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A computerized patient assignment program to distribute new hospital admissions among 12 hospitalist-led, unit-based teams at Our Lady of the Lake Hospital in Baton Rouge, La., not only saves time and improves coordination of care, but also helps to build trust and satisfaction with patients, according to a poster presented at HM12.

Lead author and hospitalist Eric Wascome, MD, says the automated program takes into account patient medical intensity scores aggregated by hospital team in deciding who should get the next patient, thus smoothing out the referral process and minimizing hard feelings that some physicians are getting more than their fair share of work. The program also adjusts for particular units and room locations and incorporates physician preferences, then spits out the next referral within minutes. It also reduces the need to reassign rooms and allows patients to be told who their next-day hospitalist will be when they are admitted to the hospital overnight.

“It takes a complicated, head-scratching process and makes it a no-brainer,” Dr. Wascome says.

The Web-based, HIPAA-compliant program has thrived since Dr. Wascome’s presentation in April 2012. “A new twist is that we’ve added the capacity to bring in doctors who are not scheduled to work if they are needed on a voluntary basis, to address higher volumes of patients, and to have them on site within an hour,” he says.

Hospitalists say they approve of computerized patient scheduling, which was programmed by Dr. Wascome based on previous spreadsheet-based approaches to scheduling. Automation, he says, makes possible greater numbers of variables.

For more information, email Dr. Wascome at [email protected].

A computerized patient assignment program to distribute new hospital admissions among 12 hospitalist-led, unit-based teams at Our Lady of the Lake Hospital in Baton Rouge, La., not only saves time and improves coordination of care, but also helps to build trust and satisfaction with patients, according to a poster presented at HM12.

Lead author and hospitalist Eric Wascome, MD, says the automated program takes into account patient medical intensity scores aggregated by hospital team in deciding who should get the next patient, thus smoothing out the referral process and minimizing hard feelings that some physicians are getting more than their fair share of work. The program also adjusts for particular units and room locations and incorporates physician preferences, then spits out the next referral within minutes. It also reduces the need to reassign rooms and allows patients to be told who their next-day hospitalist will be when they are admitted to the hospital overnight.

“It takes a complicated, head-scratching process and makes it a no-brainer,” Dr. Wascome says.

The Web-based, HIPAA-compliant program has thrived since Dr. Wascome’s presentation in April 2012. “A new twist is that we’ve added the capacity to bring in doctors who are not scheduled to work if they are needed on a voluntary basis, to address higher volumes of patients, and to have them on site within an hour,” he says.

Hospitalists say they approve of computerized patient scheduling, which was programmed by Dr. Wascome based on previous spreadsheet-based approaches to scheduling. Automation, he says, makes possible greater numbers of variables.

For more information, email Dr. Wascome at [email protected].

A computerized patient assignment program to distribute new hospital admissions among 12 hospitalist-led, unit-based teams at Our Lady of the Lake Hospital in Baton Rouge, La., not only saves time and improves coordination of care, but also helps to build trust and satisfaction with patients, according to a poster presented at HM12.

Lead author and hospitalist Eric Wascome, MD, says the automated program takes into account patient medical intensity scores aggregated by hospital team in deciding who should get the next patient, thus smoothing out the referral process and minimizing hard feelings that some physicians are getting more than their fair share of work. The program also adjusts for particular units and room locations and incorporates physician preferences, then spits out the next referral within minutes. It also reduces the need to reassign rooms and allows patients to be told who their next-day hospitalist will be when they are admitted to the hospital overnight.

“It takes a complicated, head-scratching process and makes it a no-brainer,” Dr. Wascome says.

The Web-based, HIPAA-compliant program has thrived since Dr. Wascome’s presentation in April 2012. “A new twist is that we’ve added the capacity to bring in doctors who are not scheduled to work if they are needed on a voluntary basis, to address higher volumes of patients, and to have them on site within an hour,” he says.

Hospitalists say they approve of computerized patient scheduling, which was programmed by Dr. Wascome based on previous spreadsheet-based approaches to scheduling. Automation, he says, makes possible greater numbers of variables.

For more information, email Dr. Wascome at [email protected].

WASHINGTON, D.C.—SHM joined hands today with 15 other U.S. medical specialty societies in the fight to eliminate wasteful medical tests, drugs, and treatments.

The 10,000-member SHM, which represents more than 40,000 hospitalists, released two lists of common tests and procedures that clinicians and patients should seriously question as part of the ABIM Foundation’s Choosing Wisely campaign. The campaign debuted in April 2012 with nine medical societies providing input on medical decisions that lack evidence, waste finite healthcare resources, or potentially harm patients.

“We acknowledge that there is waste in our system,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. “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.”

SHM’s Hospital Quality and Patient Safety Committee created two lists of five recommendations: one for adult hospitalists and inpatients, and one for pediatric hospitalists and patients. Examples include:

• Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless they are at high risk for gastrointestinal complications;
• Do not order continuous telemetry monitoring outside the ICU without using a protocol that governs its continuation; and
• Do not order chest radiography in children who have uncomplicated asthma or bronchiolitis.

The “avoid” lists were chosen by SHM because they potentially represent significant, needless waste of healthcare resources, according to John Bulger, DO, MBA, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa. Dr. Bulger, who chaired SHM’s Choosing Wisely committee, encourages hospitalists to stop and take a long look at the list and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committee and start collecting baseline data, he says. “We should be able to come back a year from now and show that we’ve been able to change practice using these lists,” he says.

HM pioneer Robert Wachter, MD, MHM, who heads the division of hospital medicine at the University of California at San Francisco, chairs the American Board of Internal Medicine, and sits on the board of the ABIM Foundation, agrees.

“I think you’ll be hearing similar kinds of drumbeats about waste from every national organization involved in healthcare,” says Dr. Wachter, author of the Wachter’s World blog. “I think hospitalists should be active and enthusiastic partners in the Choosing Wisely campaign and leaders in American healthcare’s efforts to figure out how to purge waste from the system and decrease unnecessary expense.”

Click here to listen to more of Dr. Wachter’s interview on the Choosing Wisely campaign.

A similar kind of focus on efficiency and cost-effectiveness was part of the initial motivation for developing hospital medicine, Dr. Wachter says. He compares the current national obsession about healthcare waste with the medical quality and patient safety movements of the past decade.

“It’s the right time, the right message, and the right messenger,” he says. “But now we’re a little scared about raised expectations. Delivering on them is going to be more difficult, even, than patient safety was because, ultimately, it will require curtailing some income streams. You can’t reach the final outcome of cutting costs in healthcare without someone making less money.” TH

 

Larry Beresford is a freelance writer in Oakland, Calif. 

 

 

WASHINGTON, D.C.—SHM joined hands today with 15 other U.S. medical specialty societies in the fight to eliminate wasteful medical tests, drugs, and treatments.

The 10,000-member SHM, which represents more than 40,000 hospitalists, released two lists of common tests and procedures that clinicians and patients should seriously question as part of the ABIM Foundation’s Choosing Wisely campaign. The campaign debuted in April 2012 with nine medical societies providing input on medical decisions that lack evidence, waste finite healthcare resources, or potentially harm patients.

“We acknowledge that there is waste in our system,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. “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.”

SHM’s Hospital Quality and Patient Safety Committee created two lists of five recommendations: one for adult hospitalists and inpatients, and one for pediatric hospitalists and patients. Examples include:

• Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless they are at high risk for gastrointestinal complications;
• Do not order continuous telemetry monitoring outside the ICU without using a protocol that governs its continuation; and
• Do not order chest radiography in children who have uncomplicated asthma or bronchiolitis.

The “avoid” lists were chosen by SHM because they potentially represent significant, needless waste of healthcare resources, according to John Bulger, DO, MBA, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa. Dr. Bulger, who chaired SHM’s Choosing Wisely committee, encourages hospitalists to stop and take a long look at the list and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committee and start collecting baseline data, he says. “We should be able to come back a year from now and show that we’ve been able to change practice using these lists,” he says.

HM pioneer Robert Wachter, MD, MHM, who heads the division of hospital medicine at the University of California at San Francisco, chairs the American Board of Internal Medicine, and sits on the board of the ABIM Foundation, agrees.

“I think you’ll be hearing similar kinds of drumbeats about waste from every national organization involved in healthcare,” says Dr. Wachter, author of the Wachter’s World blog. “I think hospitalists should be active and enthusiastic partners in the Choosing Wisely campaign and leaders in American healthcare’s efforts to figure out how to purge waste from the system and decrease unnecessary expense.”

Click here to listen to more of Dr. Wachter’s interview on the Choosing Wisely campaign.

A similar kind of focus on efficiency and cost-effectiveness was part of the initial motivation for developing hospital medicine, Dr. Wachter says. He compares the current national obsession about healthcare waste with the medical quality and patient safety movements of the past decade.

“It’s the right time, the right message, and the right messenger,” he says. “But now we’re a little scared about raised expectations. Delivering on them is going to be more difficult, even, than patient safety was because, ultimately, it will require curtailing some income streams. You can’t reach the final outcome of cutting costs in healthcare without someone making less money.” TH

 

Larry Beresford is a freelance writer in Oakland, Calif. 

 

 

WASHINGTON, D.C.—SHM joined hands today with 15 other U.S. medical specialty societies in the fight to eliminate wasteful medical tests, drugs, and treatments.

The 10,000-member SHM, which represents more than 40,000 hospitalists, released two lists of common tests and procedures that clinicians and patients should seriously question as part of the ABIM Foundation’s Choosing Wisely campaign. The campaign debuted in April 2012 with nine medical societies providing input on medical decisions that lack evidence, waste finite healthcare resources, or potentially harm patients.

“We acknowledge that there is waste in our system,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Healthcare Improvement and Innovation. “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.”

SHM’s Hospital Quality and Patient Safety Committee created two lists of five recommendations: one for adult hospitalists and inpatients, and one for pediatric hospitalists and patients. Examples include:

• Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless they are at high risk for gastrointestinal complications;
• Do not order continuous telemetry monitoring outside the ICU without using a protocol that governs its continuation; and
• Do not order chest radiography in children who have uncomplicated asthma or bronchiolitis.

The “avoid” lists were chosen by SHM because they potentially represent significant, needless waste of healthcare resources, according to John Bulger, DO, MBA, SFHM, chief quality officer at Geisinger Medical Center in Danville, Pa. Dr. Bulger, who chaired SHM’s Choosing Wisely committee, encourages hospitalists to stop and take a long look at the list and think about ways to improve their own practice. He encourages hospitalists to take the recommendations to their hospitals’ quality-improvement (QI) committee and start collecting baseline data, he says. “We should be able to come back a year from now and show that we’ve been able to change practice using these lists,” he says.

HM pioneer Robert Wachter, MD, MHM, who heads the division of hospital medicine at the University of California at San Francisco, chairs the American Board of Internal Medicine, and sits on the board of the ABIM Foundation, agrees.

“I think you’ll be hearing similar kinds of drumbeats about waste from every national organization involved in healthcare,” says Dr. Wachter, author of the Wachter’s World blog. “I think hospitalists should be active and enthusiastic partners in the Choosing Wisely campaign and leaders in American healthcare’s efforts to figure out how to purge waste from the system and decrease unnecessary expense.”

Click here to listen to more of Dr. Wachter’s interview on the Choosing Wisely campaign.

A similar kind of focus on efficiency and cost-effectiveness was part of the initial motivation for developing hospital medicine, Dr. Wachter says. He compares the current national obsession about healthcare waste with the medical quality and patient safety movements of the past decade.

“It’s the right time, the right message, and the right messenger,” he says. “But now we’re a little scared about raised expectations. Delivering on them is going to be more difficult, even, than patient safety was because, ultimately, it will require curtailing some income streams. You can’t reach the final outcome of cutting costs in healthcare without someone making less money.” TH

 

Larry Beresford is a freelance writer in Oakland, Calif. 

 

 

The lead author of a new report that says hospitalized Medicare patients are happier in facilities using a greater number of hospitalists didn't expect that would be the case.

The study, "Hospitalist Staffing and Patient Satisfaction in the National Medicare Population," which was recently published in the Journal of Hospital Medicine, sprung from the theory that hospitals using a large number of hospitalists generally would rank lower in patient satisfaction than others. In part, the expectation was tied to the belief that patients might prefer to be seen by their primary-care physician (PCP) rather than a hospitalist.

"What we'd like people to take away is that in our study—and it's only one study—hospitals with higher levels of hospitalist care had modestly higher patient satisfaction scores, especially in the areas of discharge planning and overall satisfaction," says Lena Chen, MD, MS, clinical lecturer in the division of general medicine at the University of Michigan in Ann Arbor. "It suggests that there doesn't need to be a tradeoff between greater use of hospitalist services and patient satisfaction."

The retrospective cohort study looked at 2,843 acute-care hospitals and split them into groups ranked by the percentage of patients cared for by hospitalists. Those categorized as "nonhospitalist" hospitals had a median of 0% of general medicine patients cared for by hospitalists; a "mixed" hospital had a median of 39.5% of general medicine patients cared for by hospitalists; and a "hospitalist" hospital had a median of 76.5% cared for by hospitalists, according to the report. "Hospitalist" hospitals scored better (65.6%) on global measures of satisfaction than "mixed" (63.9%) or "nonhospitalist" (63.9%) hospitals (P<0.001), the study found. Hospitalist care was not associated with patient satisfaction in the areas of room cleanliness or communication with a physician.

Dr. Chen says she would like to see the research prompt more investigation into why hospitalist care is associated with patient satisfaction.

"We all want to have satisfied patients," she adds. "It would be important to have research that explores what the factors are that lead to greater patient satisfaction. This is a first step, but it's definitely not the end of the road."

Visit our website for more information about patient satisfaction.

The lead author of a new report that says hospitalized Medicare patients are happier in facilities using a greater number of hospitalists didn't expect that would be the case.

The study, "Hospitalist Staffing and Patient Satisfaction in the National Medicare Population," which was recently published in the Journal of Hospital Medicine, sprung from the theory that hospitals using a large number of hospitalists generally would rank lower in patient satisfaction than others. In part, the expectation was tied to the belief that patients might prefer to be seen by their primary-care physician (PCP) rather than a hospitalist.

"What we'd like people to take away is that in our study—and it's only one study—hospitals with higher levels of hospitalist care had modestly higher patient satisfaction scores, especially in the areas of discharge planning and overall satisfaction," says Lena Chen, MD, MS, clinical lecturer in the division of general medicine at the University of Michigan in Ann Arbor. "It suggests that there doesn't need to be a tradeoff between greater use of hospitalist services and patient satisfaction."

The retrospective cohort study looked at 2,843 acute-care hospitals and split them into groups ranked by the percentage of patients cared for by hospitalists. Those categorized as "nonhospitalist" hospitals had a median of 0% of general medicine patients cared for by hospitalists; a "mixed" hospital had a median of 39.5% of general medicine patients cared for by hospitalists; and a "hospitalist" hospital had a median of 76.5% cared for by hospitalists, according to the report. "Hospitalist" hospitals scored better (65.6%) on global measures of satisfaction than "mixed" (63.9%) or "nonhospitalist" (63.9%) hospitals (P<0.001), the study found. Hospitalist care was not associated with patient satisfaction in the areas of room cleanliness or communication with a physician.

Dr. Chen says she would like to see the research prompt more investigation into why hospitalist care is associated with patient satisfaction.

"We all want to have satisfied patients," she adds. "It would be important to have research that explores what the factors are that lead to greater patient satisfaction. This is a first step, but it's definitely not the end of the road."

Visit our website for more information about patient satisfaction.

The lead author of a new report that says hospitalized Medicare patients are happier in facilities using a greater number of hospitalists didn't expect that would be the case.

The study, "Hospitalist Staffing and Patient Satisfaction in the National Medicare Population," which was recently published in the Journal of Hospital Medicine, sprung from the theory that hospitals using a large number of hospitalists generally would rank lower in patient satisfaction than others. In part, the expectation was tied to the belief that patients might prefer to be seen by their primary-care physician (PCP) rather than a hospitalist.

"What we'd like people to take away is that in our study—and it's only one study—hospitals with higher levels of hospitalist care had modestly higher patient satisfaction scores, especially in the areas of discharge planning and overall satisfaction," says Lena Chen, MD, MS, clinical lecturer in the division of general medicine at the University of Michigan in Ann Arbor. "It suggests that there doesn't need to be a tradeoff between greater use of hospitalist services and patient satisfaction."

The retrospective cohort study looked at 2,843 acute-care hospitals and split them into groups ranked by the percentage of patients cared for by hospitalists. Those categorized as "nonhospitalist" hospitals had a median of 0% of general medicine patients cared for by hospitalists; a "mixed" hospital had a median of 39.5% of general medicine patients cared for by hospitalists; and a "hospitalist" hospital had a median of 76.5% cared for by hospitalists, according to the report. "Hospitalist" hospitals scored better (65.6%) on global measures of satisfaction than "mixed" (63.9%) or "nonhospitalist" (63.9%) hospitals (P<0.001), the study found. Hospitalist care was not associated with patient satisfaction in the areas of room cleanliness or communication with a physician.

Dr. Chen says she would like to see the research prompt more investigation into why hospitalist care is associated with patient satisfaction.

"We all want to have satisfied patients," she adds. "It would be important to have research that explores what the factors are that lead to greater patient satisfaction. This is a first step, but it's definitely not the end of the road."

Visit our website for more information about patient satisfaction.

A recent study in which 36% of hospitalists reported that their workload exceeds safe patient census levels at least once a week could spur serious discussions on productivity and quality of care, according to one of its authors.

Daniel Brotman, MD, FACP, FHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and one of the study's authors, says the results highlight the delicate balance between pushing hospitalists to generate revenue and maintaining patient safety.

"It's certainly not in the best interest of our patients or our healthcare system to fix financial stress by expecting more clinical productivity of doctors year over year,” he says. "At some point, and it's self-evident—at least in my mind—quality starts to suffer when workload gets excessive."

The report, "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists," details findings of the first study to assess perception of unsafe workloads by directly questioning physicians, according to its authors. They electronically queried 506 hospitalists enrolled in the physicians' online network and information site QuantiaMD.com.

As many as 40% of physicians reported their typical inpatient census exceeded safe levels at least once monthly, the report noted, and physicians pegged 15 as the optimal number of patients to see on a shift dedicated to clinical work.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., says staffing shortages are likely the most common cause of heavy workloads, and that the high number of physicians reporting overloaded censuses is evidence that hospitalists are concerned their job performance is adversely affected.

"I suspect that as belt-tightening continues to occur," Dr. Brotman adds, "we're going to see the importance of [research] like this increasing, because we're going to see more and more stressed-out, overextended doctors who are having trouble delivering the care that they know they can deliver if they had more time."

 

Visit our website for more information on hospital medicine workloads.

 

A recent study in which 36% of hospitalists reported that their workload exceeds safe patient census levels at least once a week could spur serious discussions on productivity and quality of care, according to one of its authors.

Daniel Brotman, MD, FACP, FHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and one of the study's authors, says the results highlight the delicate balance between pushing hospitalists to generate revenue and maintaining patient safety.

"It's certainly not in the best interest of our patients or our healthcare system to fix financial stress by expecting more clinical productivity of doctors year over year,” he says. "At some point, and it's self-evident—at least in my mind—quality starts to suffer when workload gets excessive."

The report, "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists," details findings of the first study to assess perception of unsafe workloads by directly questioning physicians, according to its authors. They electronically queried 506 hospitalists enrolled in the physicians' online network and information site QuantiaMD.com.

As many as 40% of physicians reported their typical inpatient census exceeded safe levels at least once monthly, the report noted, and physicians pegged 15 as the optimal number of patients to see on a shift dedicated to clinical work.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., says staffing shortages are likely the most common cause of heavy workloads, and that the high number of physicians reporting overloaded censuses is evidence that hospitalists are concerned their job performance is adversely affected.

"I suspect that as belt-tightening continues to occur," Dr. Brotman adds, "we're going to see the importance of [research] like this increasing, because we're going to see more and more stressed-out, overextended doctors who are having trouble delivering the care that they know they can deliver if they had more time."

 

Visit our website for more information on hospital medicine workloads.

 

A recent study in which 36% of hospitalists reported that their workload exceeds safe patient census levels at least once a week could spur serious discussions on productivity and quality of care, according to one of its authors.

Daniel Brotman, MD, FACP, FHM, director of the hospitalist program at Johns Hopkins Hospital in Baltimore and one of the study's authors, says the results highlight the delicate balance between pushing hospitalists to generate revenue and maintaining patient safety.

"It's certainly not in the best interest of our patients or our healthcare system to fix financial stress by expecting more clinical productivity of doctors year over year,” he says. "At some point, and it's self-evident—at least in my mind—quality starts to suffer when workload gets excessive."

The report, "Impact of Attending Physician Workload on Patient Care: A Survey of Hospitalists," details findings of the first study to assess perception of unsafe workloads by directly questioning physicians, according to its authors. They electronically queried 506 hospitalists enrolled in the physicians' online network and information site QuantiaMD.com.

As many as 40% of physicians reported their typical inpatient census exceeded safe levels at least once monthly, the report noted, and physicians pegged 15 as the optimal number of patients to see on a shift dedicated to clinical work.

John Nelson, MD, MHM, a principal in Nelson Flores Hospital Medicine Consultants in La Quinta, Calif., says staffing shortages are likely the most common cause of heavy workloads, and that the high number of physicians reporting overloaded censuses is evidence that hospitalists are concerned their job performance is adversely affected.

"I suspect that as belt-tightening continues to occur," Dr. Brotman adds, "we're going to see the importance of [research] like this increasing, because we're going to see more and more stressed-out, overextended doctors who are having trouble delivering the care that they know they can deliver if they had more time."

 

Visit our website for more information on hospital medicine workloads.

 

Patrick Cawley, MD, MBA, MHM, a past president of SHM and a recipient of its prestigious Master of Hospital Medicine award, 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) in Charleston.

"What distinguished Dr. Cawley from the rest of the field is his intimate knowledge of MUSC, his medical expertise combined with graduate education in management, and his track record of improving our performance in quality and patient safety," says Raymond S. Greenberg, MD, PhD, and president of MUSC. "Given his familiarity with the issues here, Dr. Cawley can step in quickly to assume his new responsibilities. He's already demonstrating steady and thoughtful leadership."

Dr. Cawley took his first leadership course 15 years ago. That led to other courses on such topics as marketing and finance, and that led to his earning a master’s degree in business administration from the University of Massachusetts at Amherst. "Just like medicine, you never stop learning in business or trying to do things better," he says.

Dr. Cawley says hospitalists have a leg up on other physicians when it comes to moving into hospital administration. "Being a hospitalist allowed me to get into every nook and cranny of this hospital," he says. He advises other hospitalists interested in this path to seek out progressive leadership roles. “Show what you can do,” he says, “and get that management degree.”

As Dr. Cawley's administrative responsibilities continue to expand, the time he spends in clinical practice continues to decrease. Although he plans to give up clinical work for the crucial first six months in his new position, he says he hopes to return to hospitalist practice at least 10% of the time after that.

"Any CEO worth his or her salt goes out to the front lines to see what is happening," Dr. Cawley notes. "As a physician, it is easier to get to those front lines. Once there, you get a feel for how the hospital really runs."

 

Visit our website for more information about executive leadership positions in hospitals.

 

 

Patrick Cawley, MD, MBA, MHM, a past president of SHM and a recipient of its prestigious Master of Hospital Medicine award, 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) in Charleston.

"What distinguished Dr. Cawley from the rest of the field is his intimate knowledge of MUSC, his medical expertise combined with graduate education in management, and his track record of improving our performance in quality and patient safety," says Raymond S. Greenberg, MD, PhD, and president of MUSC. "Given his familiarity with the issues here, Dr. Cawley can step in quickly to assume his new responsibilities. He's already demonstrating steady and thoughtful leadership."

Dr. Cawley took his first leadership course 15 years ago. That led to other courses on such topics as marketing and finance, and that led to his earning a master’s degree in business administration from the University of Massachusetts at Amherst. "Just like medicine, you never stop learning in business or trying to do things better," he says.

Dr. Cawley says hospitalists have a leg up on other physicians when it comes to moving into hospital administration. "Being a hospitalist allowed me to get into every nook and cranny of this hospital," he says. He advises other hospitalists interested in this path to seek out progressive leadership roles. “Show what you can do,” he says, “and get that management degree.”

As Dr. Cawley's administrative responsibilities continue to expand, the time he spends in clinical practice continues to decrease. Although he plans to give up clinical work for the crucial first six months in his new position, he says he hopes to return to hospitalist practice at least 10% of the time after that.

"Any CEO worth his or her salt goes out to the front lines to see what is happening," Dr. Cawley notes. "As a physician, it is easier to get to those front lines. Once there, you get a feel for how the hospital really runs."

 

Visit our website for more information about executive leadership positions in hospitals.

 

 

Patrick Cawley, MD, MBA, MHM, a past president of SHM and a recipient of its prestigious Master of Hospital Medicine award, 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) in Charleston.

"What distinguished Dr. Cawley from the rest of the field is his intimate knowledge of MUSC, his medical expertise combined with graduate education in management, and his track record of improving our performance in quality and patient safety," says Raymond S. Greenberg, MD, PhD, and president of MUSC. "Given his familiarity with the issues here, Dr. Cawley can step in quickly to assume his new responsibilities. He's already demonstrating steady and thoughtful leadership."

Dr. Cawley took his first leadership course 15 years ago. That led to other courses on such topics as marketing and finance, and that led to his earning a master’s degree in business administration from the University of Massachusetts at Amherst. "Just like medicine, you never stop learning in business or trying to do things better," he says.

Dr. Cawley says hospitalists have a leg up on other physicians when it comes to moving into hospital administration. "Being a hospitalist allowed me to get into every nook and cranny of this hospital," he says. He advises other hospitalists interested in this path to seek out progressive leadership roles. “Show what you can do,” he says, “and get that management degree.”

As Dr. Cawley's administrative responsibilities continue to expand, the time he spends in clinical practice continues to decrease. Although he plans to give up clinical work for the crucial first six months in his new position, he says he hopes to return to hospitalist practice at least 10% of the time after that.

"Any CEO worth his or her salt goes out to the front lines to see what is happening," Dr. Cawley notes. "As a physician, it is easier to get to those front lines. Once there, you get a feel for how the hospital really runs."

 

Visit our website for more information about executive leadership positions in hospitals.

 

 

U.S. hospitals in 2011 showed improvements in their rates of central line-associated bloodstream infections (CLABSI) and in some surgical-site infections, compared with 2010, but the rate essentially hit a plateau for catheter-associated urinary tract infections (CAUTI), according to a new CDC report.

“Reductions in some of the deadliest healthcare-associated infections are encouraging, especially when you consider the costs to both patients and the health care system,” CDC director Thomas R. Frieden, MD, MPH, says. “However, the slower progress in reducing catheter-associated urinary tract infections is a call to action for hospitals to redouble their efforts to track these infections and implement control strategies we know that work.”

The report showed a 41% reduction in 2011 central-line infections compared with 2008, the baseline year for the report. In 2010, the reduction was 32% over the 2008 baseline. The improvement was seen across ICUs, general wards, and neonatal ICUs.

The CDC also reported a 17% drop in surgical-site infections since 2008, better than the 7% reduction in 2010. The biggest reductions were seen in coronary artery bypass graft surgery and cardiac surgery; little improvement was seen in infections from hip arthroplasty and vaginal hysterectomy procedures.

The rate of infections from CAUTIs was 7%, nearly the same as the 6% rate in 2010 data. The infection rate in ICUs actually went up—a 1% drop in 2011 compared with a 3% drop from baseline in 2010.

SHM is a partner in two initiatives that aim to reduce CAUTI infections: the University HealthSystems Consortium’s Partnership for Patients project and On the CUSP: STOP CAUTI, an American Hospital Association HRET effort that’s funded by the Agency for Healthcare Research and Quality-funded project.

Gregory Maynard, MD, SFHM, director of hospital medicine at the University of San Diego Medical Center and senior vice president of SHM’s Center for Healthcare Improvement and Innovation is encouraged by the CLABSI and SSI figures. The report highlights the need for more effort on CAUTI.

“I think all the tools and information are available for improvement teams,” he says. “The CDC, the HRET On the CUSP group, and others all have great toolkits.”

He also says it was telling that the CAUTI numbers were worse in the ICU than in general wards.

“The more complex the environment, the easier it is for those things to get lost,” he says. “It just will probably take more attention to it and making it more of a priority.

“The more complex the environment, the easier it is for those things to get lost. It just will probably take more attention to it and making it more of a priority…. We’re supposed to reduce these adverse events by a very significant amount and obviously we’re not getting there based on this report. We have to do a better job. Reducing CAUTI by 40% is one of goals for the $500 million Partnerships for Patients effort. With that much money involved, it should increase the pressure to get this done.”

Click here to hear more of Dr. Maynard's interview with The Hospitalist

Scott Flanders, MD, SFHM, a former SHM president and SHM’s physician leader for STOP CAUTI, says the report shows that CAUTIs may be more difficult to prevent. In part, that is because catheters are used more broadly throughout a hospital than, say, central lines, which are most common in ICUs.

 

It takes a multi-disciplinary team implementing a variety of tools: critieria for putting catheters in, managing them appropriately once they are in, and developing protocols for removing them as quickly as possible, he adds.

“Having all those elements in place are critical to preventing CAUTI and I think many hospitals around the country have not implemented all of those strategies to reduce CAUTI,” says Dr. Flanders, professor of medicine and director of hospital medicine at the University of Michigan Health System in Ann Arbor. “No single strategy used in isolation is going to be effective.”

Efforts to reduce CAUTIs have been launched more recently than efforts to reduce other infection types, he says.

“There’s been less of a drive for CAUTI,” he says. “It’s a tougher problem to tackle than some of these other issues, which is a contributing factor in the lower rate of improvement.” TH

Tom Collins is a freelance writer in South Florida.

U.S. hospitals in 2011 showed improvements in their rates of central line-associated bloodstream infections (CLABSI) and in some surgical-site infections, compared with 2010, but the rate essentially hit a plateau for catheter-associated urinary tract infections (CAUTI), according to a new CDC report.

“Reductions in some of the deadliest healthcare-associated infections are encouraging, especially when you consider the costs to both patients and the health care system,” CDC director Thomas R. Frieden, MD, MPH, says. “However, the slower progress in reducing catheter-associated urinary tract infections is a call to action for hospitals to redouble their efforts to track these infections and implement control strategies we know that work.”

The report showed a 41% reduction in 2011 central-line infections compared with 2008, the baseline year for the report. In 2010, the reduction was 32% over the 2008 baseline. The improvement was seen across ICUs, general wards, and neonatal ICUs.

The CDC also reported a 17% drop in surgical-site infections since 2008, better than the 7% reduction in 2010. The biggest reductions were seen in coronary artery bypass graft surgery and cardiac surgery; little improvement was seen in infections from hip arthroplasty and vaginal hysterectomy procedures.

The rate of infections from CAUTIs was 7%, nearly the same as the 6% rate in 2010 data. The infection rate in ICUs actually went up—a 1% drop in 2011 compared with a 3% drop from baseline in 2010.

SHM is a partner in two initiatives that aim to reduce CAUTI infections: the University HealthSystems Consortium’s Partnership for Patients project and On the CUSP: STOP CAUTI, an American Hospital Association HRET effort that’s funded by the Agency for Healthcare Research and Quality-funded project.

Gregory Maynard, MD, SFHM, director of hospital medicine at the University of San Diego Medical Center and senior vice president of SHM’s Center for Healthcare Improvement and Innovation is encouraged by the CLABSI and SSI figures. The report highlights the need for more effort on CAUTI.

“I think all the tools and information are available for improvement teams,” he says. “The CDC, the HRET On the CUSP group, and others all have great toolkits.”

He also says it was telling that the CAUTI numbers were worse in the ICU than in general wards.

“The more complex the environment, the easier it is for those things to get lost,” he says. “It just will probably take more attention to it and making it more of a priority.

“The more complex the environment, the easier it is for those things to get lost. It just will probably take more attention to it and making it more of a priority…. We’re supposed to reduce these adverse events by a very significant amount and obviously we’re not getting there based on this report. We have to do a better job. Reducing CAUTI by 40% is one of goals for the $500 million Partnerships for Patients effort. With that much money involved, it should increase the pressure to get this done.”

Click here to hear more of Dr. Maynard's interview with The Hospitalist

Scott Flanders, MD, SFHM, a former SHM president and SHM’s physician leader for STOP CAUTI, says the report shows that CAUTIs may be more difficult to prevent. In part, that is because catheters are used more broadly throughout a hospital than, say, central lines, which are most common in ICUs.

 

It takes a multi-disciplinary team implementing a variety of tools: critieria for putting catheters in, managing them appropriately once they are in, and developing protocols for removing them as quickly as possible, he adds.

“Having all those elements in place are critical to preventing CAUTI and I think many hospitals around the country have not implemented all of those strategies to reduce CAUTI,” says Dr. Flanders, professor of medicine and director of hospital medicine at the University of Michigan Health System in Ann Arbor. “No single strategy used in isolation is going to be effective.”

Efforts to reduce CAUTIs have been launched more recently than efforts to reduce other infection types, he says.

“There’s been less of a drive for CAUTI,” he says. “It’s a tougher problem to tackle than some of these other issues, which is a contributing factor in the lower rate of improvement.” TH

Tom Collins is a freelance writer in South Florida.

U.S. hospitals in 2011 showed improvements in their rates of central line-associated bloodstream infections (CLABSI) and in some surgical-site infections, compared with 2010, but the rate essentially hit a plateau for catheter-associated urinary tract infections (CAUTI), according to a new CDC report.

“Reductions in some of the deadliest healthcare-associated infections are encouraging, especially when you consider the costs to both patients and the health care system,” CDC director Thomas R. Frieden, MD, MPH, says. “However, the slower progress in reducing catheter-associated urinary tract infections is a call to action for hospitals to redouble their efforts to track these infections and implement control strategies we know that work.”

The report showed a 41% reduction in 2011 central-line infections compared with 2008, the baseline year for the report. In 2010, the reduction was 32% over the 2008 baseline. The improvement was seen across ICUs, general wards, and neonatal ICUs.

The CDC also reported a 17% drop in surgical-site infections since 2008, better than the 7% reduction in 2010. The biggest reductions were seen in coronary artery bypass graft surgery and cardiac surgery; little improvement was seen in infections from hip arthroplasty and vaginal hysterectomy procedures.

The rate of infections from CAUTIs was 7%, nearly the same as the 6% rate in 2010 data. The infection rate in ICUs actually went up—a 1% drop in 2011 compared with a 3% drop from baseline in 2010.

SHM is a partner in two initiatives that aim to reduce CAUTI infections: the University HealthSystems Consortium’s Partnership for Patients project and On the CUSP: STOP CAUTI, an American Hospital Association HRET effort that’s funded by the Agency for Healthcare Research and Quality-funded project.

Gregory Maynard, MD, SFHM, director of hospital medicine at the University of San Diego Medical Center and senior vice president of SHM’s Center for Healthcare Improvement and Innovation is encouraged by the CLABSI and SSI figures. The report highlights the need for more effort on CAUTI.

“I think all the tools and information are available for improvement teams,” he says. “The CDC, the HRET On the CUSP group, and others all have great toolkits.”

He also says it was telling that the CAUTI numbers were worse in the ICU than in general wards.

“The more complex the environment, the easier it is for those things to get lost,” he says. “It just will probably take more attention to it and making it more of a priority.

“The more complex the environment, the easier it is for those things to get lost. It just will probably take more attention to it and making it more of a priority…. We’re supposed to reduce these adverse events by a very significant amount and obviously we’re not getting there based on this report. We have to do a better job. Reducing CAUTI by 40% is one of goals for the $500 million Partnerships for Patients effort. With that much money involved, it should increase the pressure to get this done.”

Click here to hear more of Dr. Maynard's interview with The Hospitalist

Scott Flanders, MD, SFHM, a former SHM president and SHM’s physician leader for STOP CAUTI, says the report shows that CAUTIs may be more difficult to prevent. In part, that is because catheters are used more broadly throughout a hospital than, say, central lines, which are most common in ICUs.

 

It takes a multi-disciplinary team implementing a variety of tools: critieria for putting catheters in, managing them appropriately once they are in, and developing protocols for removing them as quickly as possible, he adds.

“Having all those elements in place are critical to preventing CAUTI and I think many hospitals around the country have not implemented all of those strategies to reduce CAUTI,” says Dr. Flanders, professor of medicine and director of hospital medicine at the University of Michigan Health System in Ann Arbor. “No single strategy used in isolation is going to be effective.”

Efforts to reduce CAUTIs have been launched more recently than efforts to reduce other infection types, he says.

“There’s been less of a drive for CAUTI,” he says. “It’s a tougher problem to tackle than some of these other issues, which is a contributing factor in the lower rate of improvement.” TH

Tom Collins is a freelance writer in South Florida.

Hospitalists aren’t urban planners, but it doesn’t take a zoning expert to realize that when a community sees hundreds of new homes built, some of the residents of those homes will end up in the hospital. The same logic applies when a company moves thousands of jobs to an office building a few blocks away from a hospital.

HM group leaders might not normally think about such things when analyzing whether they need to add staff, but at least one practice consultant says they should.

“If you fail to look outside the building, you will fail,” says Kenneth Hertz, FACMPE, principal of MGMA’s Health Care Consulting Group. “I think the outside metrics are almost more important. You’ve got to stay on top of what’s happening outside in your community, because the people you serve are your market, and if all you do is look within the four walls of the hospital, you will not see what’s coming.”

Hospitals often have community data available, Hertz says, but group leaders don’t always think to access it. He suggests they view the information as a routine part of their strategic planning.

Of course, Hertz adds, it’s not the only information that goes into the expansion equation, but administrators often respect group leaders who come armed with data from inside and outside the hospital about why it is necessary to make a new hire.

“It’s about open, honest discussion,” he says. “It’s about looking at information both inside the four walls and outside in the community. It’s not easy, but it can be done. But you’ve got to plan.”

Hertz says HM group leaders should plan at least 12 to 18 months out for a hire, “which I know is hard these days,” he says. But, he adds, short-term forecasting makes it “very difficult” to know when and how best to grow your group. TH

Richard Quinn is a freelance writer in New Jersey.

 

Hospitalists aren’t urban planners, but it doesn’t take a zoning expert to realize that when a community sees hundreds of new homes built, some of the residents of those homes will end up in the hospital. The same logic applies when a company moves thousands of jobs to an office building a few blocks away from a hospital.

HM group leaders might not normally think about such things when analyzing whether they need to add staff, but at least one practice consultant says they should.

“If you fail to look outside the building, you will fail,” says Kenneth Hertz, FACMPE, principal of MGMA’s Health Care Consulting Group. “I think the outside metrics are almost more important. You’ve got to stay on top of what’s happening outside in your community, because the people you serve are your market, and if all you do is look within the four walls of the hospital, you will not see what’s coming.”

Hospitals often have community data available, Hertz says, but group leaders don’t always think to access it. He suggests they view the information as a routine part of their strategic planning.

Of course, Hertz adds, it’s not the only information that goes into the expansion equation, but administrators often respect group leaders who come armed with data from inside and outside the hospital about why it is necessary to make a new hire.

“It’s about open, honest discussion,” he says. “It’s about looking at information both inside the four walls and outside in the community. It’s not easy, but it can be done. But you’ve got to plan.”

Hertz says HM group leaders should plan at least 12 to 18 months out for a hire, “which I know is hard these days,” he says. But, he adds, short-term forecasting makes it “very difficult” to know when and how best to grow your group. TH

Richard Quinn is a freelance writer in New Jersey.

 

Hospitalists aren’t urban planners, but it doesn’t take a zoning expert to realize that when a community sees hundreds of new homes built, some of the residents of those homes will end up in the hospital. The same logic applies when a company moves thousands of jobs to an office building a few blocks away from a hospital.

HM group leaders might not normally think about such things when analyzing whether they need to add staff, but at least one practice consultant says they should.

“If you fail to look outside the building, you will fail,” says Kenneth Hertz, FACMPE, principal of MGMA’s Health Care Consulting Group. “I think the outside metrics are almost more important. You’ve got to stay on top of what’s happening outside in your community, because the people you serve are your market, and if all you do is look within the four walls of the hospital, you will not see what’s coming.”

Hospitals often have community data available, Hertz says, but group leaders don’t always think to access it. He suggests they view the information as a routine part of their strategic planning.

Of course, Hertz adds, it’s not the only information that goes into the expansion equation, but administrators often respect group leaders who come armed with data from inside and outside the hospital about why it is necessary to make a new hire.

“It’s about open, honest discussion,” he says. “It’s about looking at information both inside the four walls and outside in the community. It’s not easy, but it can be done. But you’ve got to plan.”

Hertz says HM group leaders should plan at least 12 to 18 months out for a hire, “which I know is hard these days,” he says. But, he adds, short-term forecasting makes it “very difficult” to know when and how best to grow your group. TH

Richard Quinn is a freelance writer in New Jersey.

 

More than 300 hospitalists and other clinicians recently attended the 13th annual Southern Hospital Medicine Conference in Atlanta. The conference is a joint collaboration between the Emory University School of Medicine in Atlanta and Ochsner Health System New Orleans. The meeting site has alternated between the two cities each year since 2005.

The prevailing conference theme in 2012 was “Value and Values in Hospital Medicine,” alluding to the value that hospitalists bring to the medical community and hospitals and the values shared by hospitalists. The conference offered five pre-courses and more than 50 sessions focused on educating hospitalists on current best practices within core topic areas, including clinical care, quality improvement, healthcare information technology, innovative care models, systems of care, and transitions of care. A judged poster competition featured research and clinical vignettes abstracts, with interesting clinical cases as well as new research in hospital medicine.

One of the highlights of this year’s conference was the keynote address delivered by Dr. William A. Bornstein, chief quality and medical officer of Emory Healthcare. Dr. Bornstein discussed the various aspects of quality and cost in hospital care. He described the challenges in defining quality and measuring cost when trying to calculate the “value” equation in medicine (value=quality/cost). He outlined the Institute of Medicine’s previously described STEEEP (safe, timely, effective, efficient, equitable, patient-centered) aims of quality in 2001.

Dr. Bornstein’s own definition for quality is “partnering with patients and families to reliably, 100% of the time, deliver when, where, and how they want it—and with minimal waste—care based on the best available evidence and consistent with patient and family values and preferences.” To measure outcome, he said, we need to address system structure (what’s in place before the patient arrives), process (what we do for the patient), and culture (how we can get the buy-in from all stakeholders). The sum of these factors achieves outcome, which requires risk adjustment and, ideally, long-term follow-up data, he said.

Dr. Bornstein also discussed the need to develop standard processes whereby equivalent clinicians can follow similar processes to achieve the same results. When physicians “do it the same” (i.e. standardized protocols), error rates and cost decrease, he explained.

Dr. Bornstein also focused on transformative solutions to address problems in healthcare as a whole, rather than attempting to fix problems piecemeal.

Jason Stein, MD, SFHM, offered another conference highlight: a pre-conference program and plenary session on an innovative approach to improve hospital outcomes through implementation of the accountable-care unit (ACU). Dr. Stein, director of the clinical research program at Emory School of Medicine, described the current state of hospital care as asynchronous, with various providers caring for the patient without much coordination. For example, the physician sees the patient at 9 a.m., followed by the nurse at 10 a.m., and then finally the visiting family at 11 a.m. The ACU model of care would involve all the providers rounding with the patient and family at a scheduled time daily to provide synchronous care.

Dr. Stein described an ACU as a geographic inpatient area consistently responsible for the clinical, service, and cost outcomes it produces. Features of this unit include:

• Assignment of physicians by units to enhance predictability;
• Cohesiveness and communication;
• Structured interdisciplinary bedside rounds to consistently deliver evidence-based, patient-centered care;
• Evaluation of performance data by unit instead of facility or service line; and
• A dyad partnership involving a nurse unit director and a physician unit medical director.

ACU implementation at Emory has led to decreased mortality, reduced length of stay, and improved patient satisfaction compared to traditional units, according to Dr. Stein. While the ACU might not be suited for all, he said, all hospitals can learn from various components of this innovative approach to deliver better patient care.

 

The ever-changing state of HM in the U.S. remains a challenge, but it continues to generate innovation and excitement. The high number of engaged participants from 30 different states attending the 13th annual Southern Hospital Medicine Conference demonstrates that hospitalists are eager to learn and ready to improve their practice in order to provide high-value healthcare in U.S. hospitals today.

---

Dr. Lee is vice chairman in the department of hospital medicine at Ochsner Health System. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory University. Dr. Deitelzweig is system chairman in the department of hospital medicine and medical director for regional business development at Ochsner Health System. Dr. Wang is the division director of hospital medicine at Emory University. Dr. Dressler is director for education in the division of hospital medicine and an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University.

More than 300 hospitalists and other clinicians recently attended the 13th annual Southern Hospital Medicine Conference in Atlanta. The conference is a joint collaboration between the Emory University School of Medicine in Atlanta and Ochsner Health System New Orleans. The meeting site has alternated between the two cities each year since 2005.

The prevailing conference theme in 2012 was “Value and Values in Hospital Medicine,” alluding to the value that hospitalists bring to the medical community and hospitals and the values shared by hospitalists. The conference offered five pre-courses and more than 50 sessions focused on educating hospitalists on current best practices within core topic areas, including clinical care, quality improvement, healthcare information technology, innovative care models, systems of care, and transitions of care. A judged poster competition featured research and clinical vignettes abstracts, with interesting clinical cases as well as new research in hospital medicine.

One of the highlights of this year’s conference was the keynote address delivered by Dr. William A. Bornstein, chief quality and medical officer of Emory Healthcare. Dr. Bornstein discussed the various aspects of quality and cost in hospital care. He described the challenges in defining quality and measuring cost when trying to calculate the “value” equation in medicine (value=quality/cost). He outlined the Institute of Medicine’s previously described STEEEP (safe, timely, effective, efficient, equitable, patient-centered) aims of quality in 2001.

Dr. Bornstein’s own definition for quality is “partnering with patients and families to reliably, 100% of the time, deliver when, where, and how they want it—and with minimal waste—care based on the best available evidence and consistent with patient and family values and preferences.” To measure outcome, he said, we need to address system structure (what’s in place before the patient arrives), process (what we do for the patient), and culture (how we can get the buy-in from all stakeholders). The sum of these factors achieves outcome, which requires risk adjustment and, ideally, long-term follow-up data, he said.

Dr. Bornstein also discussed the need to develop standard processes whereby equivalent clinicians can follow similar processes to achieve the same results. When physicians “do it the same” (i.e. standardized protocols), error rates and cost decrease, he explained.

Dr. Bornstein also focused on transformative solutions to address problems in healthcare as a whole, rather than attempting to fix problems piecemeal.

Jason Stein, MD, SFHM, offered another conference highlight: a pre-conference program and plenary session on an innovative approach to improve hospital outcomes through implementation of the accountable-care unit (ACU). Dr. Stein, director of the clinical research program at Emory School of Medicine, described the current state of hospital care as asynchronous, with various providers caring for the patient without much coordination. For example, the physician sees the patient at 9 a.m., followed by the nurse at 10 a.m., and then finally the visiting family at 11 a.m. The ACU model of care would involve all the providers rounding with the patient and family at a scheduled time daily to provide synchronous care.

Dr. Stein described an ACU as a geographic inpatient area consistently responsible for the clinical, service, and cost outcomes it produces. Features of this unit include:

• Assignment of physicians by units to enhance predictability;
• Cohesiveness and communication;
• Structured interdisciplinary bedside rounds to consistently deliver evidence-based, patient-centered care;
• Evaluation of performance data by unit instead of facility or service line; and
• A dyad partnership involving a nurse unit director and a physician unit medical director.

ACU implementation at Emory has led to decreased mortality, reduced length of stay, and improved patient satisfaction compared to traditional units, according to Dr. Stein. While the ACU might not be suited for all, he said, all hospitals can learn from various components of this innovative approach to deliver better patient care.

 

The ever-changing state of HM in the U.S. remains a challenge, but it continues to generate innovation and excitement. The high number of engaged participants from 30 different states attending the 13th annual Southern Hospital Medicine Conference demonstrates that hospitalists are eager to learn and ready to improve their practice in order to provide high-value healthcare in U.S. hospitals today.

---

Dr. Lee is vice chairman in the department of hospital medicine at Ochsner Health System. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory University. Dr. Deitelzweig is system chairman in the department of hospital medicine and medical director for regional business development at Ochsner Health System. Dr. Wang is the division director of hospital medicine at Emory University. Dr. Dressler is director for education in the division of hospital medicine and an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University.

More than 300 hospitalists and other clinicians recently attended the 13th annual Southern Hospital Medicine Conference in Atlanta. The conference is a joint collaboration between the Emory University School of Medicine in Atlanta and Ochsner Health System New Orleans. The meeting site has alternated between the two cities each year since 2005.

The prevailing conference theme in 2012 was “Value and Values in Hospital Medicine,” alluding to the value that hospitalists bring to the medical community and hospitals and the values shared by hospitalists. The conference offered five pre-courses and more than 50 sessions focused on educating hospitalists on current best practices within core topic areas, including clinical care, quality improvement, healthcare information technology, innovative care models, systems of care, and transitions of care. A judged poster competition featured research and clinical vignettes abstracts, with interesting clinical cases as well as new research in hospital medicine.

One of the highlights of this year’s conference was the keynote address delivered by Dr. William A. Bornstein, chief quality and medical officer of Emory Healthcare. Dr. Bornstein discussed the various aspects of quality and cost in hospital care. He described the challenges in defining quality and measuring cost when trying to calculate the “value” equation in medicine (value=quality/cost). He outlined the Institute of Medicine’s previously described STEEEP (safe, timely, effective, efficient, equitable, patient-centered) aims of quality in 2001.

Dr. Bornstein’s own definition for quality is “partnering with patients and families to reliably, 100% of the time, deliver when, where, and how they want it—and with minimal waste—care based on the best available evidence and consistent with patient and family values and preferences.” To measure outcome, he said, we need to address system structure (what’s in place before the patient arrives), process (what we do for the patient), and culture (how we can get the buy-in from all stakeholders). The sum of these factors achieves outcome, which requires risk adjustment and, ideally, long-term follow-up data, he said.

Dr. Bornstein also discussed the need to develop standard processes whereby equivalent clinicians can follow similar processes to achieve the same results. When physicians “do it the same” (i.e. standardized protocols), error rates and cost decrease, he explained.

Dr. Bornstein also focused on transformative solutions to address problems in healthcare as a whole, rather than attempting to fix problems piecemeal.

Jason Stein, MD, SFHM, offered another conference highlight: a pre-conference program and plenary session on an innovative approach to improve hospital outcomes through implementation of the accountable-care unit (ACU). Dr. Stein, director of the clinical research program at Emory School of Medicine, described the current state of hospital care as asynchronous, with various providers caring for the patient without much coordination. For example, the physician sees the patient at 9 a.m., followed by the nurse at 10 a.m., and then finally the visiting family at 11 a.m. The ACU model of care would involve all the providers rounding with the patient and family at a scheduled time daily to provide synchronous care.

Dr. Stein described an ACU as a geographic inpatient area consistently responsible for the clinical, service, and cost outcomes it produces. Features of this unit include:

• Assignment of physicians by units to enhance predictability;
• Cohesiveness and communication;
• Structured interdisciplinary bedside rounds to consistently deliver evidence-based, patient-centered care;
• Evaluation of performance data by unit instead of facility or service line; and
• A dyad partnership involving a nurse unit director and a physician unit medical director.

ACU implementation at Emory has led to decreased mortality, reduced length of stay, and improved patient satisfaction compared to traditional units, according to Dr. Stein. While the ACU might not be suited for all, he said, all hospitals can learn from various components of this innovative approach to deliver better patient care.

 

The ever-changing state of HM in the U.S. remains a challenge, but it continues to generate innovation and excitement. The high number of engaged participants from 30 different states attending the 13th annual Southern Hospital Medicine Conference demonstrates that hospitalists are eager to learn and ready to improve their practice in order to provide high-value healthcare in U.S. hospitals today.

---

Dr. Lee is vice chairman in the department of hospital medicine at Ochsner Health System. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory University. Dr. Deitelzweig is system chairman in the department of hospital medicine and medical director for regional business development at Ochsner Health System. Dr. Wang is the division director of hospital medicine at Emory University. Dr. Dressler is director for education in the division of hospital medicine and an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University.

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

SHM board member Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., says there is no easy way to know when it is the right time to grow. He offers four tips to hospitalist group leaders grappling with the question:

• Benchmark: Use the SHM survey, MGMA data, or local analyses to determine best practices. But don’t be a slave to data that don’t account for the particulars of your payor mix, patient population, etc.
• Network: Meet with group leaders in nearby practices. Talk to administrators. Understand the competitive set for your hospital and know what their data sets are.
• Communicate: Talk to doctors, C-suite executives, and everyone in between. Front-line physicians and nurses often know better than practice heads which resources are needed, and where.
• Stay flexible: Don’t be wedded to needing to grow. Maybe a group has physicians who want extra shifts to handle a new schedule. Maybe the installation of new technology will improve efficiency and eliminate the need for a new physician.

Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.

“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”

It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:

• Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
• Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
• Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
• Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
• Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
• Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
• Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.

 

“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”

Practice Analysis

Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.

“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”

In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.

“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.

“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”

Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.

“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”

The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”

 

The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.

“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”

Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.

“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”

The Long View

Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.

Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”

Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.

“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”

Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.

Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.

 

“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”

---

Richard Quinn is a freelance writer in New Jersey.

Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.

“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”

It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:

• Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
• Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
• Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
• Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
• Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
• Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
• Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.

 

“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”

Practice Analysis

Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.

“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”

In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.

“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.

“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”

Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.

“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”

The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”

 

The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.

“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”

Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.

“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”

The Long View

Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.

Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”

Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.

“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”

Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.

Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.

 

“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”

---

Richard Quinn is a freelance writer in New Jersey.

Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.

“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”

It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:

• Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
• Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
• Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
• Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
• Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
• Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
• Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.

 

“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”

Practice Analysis

Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.

“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”

In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.

“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.

“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”

Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.

“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”

The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”

 

The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.

“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”

Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.

“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”

The Long View

Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.

Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”

Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.

“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”

Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.

Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.

 

“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”

---

Richard Quinn is a freelance writer in New Jersey.