Published in the August 2014 issue of Today’s Hospitalist
WHEN ROBIT UPPAL, MD, became hospitalist medical director over five hospitals in the OhioHealth system in January 2013, he didn’t find one big happy family. Instead, he found a culture defined by competition.
The competition among the hospitalist groups was fueled by differences: Two of the five groups were in employed models, while three others were private contracted groups. And the hospitals where the groups worked ranged in size from the 400-bed Columbus, Ohio-based Grant Medical Center to the 61-bed Grady Memorial Hospital in Delaware, Ohio.
Not only was morale bad, but recruiting was a nightmare. Potential recruits would find one group talking ill of another, even though both belonged to the same system.
“It was a really bad situation,” Dr. Uppal admits. “We were losing candidates to other systems because they ended up with the impression that we had a lot of broken groups.”
As consolidation sweeps through health care and more hospitalists find themselves working within multisite systems, Dr. Uppal’s experience is becoming more common. For many medical directors, gone are the days when they can focus on just one group. And a growing number of hospitalists have to get used to having their performance compared to colleagues at other sites.
Today, directors of multisite programs often find themselves in the difficult situation of bringing together groups that are used to running their own show. That frequently means merging not only different cultures, but different views on everything from compensation to workload.
At OhioHealth, Dr. Uppal reports that the five separate programs have slowly “but successfully “transitioned to a new culture of collaboration. The key has been making each group feel that it is gaining something from the new alliance.
“You need buy-in and trust that the process will create win-win situations for everybody and strengthen our partnerships with other disciplines,” he says. “That raises the bar for hospital medicine.”
Agreeing to differences
To turn the situation he found around, Dr. Uppal, who had previously been medical director of the hospitalist program at Grant, began by engaging the medical directors of each of the other sites.
They first addressed the contentious issue of hospitalist staffing, creating a standard staffing model that was used to guide the resources allocated to hospital medicine at each site.
“That helped level staffing variations and ensured that each group was supported in a similar way,” Dr. Uppal says. And instituting one recruiting process across all five sites improved both the number of recruits and the percentage of recruits the system was able to retain.
But successfully merging multiple sites into a cohesive entity requires striking a careful balance. Program directors say it’s often critical to leave some variation in place while creating common processes.
Such variations can include compensation. In Maryland, the 10 hospitalists who worked at what is now the University of Maryland Midtown Campus in Baltimore each earned more than the 30-plus hospitalists at the University of Maryland Medical Center when the two sites were brought into the same system in January 2013. Today, the salary differential still exists.
That’s because physicians at the community Midtown facility “were part of a system that was aggressive about performance-based incentives,” explains Ada Offurum, MD, associate chief in the division of general internal medicine for inpatient hospitalist services. Plus, “with lower-acuity patients, they have a higher patient census.” Dr. Offurum notes too that some of the Midtown academic hospitalists also comanage orthopedic patients and do histories and physicals for psychiatry patients.
But other changes were put in place post-merger to help standardize the two groups. For instance, Dr. Offurum notes, the Midtown physicians, who had been paid by the hour through a hospitalist staffing agency moved to the same compensation model as the university physicians. That was part of the new standard contract that included a yearly (not hourly) salary.
Room for variation
Moonlighting fees between the two sites were also adjusted. Because the moonlighting fee at the main university campus was less, “it was impossible to advertise that amount juxtaposed with Midtown’s,” Dr. Offurum explains. “Fees there were set by Midtown leadership because there needed to be enough house officers or moonlighters to cover patients for private doctors.” The compromise was to lower Midtown’s fees for hospitalists under the university umbrella while keeping the fees at the main university hospital the same.
Agreeing to maintain some differences, she points out, is part of the process because the connection between the facilities still reads more like a partnership than a complete merger. “Technically, some faculty are under one school of medicine umbrella,” says Dr. Offurum. “But there are still many faculty and departments operating as separate entities.”
Agreeing to maintain differences also works for Billings Clinic, a physician-led multispecialty group practice and hospital system. The wide-ranging system includes outreach clinics and 11 affiliated critical access hospitals across Montana and Wyoming, as well as a 285-bed hospital in Billings, Mont., and a 90-bed skilled nursing facility. Clinics are in rural communities throughout the region.
Among Billings Clinic’s 30 employed physicians who practice at affiliated critical access hospitals, 25 provide some inpatient care to their local community hospital, while five function solely as hospitalists. It takes work to provide coverage that’s consistent yet honors each rural facility’s needs and culture.
“We’re trying to create a system across a large geographical area that everybody is comfortable and familiar with,” says Clint Seger, MD, medical director of regional services. It’s been important to put common processes in place for patient transfers “who to call, for instance “given the complexities of transferring patients 100 miles or more to the closest tertiary center.
And Billings Clinic’s unique situation makes compensation complex, Dr. Seger says, because payment varies based on doctors’ contracts with individual facilities. Staffing models also vary widely. At one hospital near Yellowstone National Park, for example, doctors work 24-hour shifts.
When bringing hospitalist practices together, program directors say it’s important to start with operational issues like staffing and scheduling. That was the approach taken by Colin Findlay, MD, and Albert Soriano, MD, who became co-clinical chiefs of hospital medicine last year with Sentara Medical Group in Norfolk, Va. Sentara has two chiefs running its hospitalist program to better coordinate the group’s 90 hospitalists in eight hospitals and to allow the chiefs to remain clinically active.
“Any successful hospital medicine program has to start with happy doctors, so a set of operating principles creates that,” Dr. Findlay says. “Have specific guidelines and then be flexible.”
Hospitalists need, he adds, reasonable daily patient volume, reasonable compensation and a reasonable number of shifts per month “to be happy coming to work every day. We try to control the daily workload because that promotes quality.” Once quality is built into the system, “we let the groups be reasonably autonomous.”
Most multisite directors say getting started right away is also important. When bringing new programs into a system, it will take months to discuss and decide what changes may be needed, so don’t waste time getting started.
“There’s a one-year honeymoon,” says John Colombo, MD, chief hospitalist at Crozer Keystone Health System in Drexel Hill, Pa. “You’re better off getting as much done earlier than later because you’re being measured on results.”
And you may want to start with “low-hanging fruit,” suggests OhioHealth’s Dr. Uppal. One of the first initiatives that his team developed was a system-wide hospital medicine scorecard.
That scorecard included metrics on quality, service and length of stay. Collaborating on the project helped group members learn to work as a team, while putting the focus on some areas of opportunity.
Dr. Uppal recommends saving more contentious issues “which could include compensation changes or adopting standardized order sets “until you’ve established trust and some common ground. “You can try to jam things through and get quick ‘wins,’ ” he explains.
“But if you are not building trust and engagement, you may jeopardize long-term success.”
Go big first?
But other directors point out that they have succeeded by first tackling big issues. When he joined his five-hospital system two and a half years ago, Dr. Colombo standardized everything from corporate benefits and incentives to job requirements and descriptions, a move that initially wasn’t popular.
One group, for example, had been getting its incentive bonus so regularly that the physicians felt it was part of their salary, and they bristled at getting less than 100%. But standardization leveled the playing field among the various programs, Dr. Colombo says, and led to broader buy-in.
He also looked at census across the system to determine staffing for the four hospitalist groups, settling on 16 shifts per month. He used that figure to determine the number of FTEs needed at each site.
He avoided pushback, Dr. Colombo says, by being transparent about the process and about how decisions were being reached. He also recommends focusing on the relationship with each group to resolve any hurt feelings.
Then think big. Once basic administrative fires are doused, look to bigger issues, says Sentara’s Dr. Findlay. “The challenge is to move from worrying about staffing to changing systems of care and making meaningful, lasting improvements,” he says. Both Drs. Findlay and Soriano, as well as the Sentara site leads, are actively involved in a new system-wide initiative to define and operationalize best practices. That effort, he notes, will hopefully decrease variation throughout the Sentara system.
Avoiding culture clash
Directors point to another potential pitfall: allowing big hospitals and their culture to dominate smaller ones once they are in the same corporate fold.
Dr. Uppal says he makes a concerted effort to avoid that scenario. Given some of the adversarial relationships that existed when he first became medical director, he took pains to promote consensus.
“I’ve been very careful to be agnostic of where ideas come from and whether the hospitalists are employed or not,” he says. “I do not want a situation where the employed group is driving things.” If that were the case, he adds, “we wouldn’t have the engagement we have.”
In Maryland, Dr. Offurum similarly says she goes to bat to ensure that the culture of the much larger university hospital doesn’t dominate. “I’m advocating for Midtown at the larger table,” she says. “It would be easy for us at the university to hand down decrees.”
At PinnacleHealth in Harrisburg, Pa., it was one thing to standardize patient satisfaction initiatives between the 425-bed Harrisburg Hospital and the 140-bed Community General Osteopathic Hospital three years ago. It was quite another to honor the individual cultures, yet make them fit together.
At the larger hospital, which serves a more urban population, physicians were allowed to be less connected to the rest of the staff and community, for instance, while doctors at the smaller hospital played a much more visible role.
“The hospitals are 10 miles from each other, but they’re culturally miles apart,” says Larry Appel, MD, MBA, who became medical director of the hospitalist program two and a half years ago.
Instead of letting the larger hospital dominate, he made sure the smaller hospital was represented in committee leadership. He also keeps an office and works shifts at the smaller facility, lectures to the medical students and residents there, and even serves hamburgers at their staff picnic.
Given that PinnacleHealth’s 26 hospitalists spend 10% of their time at a location other than their home base, some standardization between groups was called for. Dr. Appel moved the doctors at the smaller hospital to the seven-on/seven-off schedule already in place in Harrisburg. At the same time, he reduced the census of the Harrisburg doctors “which could hit 25 a day “to be more on par with the 15 to 20 that was more typical at Community General Osteopathic. He also instituted geographic rounding at both locations and brought in an operations manager to help oversee both programs.
Maintaining a team lead at each hospital helps ensure that its culture remains intact, says Sentara’s Dr. Soriano. “That person is active onsite to align the group to the administrative needs of the hospital because there’s a cultural difference.”
The goal is to respect differences but function like one entity, Dr. Colombo says. Although Crozer hospitalists have a home hospital, he’s working on cross-credentialing staff to be able to move hospitalists from one group to another when some are being slammed. “If I’m shorthanded at one place or overstaffed at another,” he says, “I can have somebody slide over.” Dr. Colombo notes that it’s also important to learn each group’s culture first-hand by working shifts at each hospital. Even now, he fills in if needed, and he keeps an office and an administrative assistant in each hospital. His next step is to identify a site leader at each facility.
It helps, Dr. Colombo adds, if you avoid “wild customization” at individual sites. “Medical staffs can be hard to integrate,” he points out. “It’s a big change to have doctors think of their system first and their hospital second.”
Collaboration across OhioHealth’s hospital medicine program continues to grow, thanks in part to having a regular venue for cross-campus communication. The medical directors across all sites meet regularly, and 25 of the system’s 150 hospitalists serve on a clinical guidance council created a year ago.
They meet monthly to address such issues as multidisciplinary rounding and medication reconciliation. They are currently collaborating on implementing an Epic EHR as well as optimizing order sets, workflow and documentation.
Hospitalists at Crozer also have mandatory monthly meetings within each group, but they can attend another group’s meeting if they choose. (Dr. Colombo attends them all.) Drs. Soriano and Findlay meet with their sites monthly to provide feedback about metrics and performance.
Getting on the same page across different programs has payoffs. At PinnacleHealth, for instance, Dr. Appel says that HCAHPS scores across the system have jumped 15%, and heart failure mortality has dropped significantly.
He points out that there are now frequent social gatherings and quarterly dinners for the entire hospitalist staff hosted by the chief medical officer. Proof of success has been how seamlessly the system recently brought the 108-bed West Shore Hospital into the fold. Its lead physician is from the osteopathic hospital, while one director is from Harrisburg.
“We’ve created a nice, blended culture there,” he says. “It’s a good marriage of both worlds.”
But perhaps the greatest proof is in physician retention. Before he came on board, Dr. Appel notes that 12 of what then were 18 hospitalists, including the previous director, had left. Since he’s been there, there’s been only one unplanned resignation among the 26 hospitalists and 14 physician assistants.
In rural communities, hospitalist retention needs to be monitored because resources are limited and there is a great need for services. “When you’re the one doctor working 24-hour shifts, you can easily get six admissions in a night,” Dr. Seger says. “If there’s no backup or someone coming in the next day, it can be very challenging.”
Much of forming a workable alliance within a network with a large geographical footprint is organizing coverage. When a hospitalist in a single-hospitalist coverage model is sick, for instance, “we may need to take a provider out of scheduled clinic time to function in a hospitalist role,” he says.
Dr. Seger keeps his clinical skills sharp by working one weekend a month at West Park Hospital in Cody, Wyo. At the same time, he travels a minimum of 500 miles a week to visit the many Billings Clinic-affiliated hospitals in rural communities to listen to their concerns and adjust their schedules as needed.
“You have to connect with people to understand their experiences,” he says.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.