Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.

And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.

And enjoy all the amenities of a first-class hotel and conference center under one roof.

And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.

But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.

Choosing Wisely

Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.

Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.

On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”

New Featured Speaker

Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.

Get Your Conference In Hand

Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.

The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.

For links to download the HM13 app, visit www.hospitalmedicine.org.

Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.

And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.

And enjoy all the amenities of a first-class hotel and conference center under one roof.

And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.

But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.

Choosing Wisely

Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.

Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.

On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”

New Featured Speaker

Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.

Get Your Conference In Hand

Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.

The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.

For links to download the HM13 app, visit www.hospitalmedicine.org.

Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.

And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.

And enjoy all the amenities of a first-class hotel and conference center under one roof.

And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.

But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.

Choosing Wisely

Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.

Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.

On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”

New Featured Speaker

Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.

Get Your Conference In Hand

Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.

The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.

For links to download the HM13 app, visit www.hospitalmedicine.org.

Have you ever prescribed stress ulcer prophylaxis therapy to patients at low risk for gastrointestinal complications? Have you ever repeated CBC or chemistry testing in the face of clinical and lab stability? Have you once or twice ordered bronchodilators for children with bronchiolitis?

If you answered “yes” to any of those questions, you might want to reconsider some of your practices. That’s the message hospitalist leaders have for adult and pediatric HM practitioners interested in curbing wasteful healthcare spending.

SHM has joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, a multiyear effort to spark national dialogue about waste in the healthcare system and the kinds of common treatments that doctors and patients should think twice about before deciding to pursue. Ad hoc subcommittees of SHM’s Hospital Quality and Patient Safety Committee created lists of five adult and five pediatric treatments that hospitalists and their patients should question. Those lists were shared alongside 15 other medical specialty societies at a Feb. 21 news conference in Washington, D.C.

Dr. Wolfson

Choosing Wisely (www.choosingwisely.org) has been recognized by the professional and consumer media in a big way, says Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, which is affiliated with but distinct from the American Board of Internal Medicine (www.abim.org). “The conversation about overuse is now on the table, and people recognize that it’s an important subject to talk about—without the kind of hysterics that we’ve seen previously around, for example, rationing,” he says. “We’re talking about treatments that are not beneficial and potentially are harmful to patients … things that are ordered for many patients when the benefit does not exceed the risk. These are not absolutes; there are times when a treatment might be indicated because of a certain history or clinical finding. But be clear on what those circumstances are.”

SHM is excited to be a partner in the Choosing Wisely campaign, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. With its broad professional and consumer outreach and emphasis on informing and engaging the consumer, the Choosing Wisely effort meshes well with the center’s QI and patient safety goals.

“We acknowledge that there is waste in our system. We also believe that if you have an engaged, empowered patient, together you will make better choices, have less waste, and probably also reduce costs,” Dr. Maynard says.

Developing SHM’s “think twice” lists under a tight deadline was a challenge, says John Bulger, DO, FACP, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa., and chair of the adult committee. It was especially difficult trying to encourage the broadest possible input from experts in the field. SHM board and committee members were asked for suggested treatments that should be targeted as wasteful, and a preliminary list of 100 was grouped, whittled down, and sent to SHM members to vote on. The committee conducted two blind votes and sent a list of seven recommendations to the SHM board, which made the final choices for submission to the ABIM Foundation.

“The ABIM Foundation has fairly strict guidelines for Choosing Wisely,” Dr. Bulger says. The process was meant to be transparent and well documented, and the SHM committees will publish an article in the Journal of Hospital Medicine describing how its lists were compiled. Choices were to be made based on the evidence for treatments that lie within the specialty’s purview. “Because our practice is so diverse, you can find many core treatments that hospitalists impact on a daily basis and that are unique to the work of hospital medicine,” Dr. Bulger adds.

Fourteen pediatric hospitalists followed a similar process in developing its five suggestions.

“While this issue has been addressed in adult settings, in pediatrics, discussions about waste are almost nonexistent,” says Ricardo Quinonez, MD, FHM, a pediatric hospitalist at Texas Children’s Hospital in Houston and chair of the pediatric ad-hoc committee. “I don’t think anyone was too surprised by our list, which is heavy on respiratory illnesses. That’s what kids get admitted to the hospital for.”

Dr. Quinonez

Dr. Quinonez suggests pediatric hospitalists use the list to engage with their specialist colleagues about appropriate treatment choices. “If you want to improve quality, here’s a place to start,” he says.

Dr. Bulger

Dr. Bulger encourages hospitalists to stop and take a long look at the lists and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committees and start collecting baseline data, he says, adding that “we should be able to come back a year from now and show that we’ve been able to change practice using these lists.”

A full-day pre-course, “QI for High Value Healthcare: Making the ABIM Foundation’s Choosing Wisely Campaign a Reality,” co-led by Dr. Bulger and Ian Jenkins, MD, of the University of California at San Diego, is planned for HM13 in Washington, D.C., in May (www.hospitalmedicine2013.org).

“[The pre-course] will feature the Choosing Wisely list and how you can both implement and improve on it,” Dr. Maynard says. Longer-term, SHM hopes to compile protocols, order sets, checklists, and other tools for posting on its technical assistance web pages. “Eventually, there may be a mentored implementation program and toolkit, based on best practices from the field. … Lots of people have done bits and pieces of this in their local settings. What’s lacking is a cohesive, portable approach, and that’s what we have our eyes on.”

Wolfson says the ABIM Foundation plans to conduct surveys in the next six months to gauge whether physicians think they should be stewards of healthcare resources. “I think you’ll start to see at leading institutions where it’s no longer just ‘Why didn’t you order this test?’ But ‘Why did you—and what were you hoping to learn from it?’” he says. “Just asking that question is a good start—and saying to yourself: Am I choosing wisely?”

Larry Beresford is a freelance writer in Oakland, Calif.

Have you ever prescribed stress ulcer prophylaxis therapy to patients at low risk for gastrointestinal complications? Have you ever repeated CBC or chemistry testing in the face of clinical and lab stability? Have you once or twice ordered bronchodilators for children with bronchiolitis?

If you answered “yes” to any of those questions, you might want to reconsider some of your practices. That’s the message hospitalist leaders have for adult and pediatric HM practitioners interested in curbing wasteful healthcare spending.

SHM has joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, a multiyear effort to spark national dialogue about waste in the healthcare system and the kinds of common treatments that doctors and patients should think twice about before deciding to pursue. Ad hoc subcommittees of SHM’s Hospital Quality and Patient Safety Committee created lists of five adult and five pediatric treatments that hospitalists and their patients should question. Those lists were shared alongside 15 other medical specialty societies at a Feb. 21 news conference in Washington, D.C.

Dr. Wolfson

Choosing Wisely (www.choosingwisely.org) has been recognized by the professional and consumer media in a big way, says Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, which is affiliated with but distinct from the American Board of Internal Medicine (www.abim.org). “The conversation about overuse is now on the table, and people recognize that it’s an important subject to talk about—without the kind of hysterics that we’ve seen previously around, for example, rationing,” he says. “We’re talking about treatments that are not beneficial and potentially are harmful to patients … things that are ordered for many patients when the benefit does not exceed the risk. These are not absolutes; there are times when a treatment might be indicated because of a certain history or clinical finding. But be clear on what those circumstances are.”

SHM is excited to be a partner in the Choosing Wisely campaign, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. With its broad professional and consumer outreach and emphasis on informing and engaging the consumer, the Choosing Wisely effort meshes well with the center’s QI and patient safety goals.

“We acknowledge that there is waste in our system. We also believe that if you have an engaged, empowered patient, together you will make better choices, have less waste, and probably also reduce costs,” Dr. Maynard says.

Developing SHM’s “think twice” lists under a tight deadline was a challenge, says John Bulger, DO, FACP, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa., and chair of the adult committee. It was especially difficult trying to encourage the broadest possible input from experts in the field. SHM board and committee members were asked for suggested treatments that should be targeted as wasteful, and a preliminary list of 100 was grouped, whittled down, and sent to SHM members to vote on. The committee conducted two blind votes and sent a list of seven recommendations to the SHM board, which made the final choices for submission to the ABIM Foundation.

“The ABIM Foundation has fairly strict guidelines for Choosing Wisely,” Dr. Bulger says. The process was meant to be transparent and well documented, and the SHM committees will publish an article in the Journal of Hospital Medicine describing how its lists were compiled. Choices were to be made based on the evidence for treatments that lie within the specialty’s purview. “Because our practice is so diverse, you can find many core treatments that hospitalists impact on a daily basis and that are unique to the work of hospital medicine,” Dr. Bulger adds.

Fourteen pediatric hospitalists followed a similar process in developing its five suggestions.

“While this issue has been addressed in adult settings, in pediatrics, discussions about waste are almost nonexistent,” says Ricardo Quinonez, MD, FHM, a pediatric hospitalist at Texas Children’s Hospital in Houston and chair of the pediatric ad-hoc committee. “I don’t think anyone was too surprised by our list, which is heavy on respiratory illnesses. That’s what kids get admitted to the hospital for.”

Dr. Quinonez

Dr. Quinonez suggests pediatric hospitalists use the list to engage with their specialist colleagues about appropriate treatment choices. “If you want to improve quality, here’s a place to start,” he says.

Dr. Bulger

Dr. Bulger encourages hospitalists to stop and take a long look at the lists and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committees and start collecting baseline data, he says, adding that “we should be able to come back a year from now and show that we’ve been able to change practice using these lists.”

A full-day pre-course, “QI for High Value Healthcare: Making the ABIM Foundation’s Choosing Wisely Campaign a Reality,” co-led by Dr. Bulger and Ian Jenkins, MD, of the University of California at San Diego, is planned for HM13 in Washington, D.C., in May (www.hospitalmedicine2013.org).

“[The pre-course] will feature the Choosing Wisely list and how you can both implement and improve on it,” Dr. Maynard says. Longer-term, SHM hopes to compile protocols, order sets, checklists, and other tools for posting on its technical assistance web pages. “Eventually, there may be a mentored implementation program and toolkit, based on best practices from the field. … Lots of people have done bits and pieces of this in their local settings. What’s lacking is a cohesive, portable approach, and that’s what we have our eyes on.”

Wolfson says the ABIM Foundation plans to conduct surveys in the next six months to gauge whether physicians think they should be stewards of healthcare resources. “I think you’ll start to see at leading institutions where it’s no longer just ‘Why didn’t you order this test?’ But ‘Why did you—and what were you hoping to learn from it?’” he says. “Just asking that question is a good start—and saying to yourself: Am I choosing wisely?”

Larry Beresford is a freelance writer in Oakland, Calif.

Have you ever prescribed stress ulcer prophylaxis therapy to patients at low risk for gastrointestinal complications? Have you ever repeated CBC or chemistry testing in the face of clinical and lab stability? Have you once or twice ordered bronchodilators for children with bronchiolitis?

If you answered “yes” to any of those questions, you might want to reconsider some of your practices. That’s the message hospitalist leaders have for adult and pediatric HM practitioners interested in curbing wasteful healthcare spending.

SHM has joined the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, a multiyear effort to spark national dialogue about waste in the healthcare system and the kinds of common treatments that doctors and patients should think twice about before deciding to pursue. Ad hoc subcommittees of SHM’s Hospital Quality and Patient Safety Committee created lists of five adult and five pediatric treatments that hospitalists and their patients should question. Those lists were shared alongside 15 other medical specialty societies at a Feb. 21 news conference in Washington, D.C.

Dr. Wolfson

Choosing Wisely (www.choosingwisely.org) has been recognized by the professional and consumer media in a big way, says Daniel Wolfson, executive vice president and chief operating officer of the ABIM Foundation, which is affiliated with but distinct from the American Board of Internal Medicine (www.abim.org). “The conversation about overuse is now on the table, and people recognize that it’s an important subject to talk about—without the kind of hysterics that we’ve seen previously around, for example, rationing,” he says. “We’re talking about treatments that are not beneficial and potentially are harmful to patients … things that are ordered for many patients when the benefit does not exceed the risk. These are not absolutes; there are times when a treatment might be indicated because of a certain history or clinical finding. But be clear on what those circumstances are.”

SHM is excited to be a partner in the Choosing Wisely campaign, says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. With its broad professional and consumer outreach and emphasis on informing and engaging the consumer, the Choosing Wisely effort meshes well with the center’s QI and patient safety goals.

“We acknowledge that there is waste in our system. We also believe that if you have an engaged, empowered patient, together you will make better choices, have less waste, and probably also reduce costs,” Dr. Maynard says.

Developing SHM’s “think twice” lists under a tight deadline was a challenge, says John Bulger, DO, FACP, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa., and chair of the adult committee. It was especially difficult trying to encourage the broadest possible input from experts in the field. SHM board and committee members were asked for suggested treatments that should be targeted as wasteful, and a preliminary list of 100 was grouped, whittled down, and sent to SHM members to vote on. The committee conducted two blind votes and sent a list of seven recommendations to the SHM board, which made the final choices for submission to the ABIM Foundation.

“The ABIM Foundation has fairly strict guidelines for Choosing Wisely,” Dr. Bulger says. The process was meant to be transparent and well documented, and the SHM committees will publish an article in the Journal of Hospital Medicine describing how its lists were compiled. Choices were to be made based on the evidence for treatments that lie within the specialty’s purview. “Because our practice is so diverse, you can find many core treatments that hospitalists impact on a daily basis and that are unique to the work of hospital medicine,” Dr. Bulger adds.

Fourteen pediatric hospitalists followed a similar process in developing its five suggestions.

“While this issue has been addressed in adult settings, in pediatrics, discussions about waste are almost nonexistent,” says Ricardo Quinonez, MD, FHM, a pediatric hospitalist at Texas Children’s Hospital in Houston and chair of the pediatric ad-hoc committee. “I don’t think anyone was too surprised by our list, which is heavy on respiratory illnesses. That’s what kids get admitted to the hospital for.”

Dr. Quinonez

Dr. Quinonez suggests pediatric hospitalists use the list to engage with their specialist colleagues about appropriate treatment choices. “If you want to improve quality, here’s a place to start,” he says.

Dr. Bulger

Dr. Bulger encourages hospitalists to stop and take a long look at the lists and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committees and start collecting baseline data, he says, adding that “we should be able to come back a year from now and show that we’ve been able to change practice using these lists.”

A full-day pre-course, “QI for High Value Healthcare: Making the ABIM Foundation’s Choosing Wisely Campaign a Reality,” co-led by Dr. Bulger and Ian Jenkins, MD, of the University of California at San Diego, is planned for HM13 in Washington, D.C., in May (www.hospitalmedicine2013.org).

“[The pre-course] will feature the Choosing Wisely list and how you can both implement and improve on it,” Dr. Maynard says. Longer-term, SHM hopes to compile protocols, order sets, checklists, and other tools for posting on its technical assistance web pages. “Eventually, there may be a mentored implementation program and toolkit, based on best practices from the field. … Lots of people have done bits and pieces of this in their local settings. What’s lacking is a cohesive, portable approach, and that’s what we have our eyes on.”

Wolfson says the ABIM Foundation plans to conduct surveys in the next six months to gauge whether physicians think they should be stewards of healthcare resources. “I think you’ll start to see at leading institutions where it’s no longer just ‘Why didn’t you order this test?’ But ‘Why did you—and what were you hoping to learn from it?’” he says. “Just asking that question is a good start—and saying to yourself: Am I choosing wisely?”

Larry Beresford is a freelance writer in Oakland, Calif.

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

Ask supporters and detractors of the seven-on/seven-off schedule their favorite (or least favorite) aspect of the model, and they’ll say the same thing: how it impacts work-life balance.

Heads: “For me, I know that there’s that balance,” says Dr. Houser, who works in Rapid City, S.D. “I know that there are going to be some holidays, some weekends where I’m not going to go to the soccer game or go to the volleyball game or see the choir practice. But the other side of me knows that I will be able to make it up to the kids, if it was something that I missed. I’ll be able to devote that time that I really like to devote to my family when I’m off.”

Tails: “I really believe that [seven-on/seven-off] scheduling is probably more desirable to Generation Y, which tends to have a lot more life quality and life balance as part of their mentality,” says Eshbaugh, the administrator in Traverse City, Mich. “I think the older generation of physicians, especially because they came out of the outpatient world, they were used to working five days a week, every week.”

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

We have been doing some education with hospitals over the last three or four years of just doing the math. We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.

—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.

Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.

Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.

Dr. Houser

Dr. Eshbaugh

Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.

And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.

“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”

Viewpoints Vary

The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”

SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.

Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.

“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”

Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.

Dr. Martinek

In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.

“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”

Cost Concerns

How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.

Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.

Our program started with three physicians in 2004 and has grown to over 30 in 2012. There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.

—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member

“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.

Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.

“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”

IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”

John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.

“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”

Practice Concerns

Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.

“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”

Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.

Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.

“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”

Richard Quinn is a freelance writer in New Jersey.

Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).

Question: What type of business do you operate?

Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.

Q: Why did you give up the practice of medicine?

A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.

In short, I was deeply restless, in my early 40s, and ready for a change.

Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?

A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.

Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.

Q: Can you name some pros and cons for physicians interested in a career change?

A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.

The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.

Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).

Question: What type of business do you operate?

Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.

Q: Why did you give up the practice of medicine?

A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.

In short, I was deeply restless, in my early 40s, and ready for a change.

Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?

A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.

Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.

Q: Can you name some pros and cons for physicians interested in a career change?

A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.

The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.

Q&A with Philippa Kennealy, MD, MPH, CPCC, PCC, founder and owner of The Entrepreneurial MD (www.entrepreneurialmd.com).

Question: What type of business do you operate?

Answer: I’m a physician development and business coach. My role is to help physicians who are struggling with launching a nonclinical career or a new business, or revamping a medical practice to become a satisfying venture. Although I am personally based in Los Angeles, The Entrepreneurial MD clients can be located anywhere in the world as long as we both have phone or Internet access. About 95% of my clients are not located in Los Angeles. I’m 57 years old. I was 41 when I left medical practice and went on to have several more careers.

Q: Why did you give up the practice of medicine?

A: I left my five-member private family practice in mid-1996, after joining my group in the middle of 1988. I realized that not only was I feeling unfulfilled and frustrated by work, but that I was even starting to dread it. I particularly dreaded the nights and weekends on call—for the latter, I started getting that “sick in the stomach” feeling on Mondays. I also realized that I had become bored with the repetition of the work and loved the idea of learning a whole lot of new stuff. I had embarked on my master’s degree in public health at UCLA around that time (mid-1995) and became completely energized by being a student again in a class of adult learners.

In short, I was deeply restless, in my early 40s, and ready for a change.

Q: How would you advise other MDs who are considering the pros/cons of not seeing patients anymore?

A: Above all else, it is important to get to really know yourself. Give yourself the gift of real reflection rather than just reaction. Upon such reflection, I knew that what truly energized me in clinical practice was my connection to people rather than being able to use a stethoscope or remove a mole. I also recognized that this “passion” was portable—unless I was locked away in a room with only a computer for company, I would thrive professionally no matter what I chose next, as long as it involved being in a helping relationship with others.

Engage in conversation with others who are like-minded—your mentors, people who have made career changes, your significant others. Do your homework and recognize that in the end, it is only you who can make the decision whether to stay or leave. Be compelled to make changes in your life because you are moving toward new opportunities rather than merely running away.

Q: Can you name some pros and cons for physicians interested in a career change?

A: The pros: interesting challenges, a chance to remake your career, re-engage your brain, feel challenged; reinvent yourself, strive for the dream(s) that you may have put on hold many years before or gave up because you did medicine to please others; acquire new skills, which may be fun.

The cons: risky if unplanned, you may have to take an income hit for a while, you may be a victim of “the grass is always greener” [mindset], you may never discover what you really want if you are simply acting from dissatisfaction and aren’t willing to do the work of change. It feels scary, and it takes a certain amount of inner courage and external support to make the move.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Whether one prefers the seven-on/seven-off scheduling model or not, it’s universally agreed that a full seven days off in a row is one of the schedule’s big selling points. But what about hospitalists who choose to work on their weeks off?

“That’s a definite concern, too,” says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists for the Altoona Regional Health System in Altoona, Pa.

In rural areas, such as Dr. Martinek’s workplace in central Pennsylvania, hospitalists often have a chance to pick up additional shifts—some even have two full-time gigs. That work, known as moonlighting, can be at their home institutions or at other hospitals in the region. But the practice raises questions about how well-rested physicians can be if they are working nearly every day.

“If a group of administrators get together and say, ‘Well, my hospitalists are working at your facility and vice versa, it’s like I’m paying them a full-time equivalent … but then on their off-week, when they’re supposed to be off for their quality of life and balance, and they’re off working somewhere,’ that’s a concern,” Dr. Martinek says.

To control the practice, Dr. Martinek has put rules in place to guide hospitalists who are eager to work additional shifts either via moonlighting or locum tenens. His group stipulates that hospitalists designated as the backup person for the week cannot accept additional shifts elsewhere. Additionally, if there are open shifts at Altoona Regiona Health System, hospitalists are encouraged to accept these shifts before accepting shifts outside the health system.

Dr. Martinek says he understands physicians’ desire to take additional shifts for financial benefit, but he urges them to take the long view of their careers before burning themselves out.

“This is a marathon, not a sprint, and they need to pace themselves,” he adds. “It’s OK to want to earn some extra money while it’s there, but you’ve got to think about the longevity of your career and really take your time off.” TH

Richard Quinn is a freelance writer in New Jersey.

Hospitalist and former SHM president Patrick Cawley, MD, MBA, MHM, has been named vice president for clinical operations and executive director of the Medical University Hospital Authority at the Medical University of South Carolina (MUSC). Dr. Cawley is MUSC’s executive medical director and chief medical officer. He starts his new position in April.

Amina Ahmed, MD, has been named director of hospitalist medicine at Summit Medical Group in Berkeley Heights, N.J. Prior to 2008, when she first joined Summit, Dr. Ahmed served as an internist with privileges at several northern New Jersey facilities, including Christ Hospital, Jersey City Medical Center, and Hamilton Park Rehabilitation Center. In addition to hospital medicine, Dr. Ahmed also specializes in cardiovascular medicine.

Michael Tofano, MD, has been named hospitalist director at John T. Mather Memorial Hospital in Port Jefferson, N.Y. Dr. Tofano previously was the HM director at UMass Memorial Health Care’s hospitals in Marlborough, Mass., and Clinton, Mass. He also served as associate chief of HM at UMass Memorial Health Care in Worcester. Dr. Tofano’s training is in hospital medicine with a focus on cardiology.

Hospitalist Valerie Carter of Baptist Memorial Hospital Union County in New Albany, Miss., was recently given the DAISY Award for Extraordinary Nurses. Candidates for the award are nominated by hospital patients and their families and ultimately chosen by supervisors in the hospital’s nursing department.

Business Moves

North Hollywood, Calif.-based IPC: The Hospitalist Co. has announced the acquisitions of two new acute-care practices—Midwest Acute Care Consultants in St. Louis and AHCP of southeastern Michigan. IPC now provides and oversees hospitalist and post-acute-care practices in 28 states.

Knoxville, Tenn.-based TeamHealth, a provider of hospitalist services throughout the U.S., recently announced its acquisition of two private emergency medicine providers and one private anesthesiology firm. TeamHealth will administer ED services at San Ramon Regional Medical Center in San Ramon, Calif., and Mobile Emergency Group in Mobile, Ala. The firm also will oversee operations at hospitals served by Northern Valley Anesthesiology in Englewood, N.J.

Hospitalists at San Francisco-based Galen Inpatient Physicians are now partners with CEP America, a physician staffing firm based in Emeryville, Calif. Founded in 1975, CEP provides acute-care practice management, as well as hospitalist services to more than 100 facilities in eight states. Galen has provided hospitalist services since 2000.

Hospitalist and former SHM president Patrick Cawley, MD, MBA, MHM, has been named vice president for clinical operations and executive director of the Medical University Hospital Authority at the Medical University of South Carolina (MUSC). Dr. Cawley is MUSC’s executive medical director and chief medical officer. He starts his new position in April.

Amina Ahmed, MD, has been named director of hospitalist medicine at Summit Medical Group in Berkeley Heights, N.J. Prior to 2008, when she first joined Summit, Dr. Ahmed served as an internist with privileges at several northern New Jersey facilities, including Christ Hospital, Jersey City Medical Center, and Hamilton Park Rehabilitation Center. In addition to hospital medicine, Dr. Ahmed also specializes in cardiovascular medicine.

Michael Tofano, MD, has been named hospitalist director at John T. Mather Memorial Hospital in Port Jefferson, N.Y. Dr. Tofano previously was the HM director at UMass Memorial Health Care’s hospitals in Marlborough, Mass., and Clinton, Mass. He also served as associate chief of HM at UMass Memorial Health Care in Worcester. Dr. Tofano’s training is in hospital medicine with a focus on cardiology.

Hospitalist Valerie Carter of Baptist Memorial Hospital Union County in New Albany, Miss., was recently given the DAISY Award for Extraordinary Nurses. Candidates for the award are nominated by hospital patients and their families and ultimately chosen by supervisors in the hospital’s nursing department.

Business Moves

North Hollywood, Calif.-based IPC: The Hospitalist Co. has announced the acquisitions of two new acute-care practices—Midwest Acute Care Consultants in St. Louis and AHCP of southeastern Michigan. IPC now provides and oversees hospitalist and post-acute-care practices in 28 states.

Knoxville, Tenn.-based TeamHealth, a provider of hospitalist services throughout the U.S., recently announced its acquisition of two private emergency medicine providers and one private anesthesiology firm. TeamHealth will administer ED services at San Ramon Regional Medical Center in San Ramon, Calif., and Mobile Emergency Group in Mobile, Ala. The firm also will oversee operations at hospitals served by Northern Valley Anesthesiology in Englewood, N.J.

Hospitalists at San Francisco-based Galen Inpatient Physicians are now partners with CEP America, a physician staffing firm based in Emeryville, Calif. Founded in 1975, CEP provides acute-care practice management, as well as hospitalist services to more than 100 facilities in eight states. Galen has provided hospitalist services since 2000.

Hospitalist and former SHM president Patrick Cawley, MD, MBA, MHM, has been named vice president for clinical operations and executive director of the Medical University Hospital Authority at the Medical University of South Carolina (MUSC). Dr. Cawley is MUSC’s executive medical director and chief medical officer. He starts his new position in April.

Amina Ahmed, MD, has been named director of hospitalist medicine at Summit Medical Group in Berkeley Heights, N.J. Prior to 2008, when she first joined Summit, Dr. Ahmed served as an internist with privileges at several northern New Jersey facilities, including Christ Hospital, Jersey City Medical Center, and Hamilton Park Rehabilitation Center. In addition to hospital medicine, Dr. Ahmed also specializes in cardiovascular medicine.

Michael Tofano, MD, has been named hospitalist director at John T. Mather Memorial Hospital in Port Jefferson, N.Y. Dr. Tofano previously was the HM director at UMass Memorial Health Care’s hospitals in Marlborough, Mass., and Clinton, Mass. He also served as associate chief of HM at UMass Memorial Health Care in Worcester. Dr. Tofano’s training is in hospital medicine with a focus on cardiology.

Hospitalist Valerie Carter of Baptist Memorial Hospital Union County in New Albany, Miss., was recently given the DAISY Award for Extraordinary Nurses. Candidates for the award are nominated by hospital patients and their families and ultimately chosen by supervisors in the hospital’s nursing department.

Business Moves

North Hollywood, Calif.-based IPC: The Hospitalist Co. has announced the acquisitions of two new acute-care practices—Midwest Acute Care Consultants in St. Louis and AHCP of southeastern Michigan. IPC now provides and oversees hospitalist and post-acute-care practices in 28 states.

Knoxville, Tenn.-based TeamHealth, a provider of hospitalist services throughout the U.S., recently announced its acquisition of two private emergency medicine providers and one private anesthesiology firm. TeamHealth will administer ED services at San Ramon Regional Medical Center in San Ramon, Calif., and Mobile Emergency Group in Mobile, Ala. The firm also will oversee operations at hospitals served by Northern Valley Anesthesiology in Englewood, N.J.

Hospitalists at San Francisco-based Galen Inpatient Physicians are now partners with CEP America, a physician staffing firm based in Emeryville, Calif. Founded in 1975, CEP provides acute-care practice management, as well as hospitalist services to more than 100 facilities in eight states. Galen has provided hospitalist services since 2000.

Background

In the U.S. alone, there are an estimated 25.8 million people with diabetes, or about 8.3% of the population. Due to comorbidities of peripheral neuropathy and peripheral vascular disease associated with diabetes, these patients are at higher risk for developing foot infections. Among the myriad diabetes complications, diabetic foot infections (DFI) are the main reason for diabetes-related hospitalizations and lower-extremity amputations. U.S. hospitals admit roughly 5,700 patients per year for DFI; 71,000 lower-extremity amputations are attributed to diabetes.^1,2

Studies have demonstrated that DFI management according to guidelines improves survival, reduces complications, and is cost-effective with a major clinical outcome of reduced amputations.³ But prospective observational studies have shown that, in practice, guidelines often are not followed and can lead to poor outcomes.⁴ Studies suggest a need for more simple, straightforward guidelines.

Guidelines Update

In June 2012, the Infectious Diseases Society of America (IDSA) updated its 2004 guidelines on the management of diabetic foot infections.⁵ Although IDSA made no major changes to its recommendations, the 2012 guidelines were revised to be more simple and clear. These new guidelines have been reviewed and endorsed by SHM.

Specific recommendations include:

• All patients with suspected DFI should be assessed on three levels: the patient, the extremity involved, and the wound. Patients should be assessed for signs of systemic illness or metabolic derangements. The extremity should be examined for peripheral arterial disease (PAD) using the Ankle-Brachial Index (ABI), and those with an ABI <0.4 should be evaluated by a vascular surgeon.
• Uninfected wounds should be distinguished from infected wounds based on the presence of two or more classic signs of inflammation and purulence. All wounds should be classified based on validated systems, such as those established by IDSA or the International Working Group on the Diabetic Foot (IWGDF). The IDSA classification of wounds as uninfected, mild, moderate, and severe correlate well with the IWGDF’s PEDIS (Perfusion, Extent, Depth, Infection and Sensation) Grades 1, 2, 3, and 4. Wounds are distinguished by size (more or less than 2 cm in width), extent (depth of tissue involvement), and the presence of two or more signs of systemic inflammatory response syndrome.
• Whenever possible, management of DFI should involve multidisciplinary teams that include a microbiologist or ID expert, surgeon/podiatrist familiar with debridement of foot infections, and wound care experts familiar with dressings that provide pressure off-loading.
• All wounds should be debrided, and cultures should be sent from deep tissue via biopsy or curettage (scraping of the base of the ulcer). Wound surface swabs should not be sent for culture, as they often are inaccurate.
• All patients with severe infections and some patients with moderate infections with complicating features (i.e. severe PAD or inability to manage outpatient treatment due to psychosocial reasons) should be admitted. Those with mild infection or some moderate infections without complicating features can be managed as outpatients.
• All patients with suspected DFI should have plain radiographs of the affected limb to evaluate for bony abnormalities, soft-tissue gas, or foreign bodies, but they are only 54% sensitive and 68% specific for osteomyelitis. MRI is more sensitive (90%) and specific (up to 90%) for detecting osteomyelitis. When MRI is contraindicated, a bone scan coupled with a tagged white-blood count scan is the next best test for detecting osteomyelitis.
• Osteomyelitis, which is found in as many as 20% of mild to moderate DFI cases and as many as 50% of severe DFI cases, should be suspected in any patient with large (>2 cm square), deep, or chronic (>six weeks) wounds, as well as those who have wounds overlying a bony prominence or have a positive probe-to-bone (PTB) test. The most definitive diagnosis of osteomyelitis is via bone biopsy for culture and histology. Patients with osteomyelitis can be managed surgically with resection or medically with prolonged antibiotics (>four weeks). If surgical resection removes the infected bone with clean margins, the antibiotic course can be shortened to two to five days post-operatively.
• Effective treatment includes both wound care as well as antibiotic therapy. Antibiotics should be started after cultures are sent. Empiric antibiotics for mild to moderate infections in patients who have not been recently treated can be directed at gram-positive cocci (GPC), as Staphylococcus is the most common causal organism identified. Patients with severe infection can be started empirically on parenteral broad-spectrum antibiotics covering for GPC (particularly methicillin-resistant Staphylococcus aureus in at-risk patients), gram-negative bacteria, and obligate anaerobes. Antibiotics should be tailored once culture and sensitivity results are available. Generally, mild infections should be treated for one to two weeks and moderate to severe infections for two to three weeks, if there is no suspicion of osteomyelitis.

Analysis

The United Kingdom National Institute for Clinical Excellence (NICE) guideline development group published guidelines for inpatient management of diabetic foot problems in 2011.⁶ The NICE guidelines are largely similar to the 2012 IDSA guidelines. NICE guidelines call for each hospital to have a care pathway for all patients who present with a diabetic foot problem, and that these patients should be cared for by a multidisciplinary team, including appropriate wound care and debridement, assessment of vascular function, imaging with plain radiographs and MRI if osteomyelitis is suspected, and directed antibiotic therapy.

HM Takeaways

Diabetic foot infections are a common occurrence, and the guidelines for their management demonstrate how coordinated clinical care is important for improving patient care and outcomes. As health reimbursement moves toward a model of bundled payments for treatment and a greater emphasis on measureable outcomes, hospitalists are well positioned to be managers of such organized approaches with multidisciplinary teams.

Dr. Ly is a hospitalist in the division of hospital medicine at the University of California at San Francisco.

References

1. Centers for Disease Control and Prevention. Age-Adjusted Hospital Discharge Rates for Peripheral Arterial Disease (PAD), Ulcer/Inflammation/Infection (ULCER), or Neuropathy as First-Listed Diagnosis per 1,000 Diabetic Population, United States, 1988–2007. CDC website. Available at: http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig2_pop.htm. Accessed Jan. 28, 2013.
2. Centers for Disease Control and Prevention. Number (in thousands) of hospital discharges for nontraumatic lower extremity amputation with diabetes as a listed diagnosis, 1988-2006. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig1.htm. Accessed Jan. 28, 2013.
3. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27:901-907.Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50:18-25.
4. Lipsky BA, Berendt AR, Comia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012;54(12):132-173.
5. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M. Inpatient management of diabetic foot problems: summary of NICE guidance. BMJ. 2011;342:d1280.

Background

In the U.S. alone, there are an estimated 25.8 million people with diabetes, or about 8.3% of the population. Due to comorbidities of peripheral neuropathy and peripheral vascular disease associated with diabetes, these patients are at higher risk for developing foot infections. Among the myriad diabetes complications, diabetic foot infections (DFI) are the main reason for diabetes-related hospitalizations and lower-extremity amputations. U.S. hospitals admit roughly 5,700 patients per year for DFI; 71,000 lower-extremity amputations are attributed to diabetes.^1,2

Studies have demonstrated that DFI management according to guidelines improves survival, reduces complications, and is cost-effective with a major clinical outcome of reduced amputations.³ But prospective observational studies have shown that, in practice, guidelines often are not followed and can lead to poor outcomes.⁴ Studies suggest a need for more simple, straightforward guidelines.

Guidelines Update

In June 2012, the Infectious Diseases Society of America (IDSA) updated its 2004 guidelines on the management of diabetic foot infections.⁵ Although IDSA made no major changes to its recommendations, the 2012 guidelines were revised to be more simple and clear. These new guidelines have been reviewed and endorsed by SHM.

Specific recommendations include:

• All patients with suspected DFI should be assessed on three levels: the patient, the extremity involved, and the wound. Patients should be assessed for signs of systemic illness or metabolic derangements. The extremity should be examined for peripheral arterial disease (PAD) using the Ankle-Brachial Index (ABI), and those with an ABI <0.4 should be evaluated by a vascular surgeon.
• Uninfected wounds should be distinguished from infected wounds based on the presence of two or more classic signs of inflammation and purulence. All wounds should be classified based on validated systems, such as those established by IDSA or the International Working Group on the Diabetic Foot (IWGDF). The IDSA classification of wounds as uninfected, mild, moderate, and severe correlate well with the IWGDF’s PEDIS (Perfusion, Extent, Depth, Infection and Sensation) Grades 1, 2, 3, and 4. Wounds are distinguished by size (more or less than 2 cm in width), extent (depth of tissue involvement), and the presence of two or more signs of systemic inflammatory response syndrome.
• Whenever possible, management of DFI should involve multidisciplinary teams that include a microbiologist or ID expert, surgeon/podiatrist familiar with debridement of foot infections, and wound care experts familiar with dressings that provide pressure off-loading.
• All wounds should be debrided, and cultures should be sent from deep tissue via biopsy or curettage (scraping of the base of the ulcer). Wound surface swabs should not be sent for culture, as they often are inaccurate.
• All patients with severe infections and some patients with moderate infections with complicating features (i.e. severe PAD or inability to manage outpatient treatment due to psychosocial reasons) should be admitted. Those with mild infection or some moderate infections without complicating features can be managed as outpatients.
• All patients with suspected DFI should have plain radiographs of the affected limb to evaluate for bony abnormalities, soft-tissue gas, or foreign bodies, but they are only 54% sensitive and 68% specific for osteomyelitis. MRI is more sensitive (90%) and specific (up to 90%) for detecting osteomyelitis. When MRI is contraindicated, a bone scan coupled with a tagged white-blood count scan is the next best test for detecting osteomyelitis.
• Osteomyelitis, which is found in as many as 20% of mild to moderate DFI cases and as many as 50% of severe DFI cases, should be suspected in any patient with large (>2 cm square), deep, or chronic (>six weeks) wounds, as well as those who have wounds overlying a bony prominence or have a positive probe-to-bone (PTB) test. The most definitive diagnosis of osteomyelitis is via bone biopsy for culture and histology. Patients with osteomyelitis can be managed surgically with resection or medically with prolonged antibiotics (>four weeks). If surgical resection removes the infected bone with clean margins, the antibiotic course can be shortened to two to five days post-operatively.
• Effective treatment includes both wound care as well as antibiotic therapy. Antibiotics should be started after cultures are sent. Empiric antibiotics for mild to moderate infections in patients who have not been recently treated can be directed at gram-positive cocci (GPC), as Staphylococcus is the most common causal organism identified. Patients with severe infection can be started empirically on parenteral broad-spectrum antibiotics covering for GPC (particularly methicillin-resistant Staphylococcus aureus in at-risk patients), gram-negative bacteria, and obligate anaerobes. Antibiotics should be tailored once culture and sensitivity results are available. Generally, mild infections should be treated for one to two weeks and moderate to severe infections for two to three weeks, if there is no suspicion of osteomyelitis.

Analysis

The United Kingdom National Institute for Clinical Excellence (NICE) guideline development group published guidelines for inpatient management of diabetic foot problems in 2011.⁶ The NICE guidelines are largely similar to the 2012 IDSA guidelines. NICE guidelines call for each hospital to have a care pathway for all patients who present with a diabetic foot problem, and that these patients should be cared for by a multidisciplinary team, including appropriate wound care and debridement, assessment of vascular function, imaging with plain radiographs and MRI if osteomyelitis is suspected, and directed antibiotic therapy.

HM Takeaways

Diabetic foot infections are a common occurrence, and the guidelines for their management demonstrate how coordinated clinical care is important for improving patient care and outcomes. As health reimbursement moves toward a model of bundled payments for treatment and a greater emphasis on measureable outcomes, hospitalists are well positioned to be managers of such organized approaches with multidisciplinary teams.

Dr. Ly is a hospitalist in the division of hospital medicine at the University of California at San Francisco.

References

1. Centers for Disease Control and Prevention. Age-Adjusted Hospital Discharge Rates for Peripheral Arterial Disease (PAD), Ulcer/Inflammation/Infection (ULCER), or Neuropathy as First-Listed Diagnosis per 1,000 Diabetic Population, United States, 1988–2007. CDC website. Available at: http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig2_pop.htm. Accessed Jan. 28, 2013.
2. Centers for Disease Control and Prevention. Number (in thousands) of hospital discharges for nontraumatic lower extremity amputation with diabetes as a listed diagnosis, 1988-2006. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig1.htm. Accessed Jan. 28, 2013.
3. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27:901-907.Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50:18-25.
4. Lipsky BA, Berendt AR, Comia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012;54(12):132-173.
5. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M. Inpatient management of diabetic foot problems: summary of NICE guidance. BMJ. 2011;342:d1280.

Background

In the U.S. alone, there are an estimated 25.8 million people with diabetes, or about 8.3% of the population. Due to comorbidities of peripheral neuropathy and peripheral vascular disease associated with diabetes, these patients are at higher risk for developing foot infections. Among the myriad diabetes complications, diabetic foot infections (DFI) are the main reason for diabetes-related hospitalizations and lower-extremity amputations. U.S. hospitals admit roughly 5,700 patients per year for DFI; 71,000 lower-extremity amputations are attributed to diabetes.^1,2

Studies have demonstrated that DFI management according to guidelines improves survival, reduces complications, and is cost-effective with a major clinical outcome of reduced amputations.³ But prospective observational studies have shown that, in practice, guidelines often are not followed and can lead to poor outcomes.⁴ Studies suggest a need for more simple, straightforward guidelines.

Guidelines Update

In June 2012, the Infectious Diseases Society of America (IDSA) updated its 2004 guidelines on the management of diabetic foot infections.⁵ Although IDSA made no major changes to its recommendations, the 2012 guidelines were revised to be more simple and clear. These new guidelines have been reviewed and endorsed by SHM.

Specific recommendations include:

• All patients with suspected DFI should be assessed on three levels: the patient, the extremity involved, and the wound. Patients should be assessed for signs of systemic illness or metabolic derangements. The extremity should be examined for peripheral arterial disease (PAD) using the Ankle-Brachial Index (ABI), and those with an ABI <0.4 should be evaluated by a vascular surgeon.
• Uninfected wounds should be distinguished from infected wounds based on the presence of two or more classic signs of inflammation and purulence. All wounds should be classified based on validated systems, such as those established by IDSA or the International Working Group on the Diabetic Foot (IWGDF). The IDSA classification of wounds as uninfected, mild, moderate, and severe correlate well with the IWGDF’s PEDIS (Perfusion, Extent, Depth, Infection and Sensation) Grades 1, 2, 3, and 4. Wounds are distinguished by size (more or less than 2 cm in width), extent (depth of tissue involvement), and the presence of two or more signs of systemic inflammatory response syndrome.
• Whenever possible, management of DFI should involve multidisciplinary teams that include a microbiologist or ID expert, surgeon/podiatrist familiar with debridement of foot infections, and wound care experts familiar with dressings that provide pressure off-loading.
• All wounds should be debrided, and cultures should be sent from deep tissue via biopsy or curettage (scraping of the base of the ulcer). Wound surface swabs should not be sent for culture, as they often are inaccurate.
• All patients with severe infections and some patients with moderate infections with complicating features (i.e. severe PAD or inability to manage outpatient treatment due to psychosocial reasons) should be admitted. Those with mild infection or some moderate infections without complicating features can be managed as outpatients.
• All patients with suspected DFI should have plain radiographs of the affected limb to evaluate for bony abnormalities, soft-tissue gas, or foreign bodies, but they are only 54% sensitive and 68% specific for osteomyelitis. MRI is more sensitive (90%) and specific (up to 90%) for detecting osteomyelitis. When MRI is contraindicated, a bone scan coupled with a tagged white-blood count scan is the next best test for detecting osteomyelitis.
• Osteomyelitis, which is found in as many as 20% of mild to moderate DFI cases and as many as 50% of severe DFI cases, should be suspected in any patient with large (>2 cm square), deep, or chronic (>six weeks) wounds, as well as those who have wounds overlying a bony prominence or have a positive probe-to-bone (PTB) test. The most definitive diagnosis of osteomyelitis is via bone biopsy for culture and histology. Patients with osteomyelitis can be managed surgically with resection or medically with prolonged antibiotics (>four weeks). If surgical resection removes the infected bone with clean margins, the antibiotic course can be shortened to two to five days post-operatively.
• Effective treatment includes both wound care as well as antibiotic therapy. Antibiotics should be started after cultures are sent. Empiric antibiotics for mild to moderate infections in patients who have not been recently treated can be directed at gram-positive cocci (GPC), as Staphylococcus is the most common causal organism identified. Patients with severe infection can be started empirically on parenteral broad-spectrum antibiotics covering for GPC (particularly methicillin-resistant Staphylococcus aureus in at-risk patients), gram-negative bacteria, and obligate anaerobes. Antibiotics should be tailored once culture and sensitivity results are available. Generally, mild infections should be treated for one to two weeks and moderate to severe infections for two to three weeks, if there is no suspicion of osteomyelitis.

Analysis

The United Kingdom National Institute for Clinical Excellence (NICE) guideline development group published guidelines for inpatient management of diabetic foot problems in 2011.⁶ The NICE guidelines are largely similar to the 2012 IDSA guidelines. NICE guidelines call for each hospital to have a care pathway for all patients who present with a diabetic foot problem, and that these patients should be cared for by a multidisciplinary team, including appropriate wound care and debridement, assessment of vascular function, imaging with plain radiographs and MRI if osteomyelitis is suspected, and directed antibiotic therapy.

HM Takeaways

Diabetic foot infections are a common occurrence, and the guidelines for their management demonstrate how coordinated clinical care is important for improving patient care and outcomes. As health reimbursement moves toward a model of bundled payments for treatment and a greater emphasis on measureable outcomes, hospitalists are well positioned to be managers of such organized approaches with multidisciplinary teams.

Dr. Ly is a hospitalist in the division of hospital medicine at the University of California at San Francisco.

References

1. Centers for Disease Control and Prevention. Age-Adjusted Hospital Discharge Rates for Peripheral Arterial Disease (PAD), Ulcer/Inflammation/Infection (ULCER), or Neuropathy as First-Listed Diagnosis per 1,000 Diabetic Population, United States, 1988–2007. CDC website. Available at: http://www.cdc.gov/diabetes/statistics/hosplea/diabetes_complications/fig2_pop.htm. Accessed Jan. 28, 2013.
2. Centers for Disease Control and Prevention. Number (in thousands) of hospital discharges for nontraumatic lower extremity amputation with diabetes as a listed diagnosis, 1988-2006. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/diabetes/statistics/lea/fig1.htm. Accessed Jan. 28, 2013.
3. Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care. 2004;27:901-907.Prompers L, Huijberts M, Apelqvist J, et al. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50:18-25.
4. Lipsky BA, Berendt AR, Comia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis. 2012;54(12):132-173.
5. Tan T, Shaw EJ, Siddiqui F, Kandaswamy P, Barry PW, Baker M. Inpatient management of diabetic foot problems: summary of NICE guidance. BMJ. 2011;342:d1280.

Nurse practitioners (NPs) and physician assistants (PAs), referred to as nonphysician providers (NPPs) in billing policy, provide many different services in the hospital setting. Roles include:

• Rounding independently and following patients of varying acuity with physician supervision. The NPP may ask the physician to see the patient, as necessary, if a change in the patient’s condition arises and warrants physician evaluation.
• Providing prompt consultative
• services when the physician is not
• readily available.
• Rounding alongside the physician and expediting the work of admission services through a combined effort.

Hospitalist programs may elect one model over another, or utilize NPPs according to existing need and shifting census. Employers must be aware of state and federal regulations, facility-imposed standards of care, and billing requirements surrounding NPP services.

Medicare Enrollment and Billing Eligibility

Certified PAs and NPs may provide covered services to Medicare beneficiaries in accordance with their state scope of practice under state law and corresponding supervision/collaboration requirements. They can submit claims for these services, providing they meet enrollment qualifications.¹

PAs must have:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
• Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and
• A license as a PA in the practicing state.

NPs must:

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• After Jan. 1, 2001, be a registered nurse who is authorized and licensed by the state to practice as an NP and be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

Independent Billing

NPPs can see patients in any setting without the presence of a physician. The physician is not required to see the patient but must be available by phone or beeper in accordance with supervisory/collaborative guidelines. Physician cosignature is not required unless mandated by state law or the facility.

NPPs document and report their services according to the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines (available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html). The NPP should be listed as the rendering provider on the claim form. Currently, insurance programs Medicare and Aetna Inc. consistently enroll and recognize NPPs as billing providers and reimburse these services at 85% of the allowable physician rate.²

Shared/Split Billing

When two providers (a physician and NPP) from the same group (direct employment or a lease arrangement contractually linking the providers) perform a service for the same patient on the same calendar day, CMS allows the combined services to be reported under a single provider’s name.

Allowable services. NPPs are only limited by the state scope of practice under state law, and the facility rules in which the NPPs practice. Services must be performed under the appropriate level of supervision or collaboration. Medicare reimburses reasonable and necessary services not otherwise excluded from coverage.

However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded.³

Physician requirement. Shared/split rules require a face-to-face patient encounter by each provider on the same calendar day. There are no billing mandates requiring the NPP to see the patient before the physician does, although practice style might govern this decision.⁴ CMS does not specify the extent of provider involvement, but it could be established by local Medicare contractor requirements. Some contractors reference physician participation as a “substantive” service without further elaboration on specific parameters. Therefore, the physician determines the critical or key portion of his/her personal service. Minimalistic documentation can be problematic for quality or medicolegal aspects of patient care, and physicians might benefit from a more detailed notation of participation.

Documentation. Physician documentation must include an attestation that supports the physician encounter (e.g. “Patient seen and examined by me”), the individual with whom the service is shared (e.g. “Agree with note by X”), their portion of the rendered service (e.g. “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR”), the date, and a legible signature. NPP documentation should include as similar reference to the physician with whom the service is being shared for better charge capture. It alerts coders, auditors, and payor representatives to consider both notes in support of the billed service and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Although the visit level is supported by both provider services, only one claim may be submitted for a shared/split service. The rendering provider listed on the claim can be the physician (reimbursed at 100% of the Medicare allowable physician rate) or the NPP (reimbursed at 85% of the allowable physician rate).

Non-Medicare Claims

Shared/split billing policy only applies to Medicare beneficiaries, while independent billing policy applies to Medicare and Aetna. Excessive costs prevent most other non-Medicare insurers from credentialing and enrollment NPPs. Absence of payor policy does not disqualify reimbursement for shared services, but it does require additional measures to establish recognition of NPP services and a corresponding reimbursement model.

After determining payor mix, develop a reasonable guideline for those payors who do not enroll NPPs. Delineate, in writing, a predetermined time frame for guideline implementation unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option⁵:

• Type of NPPs involved in patient care;
• Category of services provided;
• Service location(s);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

Guidelines can be developed for any of the billing options (independent, “incident-to,” shared/split). Be sure to obtain written payor response before initiating the billing process.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

NPP Billing Reminders

Discharge Day Management Services

Discharge day management (99238-99239) often is delegated to qualified NPPs.³ Because this service is time-based, the final code selection is based upon the total time spent with the patient, and on the patient’s unit/floor, coordinating care prior to the patient leaving the hospital on the day of discharge. If this service is solely provided by the NPP, the NPP must report the appropriate code under his/her own name on the claim form (for eligible payors). If this service is shared with the physician, report the code representing the cumulative, documented time in both notes, provided that each note identifies the face-toface service from each provider, and his/her corresponding participation.

Admission Services

Many questions arise about NPPs performing the admission service because NPPs might not be given “admitting” privileges by the facility in which they practice. NPPs may provide and/or participate in services according to their state scope practice and facility-imposed guidelines. Billing policy supports state law and will reimburse any “independent” service permitted by the state. Facilities may limit NPP scope of practice by disallowing independent admission service but permittin a shared service with the physician. If this service is shared with the physician, report the code representing the cumulative, documented encounter, provided that each note identifies the face-to-face service from each provider, and his/her corresponding participation

Consultation Services

Prior to Medicare’s elimination of consultation services (99241-99245, 99251-99255), shared/split billing rules excluded consultations from this claim-reporting model.³ Since the elimination of consults, “consultations” are reported as initial hospital care services (99221-99223).³ Therefore, consultative services can be shared by NPPs and physicians, and reported as a cumulative initial hospital service through the shared/ split billing model. Other payors still accept consultation codes and do not have a specified shared/split model. This allows for the consultative service to be reported as a cumulative NPP/physician effort under the physician name, as long as a written contractual agreement exists allowing this billing option.

References

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed Nov. 5, 2012.
2. Aetna Inc. Aetna office links updates. Reminder: Reimbursement change for mid-level practitioners. Aetna Inc. website. Available at www.aetna.com/provider/data/OLU_MA_JUN2010_final.pdf. Accessed Nov. 6, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan 21, 2013.
5. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2011. Northbrook, Ill.: American College of Chest Physicians, 2010.

Nurse practitioners (NPs) and physician assistants (PAs), referred to as nonphysician providers (NPPs) in billing policy, provide many different services in the hospital setting. Roles include:

• Rounding independently and following patients of varying acuity with physician supervision. The NPP may ask the physician to see the patient, as necessary, if a change in the patient’s condition arises and warrants physician evaluation.
• Providing prompt consultative
• services when the physician is not
• readily available.
• Rounding alongside the physician and expediting the work of admission services through a combined effort.

Hospitalist programs may elect one model over another, or utilize NPPs according to existing need and shifting census. Employers must be aware of state and federal regulations, facility-imposed standards of care, and billing requirements surrounding NPP services.

Medicare Enrollment and Billing Eligibility

Certified PAs and NPs may provide covered services to Medicare beneficiaries in accordance with their state scope of practice under state law and corresponding supervision/collaboration requirements. They can submit claims for these services, providing they meet enrollment qualifications.¹

PAs must have:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
• Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and
• A license as a PA in the practicing state.

NPs must:

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• After Jan. 1, 2001, be a registered nurse who is authorized and licensed by the state to practice as an NP and be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

Independent Billing

NPPs can see patients in any setting without the presence of a physician. The physician is not required to see the patient but must be available by phone or beeper in accordance with supervisory/collaborative guidelines. Physician cosignature is not required unless mandated by state law or the facility.

NPPs document and report their services according to the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines (available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html). The NPP should be listed as the rendering provider on the claim form. Currently, insurance programs Medicare and Aetna Inc. consistently enroll and recognize NPPs as billing providers and reimburse these services at 85% of the allowable physician rate.²

Shared/Split Billing

When two providers (a physician and NPP) from the same group (direct employment or a lease arrangement contractually linking the providers) perform a service for the same patient on the same calendar day, CMS allows the combined services to be reported under a single provider’s name.

Allowable services. NPPs are only limited by the state scope of practice under state law, and the facility rules in which the NPPs practice. Services must be performed under the appropriate level of supervision or collaboration. Medicare reimburses reasonable and necessary services not otherwise excluded from coverage.

However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded.³

Physician requirement. Shared/split rules require a face-to-face patient encounter by each provider on the same calendar day. There are no billing mandates requiring the NPP to see the patient before the physician does, although practice style might govern this decision.⁴ CMS does not specify the extent of provider involvement, but it could be established by local Medicare contractor requirements. Some contractors reference physician participation as a “substantive” service without further elaboration on specific parameters. Therefore, the physician determines the critical or key portion of his/her personal service. Minimalistic documentation can be problematic for quality or medicolegal aspects of patient care, and physicians might benefit from a more detailed notation of participation.

Documentation. Physician documentation must include an attestation that supports the physician encounter (e.g. “Patient seen and examined by me”), the individual with whom the service is shared (e.g. “Agree with note by X”), their portion of the rendered service (e.g. “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR”), the date, and a legible signature. NPP documentation should include as similar reference to the physician with whom the service is being shared for better charge capture. It alerts coders, auditors, and payor representatives to consider both notes in support of the billed service and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Although the visit level is supported by both provider services, only one claim may be submitted for a shared/split service. The rendering provider listed on the claim can be the physician (reimbursed at 100% of the Medicare allowable physician rate) or the NPP (reimbursed at 85% of the allowable physician rate).

Non-Medicare Claims

Shared/split billing policy only applies to Medicare beneficiaries, while independent billing policy applies to Medicare and Aetna. Excessive costs prevent most other non-Medicare insurers from credentialing and enrollment NPPs. Absence of payor policy does not disqualify reimbursement for shared services, but it does require additional measures to establish recognition of NPP services and a corresponding reimbursement model.

After determining payor mix, develop a reasonable guideline for those payors who do not enroll NPPs. Delineate, in writing, a predetermined time frame for guideline implementation unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option⁵:

• Type of NPPs involved in patient care;
• Category of services provided;
• Service location(s);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

Guidelines can be developed for any of the billing options (independent, “incident-to,” shared/split). Be sure to obtain written payor response before initiating the billing process.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

NPP Billing Reminders

Discharge Day Management Services

Discharge day management (99238-99239) often is delegated to qualified NPPs.³ Because this service is time-based, the final code selection is based upon the total time spent with the patient, and on the patient’s unit/floor, coordinating care prior to the patient leaving the hospital on the day of discharge. If this service is solely provided by the NPP, the NPP must report the appropriate code under his/her own name on the claim form (for eligible payors). If this service is shared with the physician, report the code representing the cumulative, documented time in both notes, provided that each note identifies the face-toface service from each provider, and his/her corresponding participation.

Admission Services

Many questions arise about NPPs performing the admission service because NPPs might not be given “admitting” privileges by the facility in which they practice. NPPs may provide and/or participate in services according to their state scope practice and facility-imposed guidelines. Billing policy supports state law and will reimburse any “independent” service permitted by the state. Facilities may limit NPP scope of practice by disallowing independent admission service but permittin a shared service with the physician. If this service is shared with the physician, report the code representing the cumulative, documented encounter, provided that each note identifies the face-to-face service from each provider, and his/her corresponding participation

Consultation Services

Prior to Medicare’s elimination of consultation services (99241-99245, 99251-99255), shared/split billing rules excluded consultations from this claim-reporting model.³ Since the elimination of consults, “consultations” are reported as initial hospital care services (99221-99223).³ Therefore, consultative services can be shared by NPPs and physicians, and reported as a cumulative initial hospital service through the shared/ split billing model. Other payors still accept consultation codes and do not have a specified shared/split model. This allows for the consultative service to be reported as a cumulative NPP/physician effort under the physician name, as long as a written contractual agreement exists allowing this billing option.

References

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed Nov. 5, 2012.
2. Aetna Inc. Aetna office links updates. Reminder: Reimbursement change for mid-level practitioners. Aetna Inc. website. Available at www.aetna.com/provider/data/OLU_MA_JUN2010_final.pdf. Accessed Nov. 6, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan 21, 2013.
5. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2011. Northbrook, Ill.: American College of Chest Physicians, 2010.

Nurse practitioners (NPs) and physician assistants (PAs), referred to as nonphysician providers (NPPs) in billing policy, provide many different services in the hospital setting. Roles include:

• Rounding independently and following patients of varying acuity with physician supervision. The NPP may ask the physician to see the patient, as necessary, if a change in the patient’s condition arises and warrants physician evaluation.
• Providing prompt consultative
• services when the physician is not
• readily available.
• Rounding alongside the physician and expediting the work of admission services through a combined effort.

Hospitalist programs may elect one model over another, or utilize NPPs according to existing need and shifting census. Employers must be aware of state and federal regulations, facility-imposed standards of care, and billing requirements surrounding NPP services.

Medicare Enrollment and Billing Eligibility

Certified PAs and NPs may provide covered services to Medicare beneficiaries in accordance with their state scope of practice under state law and corresponding supervision/collaboration requirements. They can submit claims for these services, providing they meet enrollment qualifications.¹

PAs must have:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
• Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and
• A license as a PA in the practicing state.

NPs must:

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• After Jan. 1, 2001, be a registered nurse who is authorized and licensed by the state to practice as an NP and be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

Independent Billing

NPPs can see patients in any setting without the presence of a physician. The physician is not required to see the patient but must be available by phone or beeper in accordance with supervisory/collaborative guidelines. Physician cosignature is not required unless mandated by state law or the facility.

NPPs document and report their services according to the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines (available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html). The NPP should be listed as the rendering provider on the claim form. Currently, insurance programs Medicare and Aetna Inc. consistently enroll and recognize NPPs as billing providers and reimburse these services at 85% of the allowable physician rate.²

Shared/Split Billing

When two providers (a physician and NPP) from the same group (direct employment or a lease arrangement contractually linking the providers) perform a service for the same patient on the same calendar day, CMS allows the combined services to be reported under a single provider’s name.

Allowable services. NPPs are only limited by the state scope of practice under state law, and the facility rules in which the NPPs practice. Services must be performed under the appropriate level of supervision or collaboration. Medicare reimburses reasonable and necessary services not otherwise excluded from coverage.

However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded.³

Physician requirement. Shared/split rules require a face-to-face patient encounter by each provider on the same calendar day. There are no billing mandates requiring the NPP to see the patient before the physician does, although practice style might govern this decision.⁴ CMS does not specify the extent of provider involvement, but it could be established by local Medicare contractor requirements. Some contractors reference physician participation as a “substantive” service without further elaboration on specific parameters. Therefore, the physician determines the critical or key portion of his/her personal service. Minimalistic documentation can be problematic for quality or medicolegal aspects of patient care, and physicians might benefit from a more detailed notation of participation.

Documentation. Physician documentation must include an attestation that supports the physician encounter (e.g. “Patient seen and examined by me”), the individual with whom the service is shared (e.g. “Agree with note by X”), their portion of the rendered service (e.g. “Pulse oximetry 94% on room air. Audible rhonchi at bilateral lung bases. Start O2 2L nasal cannula. Obtain CXR”), the date, and a legible signature. NPP documentation should include as similar reference to the physician with whom the service is being shared for better charge capture. It alerts coders, auditors, and payor representatives to consider both notes in support of the billed service and ensures that the correct notes are sent to the payor in the event of claim denial and subsequent appeal.

Although the visit level is supported by both provider services, only one claim may be submitted for a shared/split service. The rendering provider listed on the claim can be the physician (reimbursed at 100% of the Medicare allowable physician rate) or the NPP (reimbursed at 85% of the allowable physician rate).

Non-Medicare Claims

Shared/split billing policy only applies to Medicare beneficiaries, while independent billing policy applies to Medicare and Aetna. Excessive costs prevent most other non-Medicare insurers from credentialing and enrollment NPPs. Absence of payor policy does not disqualify reimbursement for shared services, but it does require additional measures to establish recognition of NPP services and a corresponding reimbursement model.

After determining payor mix, develop a reasonable guideline for those payors who do not enroll NPPs. Delineate, in writing, a predetermined time frame for guideline implementation unless the payor can provide an alternate billing option. Some experts suggest physician groups outline the following key issues when structuring a billing option⁵:

• Type of NPPs involved in patient care;
• Category of services provided;
• Service location(s);
• Physician involvement;
• Mechanism for reporting services; and
• Documentation requirements.

Guidelines can be developed for any of the billing options (independent, “incident-to,” shared/split). Be sure to obtain written payor response before initiating the billing process.

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

NPP Billing Reminders

Discharge Day Management Services

Discharge day management (99238-99239) often is delegated to qualified NPPs.³ Because this service is time-based, the final code selection is based upon the total time spent with the patient, and on the patient’s unit/floor, coordinating care prior to the patient leaving the hospital on the day of discharge. If this service is solely provided by the NPP, the NPP must report the appropriate code under his/her own name on the claim form (for eligible payors). If this service is shared with the physician, report the code representing the cumulative, documented time in both notes, provided that each note identifies the face-toface service from each provider, and his/her corresponding participation.

Admission Services

Many questions arise about NPPs performing the admission service because NPPs might not be given “admitting” privileges by the facility in which they practice. NPPs may provide and/or participate in services according to their state scope practice and facility-imposed guidelines. Billing policy supports state law and will reimburse any “independent” service permitted by the state. Facilities may limit NPP scope of practice by disallowing independent admission service but permittin a shared service with the physician. If this service is shared with the physician, report the code representing the cumulative, documented encounter, provided that each note identifies the face-to-face service from each provider, and his/her corresponding participation

Consultation Services

Prior to Medicare’s elimination of consultation services (99241-99245, 99251-99255), shared/split billing rules excluded consultations from this claim-reporting model.³ Since the elimination of consults, “consultations” are reported as initial hospital care services (99221-99223).³ Therefore, consultative services can be shared by NPPs and physicians, and reported as a cumulative initial hospital service through the shared/ split billing model. Other payors still accept consultation codes and do not have a specified shared/split model. This allows for the consultative service to be reported as a cumulative NPP/physician effort under the physician name, as long as a written contractual agreement exists allowing this billing option.

References

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual: Chapter 15, Section 190-200. Centers for Medicare & Medicaid website. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Accessed Nov. 5, 2012.
2. Aetna Inc. Aetna office links updates. Reminder: Reimbursement change for mid-level practitioners. Aetna Inc. website. Available at www.aetna.com/provider/data/OLU_MA_JUN2010_final.pdf. Accessed Nov. 6, 2012.
3. Abraham M, Ahlman J, Anderson C, Boudreau A, Connelly J. Current Procedural Terminology 2012 Professional Edition. Chicago: American Medical Association Press; 2011.
4. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.1B. Centers for Medicare & Medicaid website. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan 21, 2013.
5. Pohlig, C. Nonphysician Providers in Your Practice. In: Coding for Chest Medicine 2011. Northbrook, Ill.: American College of Chest Physicians, 2010.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.

Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?

Study design: Single-institution quality-improvement initiative.

Setting: Cincinnati Children’s Hospital Medical Center.

Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.

SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).

This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.

Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.

Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.

Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.