they have more data.

That’s not to say that data aren’t important for smaller groups. But “when you talk to five people about their outcomes or cost per case, the answer can be, ‘My patients were sicker,’ ” notes Dr. Short from Beverly Hospital. “When you have 30 doctors, you have a comparison group. You can now say, ‘This is the average of our group. This is why you are an outlier.’ You have the power to shape behavior based on data.”

But that advantage can also be a challenge. Larger programs are expected to develop professional infrastructure and management, and they’re judged harshly if they don’t. Large groups are also perceived to be capable of doing more than smaller ones, whether it’s reducing length of stay or ensuring that all inpatients leave with proper immunizations. As you grow, says Dr. DeLue, you should expect more of those types of assignments.

“When you are a bigger group,” Dr. DeLue says, “people expect you to move mountains because you’re controlling the substrate, which is the patients. When you are a smaller group, you get some immunity.”

Administrators, Dr. DeLue adds, just want to see a smaller group “trying hard. But once you are a large program, you are expected to be able to effect change. You are not going to get a free pass.”

Deborah Gesensway is a freelance writer based in Toronto who covers U.S. health care.

Getting big? Your leaders need to evolve

ALTHOUGH BIG AND SMALL GROUPS face many of the same challenges, some problems loom much larger for big programs. Growing groups, for example, often require either a new leader or a new leadership style.

Erik DeLue, MD, MBA, director of the 28-doctor hospitalist group at Virtua Memorial in Mt. Holly, N.J., says he has noticed that he can no longer be as reactive, impulsive or hands-on as when his group was smaller.

“My biggest piece of advice is to not send out any e-mail on the day you want to write it,” says Dr. DeLue. “You always have to think of all the stakeholders and what it means for everybody. You can’t do this on instinct alone; you have to train yourself.”

While the physician leader of a small program can effectively lead by example, physicians heading up groups of 20 or more physicians “will kill themselves trying to do that.” That’s according to Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC, a national consulting and management services company, who says that leaders of big practices need to figure out the right balance between clinical and administrative work. Tilt too far either way, he says, and physicians will lose credibility with their colleagues or neglect a burgeoning administrative workload.

Delegation is a steep part of the leadership learning curve. “I had to learn to let go and realize that I couldn’t be the human resources guy, the quality improvement guy and the contracting guy, and still see patients,” says Weston Chandler, MD, who founded Pacific Hospitalist Associates in Newport Beach, Calif., and has grown the group to almost 40 physicians. Instead, one physician who has an MPH was given the job of heading up quality improvement, while another “the physician with “the calmest personality” within the group “is now director of human resources.

Thomas McIlraith, MD, chair of the 51-physician hospital medicine group at three Catholic Healthcare West hospitals in Sacramento, Calif., says he created a “leadership infrastructure” with a site leader at each facility. He also relies on an RN operations manager who takes care of scheduling and other key administrative issues.

But he emphasizes the importance of knowing where to draw the line on delegation. “One thing I have never been willing to delegate is a relationship with the doctors in my department,” says Dr. McIlraith. “I do all the hiring. I also do all the new orientation of our doctors.”