“There’s no limit to how complicated things can get, on account of one thing always leading to another.”—E.B. White, Charlotte’s Web
E.B. White may not have been talking about hospitalists and their facilities, but he could have been. We are intricately involved in our facilities and, as we begin to make changes for our patients by changing the system and its processes, one thing leads to another.
Why should we bother to have partnerships with our facilities?
Hospitalist medicine has a unique feature: We need a facility to practice in. An ambulatory physician, while maintaining an office, can choose from a number of facilities. Unlike some procedural specialists, we cannot take our patients to an outpatient surgical center or other venue. If our hospital is not performing well, we have a difficult practice situation. It is imperative that we work with our facilities to ensure their success. We can create a rewarding practice environment by creating a highly functioning partnership.
If our goal is to deliver great care to patient populations, we cannot do this alone. In order for us to leverage our specialized knowledge we must leverage and master our partnerships with our facility. Ideally, in a partnership the objectives, values, and approaches are mutually reinforcing. There is agreement on the short-term and long-term goals. By operating with others in this partnership, new levels of unexpected performance are generated.
But partnership is a difficult thing. Though we are intricately entwined with the hospitals in which we practice, often we are not partnering. Partnerships occur at different levels. We may be partnering at a level that does not encourage results. In the dysfunctional partnership, the parties perceive little or no mutual benefit. They apply competitive negotiation skills to get their way regardless of the impact on relationships or outcomes. No one is really committed to anyone. Many times in a partnership, we demand what we want:
- A case manager for our team, seven days a week;
- A better office or computer system;
- Better emergency department procedures; or
- More time off.
Such demands without discussion and without consideration of the other’s point of view occur in a dysfunctional partnership.
But we have the opportunity to move these discussions in a positive manner because there are so many things that we directly control that cause the success or failure of our facilities. Our recognition of these needs can create an opportunity for us to prove our ability to partner. Typically, physicians have not supported administrative initiatives. It is well known that most administrators see the doctors as a project to work around instead of a partner in their success. Indeed for years many doctors established a sport of thwarting administrative plans and ideas; however, we need to proactively establish a new paradigm where we are the partners in improving care for our patient populations. Stuck for ideas on overlapping opportunity? Here are a few thoughts.
Everyone hears about medical record timeliness at their facilities. But why does anyone care about this? Does the Medical Executive Committee like to send out suspension letters? Do the individuals in medical records like to harass doctors? Of course not; this is a matter of vital financial interest to the hospital. The medical record cannot be billed until the record is complete: all consultations, discharge information, admission dictations, and all signatures.
Imagine how it must be to have your income held up because of someone else’s failure to perform. Imagine how frustrated you would be if your paycheck was held up because a nurse had not finish charting. A proactive stance on this mission-critical issue for the hospital demonstrates the group’s commitment to its partner. Taking a proactive stance on this often leads to reorganizing and reworking the medical records department processes. Taking the first step demonstrates your interest in the needs of others. It may lead to an electronic medical record or new systems. A partnership starts to evolve.
Patient satisfaction is a tricky item. It varies greatly and is based on how and when information is collected. We can take the stance that these are flawed results and of no interest to us, or we can choose to identify the key elements that we can affect. By choosing to participate in a project, our partnership can grow. This may mean learning a great detail about something non-medical and then figuring out how to best communicate that to the physician team. It may involve learning from other experts: risk management specialists, skilled executives, and statisticians. It may result in changing the system of collection, reporting, and feedback. This change benefits all parties, not just one over the other.
A project that has great value for our partners is to improve their financial performance by collaborating on documentation. A hospital is paid very differently than a physician. The hospital’s income depends on what physicians write in the chart. This puts them in a position of dependence on physician handwriting! The difficulty for doctors is that the term definitions in some cases do not correspond to medical terms. By creating a program where the physicians meet weekly with a facility expert, dialogue can foster a partnership. The physicians provide the willingness to learn and the facility provides the expertise and time in a supportive manner. The physician gains an appreciation for the idiosyncrasies of hospital payments and can assist in improving the case mix index and diagnosis capture. When hospitalists and the hospital work together the facility becomes more financially stable and, therefore, the future jobs of the hospitalist group become more secure.
Everyone likes working in a happy and safe environment. As part of that environment, we have responsibilities to our fellow workers. We can complain about performance of our non-physicians colleagues or we can proactively partner to improve our relationships with them. In addition to the obvious—treating them with respect and as part of the team—we can create processes to improve their daily work.
How much variation is there among the way your group approaches diagnoses? Can the nursing and pharmacy staff assume a consistent approach for each patient? Our goal—to create care for patient populations not individual patients—must address this. Do you extract their expertise when designing these care programs? It can be of great value to us in assisting our patients and redesigning care. It creates an environment of value and satisfaction that leads to retention. Why do we care about retention? A stable nursing, therapy, social work, and case management staff adds to our daily satisfaction. We can’t get there alone. We need to partner with our co-workers with inclusion and education.
How about the emergency department? There is often a strain in our relationship with these important colleagues. Are we creating programs, process, and guidelines with our professional colleagues that work for everyone? There are many important points of collaboration, and sometimes we need to extend a hand first to get forward momentum.
Some partnerships are characterized by an integration of value and skills—interdependence. Commitment and coordination across activities is a common factor. If our goal is to achieve an excellence in partnering with our facilities, we need to begin the dialogue about what we can accomplish in common that supports both parties. It appears we are interdependent, but moving to partnership is a more mature step.
There are endless projects on which we can collaborate to move our patients, our communities, our facilities, and ourselves to a better place. Let’s start with one action toward one goal. As one thing leads to another, we can achieve things that we never thought possible. TH
Dr. Gorman is the president of SHM.