Published in the November 2004 issue of Today’s Hospitalist
Your hospitalist program has been up and running for a couple of years, and things are going well. You’ve picked up the care of unassigned patients, reduced length of stay and made a significant dent in costs.
While your program is growing and hospital administrators are happy, you know that now is not the time to rest on your laurels. In a what-have-you-done-for-me-lately world, you realize that you need to keep an eye on the future and look for ways to expand your program’s mission.
But what exactly does that mean? If you’re like many programs, you’re already swamped by requests for consults from your colleagues in surgery, psychiatry or ob/gyn, and you and your colleagues are already serving on multiple committees. What services are so important that you absolutely need to make room for them on your already crowded plate?
While the details differ from program to program and hospital to hospital, veteran hospitalists point to a few concepts that can keep hospitalist programs on a strong growth track. Here’s a look at how several well-established hospitalist programs have grown into their roles as leaders of the inpatient environment–and some of the lessons they’ve learned along the way.
Pay for performance
One of the prime areas that hospitalist programs expand into is quality improvement, and for good reason. According to Tosha Wetterneck, MD, a hospitalist and assistant professor of medicine at the University of Wisconsin, safety improvement represents the single most important area of focus for maturing programs.
“For a long time, hospitals have looked to physicians for help with quality and safety, but they have had a hard time identifying physician champions for those initiatives,” says Dr. Wetterneck, who spends nearly one-third of her time on quality improvement and safety projects. “Hospitalists have brought that to the forefront. With the current regulatory environment, hospitalists are being looked to as champions for these efforts.”
And while academic centers have typically been more willing to give individual hospitalists time to serve on quality improvement initiatives, a new trend in quality improvement–pay for performance–may draw even the busiest community-based hospitalists into quality improvement activities.
As the federal government and agencies like the Joint Commission on Accreditation of Healthcare Organizations roll out pay-for-performance plans, hospitals are feeling pressured to meet an ever-rising performance-measurement bar. At the same time, they face stagnant reimbursements and stiffening competition. Many feel squeezed on all sides.
The good news for hospitalist programs is that they are in an ideal position to help their hospital–and themselves. “Hospitals have to be mean and lean, and the hospitalist program, if it’s designed intelligently, is in a perfect position to lead that effort,” says Ron Greeno, MD, CEO of Cogent Healthcare in Irvine, Calif.
A prime example of how hospitalists are helping address pay-for-performance initiatives can be found in Mercy Inpatient Medical Services in Springfield, Mass. Winthrop Whitcomb, MD, a veteran hospitalist who heads the program and co-founded the Society of Hospital Medicine, says that pay for performance is hands down the most important new development in the quality improvement arena.
While a relatively small group of payers is pioneering the concept, he says, Medicare already has plans to offer quality incentives, and it’s just a matter of time before others jump on board. He predicts that in the not-too-distant future, payers of all stripes will demand an expanded “portfolio of quality measures” and evidence of improved care processes.
Dr. Whitcomb’s 14-physician program, which celebrated its 11th anniversary this year, recently became one of the first hospitalist groups in the country to participate in a pay-for-performance plan. Blue Cross Blue Shield of Massachusetts is offering financial incentives to hospitals that meet targets for giving pnuemococcal vaccine to inpatients with pneumonia, prescribing ACE inhibitors to patients with congestive heart failure, and assessing left ventricular function in patients with various cardiovascular conditions.
Because Mercy’s hospitalists manage 80 percent of medicine patients, the group’s doctors will receive a substantial bonus if they meet or exceed those targets. Nine months into the program, the group has increased the number of patients who receive a pneumococcal vaccination from 45 percent to 87 percent, Dr. Whitcomb notes, and it expects to receive a bonus.
Room for growth
Pay for performance may be the wave of the future, but you don’t have to take part in a cutting-edge incentive program to broaden your program’s role in quality improvement. Hospitalist programs can come to the rescue in many ways, from helping hospitals document and substantiate their quality improvement initiatives to standardizing protocols and clinical pathways.
Larry Vidrine, MD, medical director of Team Health in Knoxville, Tenn., which operates 17 hospitalist programs, sees a long list of needs. In recent months, Team Health’s clients have asked hospitalists to take on everything from assuming primary responsibility for admitting subspecialists’ emergency department patients to handling perioperative consults of surgical patients and backing up over-burdened ICU intensivists.
Hospitalists, for example, are beginning to take a larger role in palliative care management, which Dr. Vidrine views as a natural fit. “What hospitals expect from their groups varies significantly,” Dr. Vidrine says, “but it is clear that there are plenty of potential opportunities for maturing hospitalist programs.”
In particular, he sees the handling of emergency department admissions for subspecialists as a chief value-added service that maturing hospitalist programs are providing–and one for which demand will grow. “It’s a function of the shortage of subspecialists and the demand that is occurring with ED admissions,” Dr. Vidrine says. “Many of these patients have medical comorbidities that some subspecialists, frankly, don’t feel comfortable managing anymore.”
“That, and perioperative management, are two areas where hospitals are coming to us and asking if we can help,” he explains. “We’re also getting more requests for services that emulate intensivist programs.”
While Anthony Ferkich, MD, administrator of the hospitalist program at Paradise Valley Hospital in National City, Calif., agrees that quality improvement efforts like clinical pathways have been key to his program’s success, he hopes to next tackle the notoriously thorny exchanges between hospitalists and specialists. The goal is to more clearly delineate who will admit which patients and who will assume primary post-admission responsibility.
“We need to have clear definitions for admission criteria that state which service is responsible for which patients,” Dr. Ferkich says, “but this is a politically difficult area. I would say that the perfect fourth-generation program would be one in which the consultants adhere to what the hospitalists recommend.”
Even as they face pressure to expand their services or enter into risk- and reward-sharing arrangements, some hospitalist programs are being challenged to demonstrate, with hard numbers, the value they bring.
In response, savvy hospitalist programs are setting up systems to gather the data they need to demonstrate that value, says Martin Buser, MPH, a founding partner of Hospitalist Management Resources LLC, a hospitalist consulting firm with offices in San Diego and Colorado Springs, Colo. Programs that are behind the data curve, he adds, have begun scrambling to make up for lost time. “The first thing we ask when we assist a hospitalist group renegotiate their financial support,” Mr. Buser says, “is, ‘Show me your data!’ Unfortunately, most don’t have it.”
“The better maturing programs have set up systems that benchmark their performance, monitor length of stay, target outliers, track denied days, and monitor patient, physician and nursing satisfaction,” Mr. Buser explains.
And while collecting data may be critical, Mr. Buser emphasizes that hospitalist programs must also go a step further and talk to hospital administrators to review those data and their performance. Quarterly meetings, he notes, are one way to build strong relationships with both hospital administrators and clinical leadership.
“You want to get to know them before you need them to renew your contract,” Mr. Buser advises. “You want to be able to show them how you’re performing, before they ask, ‘What have you done for me lately?’ ”
Even academic center-based programs can expect to feel some heat when it comes to performance, suggests Peter Kaboli, MD, a hospitalist at the University of Iowa Hospitals and Clinics and the Iowa City VA hospital.
“Because we’re recognized as a group with an inherent interest in inpatient care,” Dr. Kaboli says, “people are coming to us with their problems, and they’re expecting that we can help.” His group, for example, was recently charged with leading an initiative to improve test utilization.
“One of the central issues in evolving hospitalist programs is whether there is a need to prove their value beyond just some increased efficiency, and I think we’re seeing that,” Dr. Kaboli adds. “After all, the length-of-stay [reduction] story only goes so far. It becomes a matter of what programs can do to show continued value when reducing length of stay another half-day isn’t feasible–or clinically advisable.”
And if you can collect good data and prove your value, you’re less likely to encounter resistance to requests for support down the road, whether it’s in the form of compensation or personnel to bolster operations.
The six-year-old hospitalist program at Palomar Medical Center in Escondido, Calif., has become the hospital’s darling because of its track record in managing inpatients and ensuring they don’t “crash” after they leave. It also serves as a case study in how hospitalist programs can parlay a good relationship and reputation into more resources to further their mission.
“We were able to clearly show that we provide length-of-stay benefits and reductions in costs per admission and returns to the ER,” says Dan Harrison, MD, medical director of Palomar Hospitalists. “The administrator appreciates that, and that’s why we now have a lot of things that people consider second generation.”
For example, the eight-physician program now has a dedicated team coordinator–someone Dr. Harrison describes as the group’s “den mother” and a dedicated discharge planner. Both positions are supported by hospital funds.
The team coordinator takes notes during daily rounds and coordinates all aspects of specialists’ consults, ensuring that each patient leaves with an appointment for follow-up care. The discharge planner acts as a hospital liaison, handling post-discharge issues that range from skilled nursing facility placement and DME orders to home health care.
And in a lesson for other hospitalist programs, the Palomar group has woven itself into the very fabric of the hospital. It regularly communicates with hospital administrators, both in meetings held once a month and more frequently via e-mail, and it makes sure that each hospitalist assumes a key committee position.
While Dr. Harrison is now chair of pediatrics, he was formerly chair of medicine. “The hospital loves us because we’re the committee members who actually show up,” he quips.
Across the country at Lee Memorial Healthcare System in Fort Myers, Fla., hospitalists’ vital role in quality improvement efforts has led to a tight relationship with hospital administrators.
“At this point, we’re considering hospitalists strategic partners,” says Chuck Krivenko, MD, Lee Memorial’s chief medical officer for clinical and quality services. “They come to our major quality management meetings, they are invited to our clinical performance committee meetings, and because they’re managing more than a third of our admissions, we’ve come to think of them as a vehicle to change our culture.”
Because of that relationship, Lee Memorial’s hospitalists are included in a host of initiatives. In one project, they are helping to create an innovative discharge scheduling program that sets timeframes for patient discharge times.
The goal is to free up vacated beds within an hour of a patient’s departure. The system can also provide an “air traffic controller’s” view of bed availability at any given moment.
The importance of leadership
Regardless of the exact direction hospitalist programs take, industry experts say that a proactive stance will be crucial to long-term success.
Cogent’s Dr. Greeno says that while hospitalist programs need to take a lead role in systems improvement, they also need to do a better job of cultivating physician leaders within their ranks. While he thinks the area of leadership skills has received short shrift among many programs, he says it’s quickly becoming a requisite for second- and third-generation programs.
“Hospitalists need to identify the people in their programs who have leadership capabilities and then provide the training they need to develop those skills,” Dr. Greeno explains. “It isn’t rocket science, just a lot of hard work. And it’s a matter of putting the resources into it.”
Mark Weiner, MD, president of hospitalist services for Team Health and a longtime consultant in hospitalist program development, adds a further recommendation: Position your program to serve as an incubator of sorts for any initiative the sponsoring hospital wishes to pursue.
“Because of their creativity and the fact that hospitalists have become a component part of the hospital,” Dr. Weiner says, “hospitalists have an opportunity to serve as an incubator for new and pilot projects, whether it’s hands-on clinical trials of new procedures or implementation of protocols. That’s an opportunity hospitalists are just beginning to address.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.
A veteran hospitalist program’s strategies for success
While many hospitals are getting their first hospitalist program up and running, a handful of third- and even fourth-generation hospitalist programs have been flourishing for years. The hospitalist program at Baptist Hospital in Pensacola, Fla., is not only one of the forerunners of the movement, but a good example of the cutting-edge nature of the specialty.
Like hospitalists everywhere, the physicians in the Baptist Hospital program were originally brought in to care for unassigned patients and provide relief for primary care physicians. Over the 10-plus years the program has been functioning, however, it has become a key player in virtually every area of clinical care operations.
After meeting its initial objectives, the four-physician service began managing patients for orthopedic surgeons, general surgeons and neurosurgeons. Today, the program is taking a lead role in helping Baptist, recent winner of the coveted Malcolm Baldrige award, meet the new quality standards established by Medicare and the Joint Commission on Accreditation of Healthcare Organizations.
Because the hospitalists care for 40 percent to 45 percent of medical admissions, explains Craig Miller, MD, Baptist’s senior vice president of medical affairs, they have taken on initiatives like inappropriate order abbreviations. Hospitalists also closely manage disease states like community-acquired pneumonia, congestive heart failure and acute MI.
And while Baptist has charged its hospitalists, who work for Cogent Healthcare, with running these initiatives, it has given them a financial stake in their success. The hospital has set aside an incentive of $300,000 and plans to reward its hospitalists based on how well they adhere to nine quality parameters.
“We’ve learned that it’s easier to go to four or five doctors, give them the support they need and ask, ‘Can you help us?’ ” Dr. Miller says, rather than approach 50 physicians and try to enlist their support.