Expert Commentary

Last month, I wrote about the attributes of hospitalist practices that I associate with success. This month, I’ll do the opposite. That is, I’ll write about strategies your practice could, or even should, do without. Of course, all of these things are open to debate, and some thoughtful people might (and in my experience, probably will) arrive at different conclusions.

So I offer my list as food for thought, and if your practice relies on some of these strategies, you shouldn’t feel threatened by my opinion. But you might want to think about whether they’ve been made part of your practice by design, or if things just evolved this way without careful consideration of alternatives. I’ve listed them in no particular order.

Fixed-duration day shifts. My sense is that the majority of practices have a day shift with a predetermined start and end. That is, the hospitalist is expected to arrive and depart at the same time each day.

This seems to make a lot of sense, but it ignores the dramatic variations in workload a practice will have. For example, a practice that is appropriately staffed with four daytime hospitalists, and schedules each of them to work a 12-hour shift, provides 48 hours of daytime hospitalist manpower each day. But that will turn out to be precisely the right level of staffing only a few days a year. On all other days, daytime staffing will be optimal with a different number of hours. So it would make sense for the doctors to work more or less on those days.

Telling doctors that their shift always starts at the same time has significant lifestyle advantages. But it can inhibit the doctors who would be happy to start earlier to address more discharges early in the day and potentially go home earlier. So, just like most other doctors at your hospital have, why not let the doctors have significant latitude in when they start and stop working each day? In most cases, it might be necessary to have a time by which every doctor must be available to respond to pages (and one who must be on-site before the night doctor leaves), but they should feel free to actually arrive and start working when they choose. Most will make good choices and will likely feel a little more empowered and happy with their work.

And, at the end of the day, it might be reasonable to allow some of the day-shift doctors to leave when their work is done, and allow the others to stay to handle admissions until the night shift takes over. Those who leave early might still be required to respond to pages until a specified time.

Shifts that don’t involve rounding on “continuity” patients, such as night and evening (“swing”) shifts, usually should be arranged with predetermined start. I wrote in more detail on this topic in January 2007 and October 2010.

Contractual vacation provisions. Hospitalists should have significant amounts of time off. We work a lot of evenings, nights, and weekends, and we must have liberal amounts of time away from work. But for many practices, there is no advantage in classifying this time as vacation (or CME, etc.) time. In most cases, it makes the most sense to simply specify how much work (e.g. number of shifts) a doctor is to do each year and not specify a number of days or hours of vacation time. For more detail, read “The Vacation Conundrum” from March 2007.

If your practice has a vacation system that works well, then stick with it. But if you or your administrators are going nuts trying to categorize nonworking days between vacation and days the doctor simply wasn’t scheduled, then it might be best to stop trying. Just settle on the number of shifts (or some other metric) that a doctor is to work each year.

Tenure-based salary increases. It makes a lot of sense to pay doctors in most specialties an increasing salary based on his or her tenure with the practice. As they build a patient population and a referral stream, they generate more revenue and should benefit accordingly. But a new hospitalist who joins an existing group almost never has to build the referrals. In most cases, the group hired the doctor because the referrals are already coming and the practice needs more help, or the new doctor is replacing a departing one. So paying a new hospitalist a lower salary that increases automatically every few years isn’t really a raise earned by the doctor’s improved financial performance. Usually it’s just a system of withholding money that could be available for compensation for the doctor’s first few years in the practice. This lower starting salary might adversely impact recruiting. For more, see “Compensation Conundrum” from December 2009.

Poor roles for nonphysician providers (NPPs). I’ve worked with a lot of practices that have NPs and PAs (and, in some cases, RNs) who are doing what amounts to clerical work. They’re faxing discharge summaries, making calls to schedule patient appointments, dividing up the overnight admissions for the day rounders, etc.

Don’t make this mistake. Hire a secretary for that sort of work. And be sure that the roles occupied by trained clinicians (PAs, NPs, RNs, etc.) are professionally satisfying and will position them to make an effective contribution to the practice.

For more on this topic, see “The 411 on NPPs” from September 2008 and “Role Refinement” from September 2009; the latter features the perspective of Ryan Genzink, a thoughtful PA-C from Michigan.

Blinded performance reporting. First, make sure your practice provides regular, meaningful reports on each doctor’s performance and the group as a whole. This usually takes the form of a dashboard or report card. In my experience, too few practices do this. Make sure your group isn’t in that category.

Groups that do provide performance data often allow each doctor to see only his or her data. If data about other individuals in the group are provided, the names have often been removed. With exception of certain human resources issues (e.g. counseling a doctor to prevent termination), I think all performance data in the group should be shared by name with the whole group. In most practices, everyone should know by name which doctors are the high and low producers, each doctor’s compensation, and CPT coding practices (e.g. the portion of discharges coded at the high level).

When clinical performance can be attributed to individual providers, report those metrics openly, too. This usually creates greater cohesion within the group and helps foster a mentality of practice ownership. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

Last month, I wrote about the attributes of hospitalist practices that I associate with success. This month, I’ll do the opposite. That is, I’ll write about strategies your practice could, or even should, do without. Of course, all of these things are open to debate, and some thoughtful people might (and in my experience, probably will) arrive at different conclusions.

So I offer my list as food for thought, and if your practice relies on some of these strategies, you shouldn’t feel threatened by my opinion. But you might want to think about whether they’ve been made part of your practice by design, or if things just evolved this way without careful consideration of alternatives. I’ve listed them in no particular order.

Fixed-duration day shifts. My sense is that the majority of practices have a day shift with a predetermined start and end. That is, the hospitalist is expected to arrive and depart at the same time each day.

This seems to make a lot of sense, but it ignores the dramatic variations in workload a practice will have. For example, a practice that is appropriately staffed with four daytime hospitalists, and schedules each of them to work a 12-hour shift, provides 48 hours of daytime hospitalist manpower each day. But that will turn out to be precisely the right level of staffing only a few days a year. On all other days, daytime staffing will be optimal with a different number of hours. So it would make sense for the doctors to work more or less on those days.

Telling doctors that their shift always starts at the same time has significant lifestyle advantages. But it can inhibit the doctors who would be happy to start earlier to address more discharges early in the day and potentially go home earlier. So, just like most other doctors at your hospital have, why not let the doctors have significant latitude in when they start and stop working each day? In most cases, it might be necessary to have a time by which every doctor must be available to respond to pages (and one who must be on-site before the night doctor leaves), but they should feel free to actually arrive and start working when they choose. Most will make good choices and will likely feel a little more empowered and happy with their work.

And, at the end of the day, it might be reasonable to allow some of the day-shift doctors to leave when their work is done, and allow the others to stay to handle admissions until the night shift takes over. Those who leave early might still be required to respond to pages until a specified time.

Shifts that don’t involve rounding on “continuity” patients, such as night and evening (“swing”) shifts, usually should be arranged with predetermined start. I wrote in more detail on this topic in January 2007 and October 2010.

Contractual vacation provisions. Hospitalists should have significant amounts of time off. We work a lot of evenings, nights, and weekends, and we must have liberal amounts of time away from work. But for many practices, there is no advantage in classifying this time as vacation (or CME, etc.) time. In most cases, it makes the most sense to simply specify how much work (e.g. number of shifts) a doctor is to do each year and not specify a number of days or hours of vacation time. For more detail, read “The Vacation Conundrum” from March 2007.

If your practice has a vacation system that works well, then stick with it. But if you or your administrators are going nuts trying to categorize nonworking days between vacation and days the doctor simply wasn’t scheduled, then it might be best to stop trying. Just settle on the number of shifts (or some other metric) that a doctor is to work each year.

Tenure-based salary increases. It makes a lot of sense to pay doctors in most specialties an increasing salary based on his or her tenure with the practice. As they build a patient population and a referral stream, they generate more revenue and should benefit accordingly. But a new hospitalist who joins an existing group almost never has to build the referrals. In most cases, the group hired the doctor because the referrals are already coming and the practice needs more help, or the new doctor is replacing a departing one. So paying a new hospitalist a lower salary that increases automatically every few years isn’t really a raise earned by the doctor’s improved financial performance. Usually it’s just a system of withholding money that could be available for compensation for the doctor’s first few years in the practice. This lower starting salary might adversely impact recruiting. For more, see “Compensation Conundrum” from December 2009.

Poor roles for nonphysician providers (NPPs). I’ve worked with a lot of practices that have NPs and PAs (and, in some cases, RNs) who are doing what amounts to clerical work. They’re faxing discharge summaries, making calls to schedule patient appointments, dividing up the overnight admissions for the day rounders, etc.

Don’t make this mistake. Hire a secretary for that sort of work. And be sure that the roles occupied by trained clinicians (PAs, NPs, RNs, etc.) are professionally satisfying and will position them to make an effective contribution to the practice.

For more on this topic, see “The 411 on NPPs” from September 2008 and “Role Refinement” from September 2009; the latter features the perspective of Ryan Genzink, a thoughtful PA-C from Michigan.

Blinded performance reporting. First, make sure your practice provides regular, meaningful reports on each doctor’s performance and the group as a whole. This usually takes the form of a dashboard or report card. In my experience, too few practices do this. Make sure your group isn’t in that category.

Groups that do provide performance data often allow each doctor to see only his or her data. If data about other individuals in the group are provided, the names have often been removed. With exception of certain human resources issues (e.g. counseling a doctor to prevent termination), I think all performance data in the group should be shared by name with the whole group. In most practices, everyone should know by name which doctors are the high and low producers, each doctor’s compensation, and CPT coding practices (e.g. the portion of discharges coded at the high level).

When clinical performance can be attributed to individual providers, report those metrics openly, too. This usually creates greater cohesion within the group and helps foster a mentality of practice ownership. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

Last month, I wrote about the attributes of hospitalist practices that I associate with success. This month, I’ll do the opposite. That is, I’ll write about strategies your practice could, or even should, do without. Of course, all of these things are open to debate, and some thoughtful people might (and in my experience, probably will) arrive at different conclusions.

So I offer my list as food for thought, and if your practice relies on some of these strategies, you shouldn’t feel threatened by my opinion. But you might want to think about whether they’ve been made part of your practice by design, or if things just evolved this way without careful consideration of alternatives. I’ve listed them in no particular order.

Fixed-duration day shifts. My sense is that the majority of practices have a day shift with a predetermined start and end. That is, the hospitalist is expected to arrive and depart at the same time each day.

This seems to make a lot of sense, but it ignores the dramatic variations in workload a practice will have. For example, a practice that is appropriately staffed with four daytime hospitalists, and schedules each of them to work a 12-hour shift, provides 48 hours of daytime hospitalist manpower each day. But that will turn out to be precisely the right level of staffing only a few days a year. On all other days, daytime staffing will be optimal with a different number of hours. So it would make sense for the doctors to work more or less on those days.

Telling doctors that their shift always starts at the same time has significant lifestyle advantages. But it can inhibit the doctors who would be happy to start earlier to address more discharges early in the day and potentially go home earlier. So, just like most other doctors at your hospital have, why not let the doctors have significant latitude in when they start and stop working each day? In most cases, it might be necessary to have a time by which every doctor must be available to respond to pages (and one who must be on-site before the night doctor leaves), but they should feel free to actually arrive and start working when they choose. Most will make good choices and will likely feel a little more empowered and happy with their work.

And, at the end of the day, it might be reasonable to allow some of the day-shift doctors to leave when their work is done, and allow the others to stay to handle admissions until the night shift takes over. Those who leave early might still be required to respond to pages until a specified time.

Shifts that don’t involve rounding on “continuity” patients, such as night and evening (“swing”) shifts, usually should be arranged with predetermined start. I wrote in more detail on this topic in January 2007 and October 2010.

Contractual vacation provisions. Hospitalists should have significant amounts of time off. We work a lot of evenings, nights, and weekends, and we must have liberal amounts of time away from work. But for many practices, there is no advantage in classifying this time as vacation (or CME, etc.) time. In most cases, it makes the most sense to simply specify how much work (e.g. number of shifts) a doctor is to do each year and not specify a number of days or hours of vacation time. For more detail, read “The Vacation Conundrum” from March 2007.

If your practice has a vacation system that works well, then stick with it. But if you or your administrators are going nuts trying to categorize nonworking days between vacation and days the doctor simply wasn’t scheduled, then it might be best to stop trying. Just settle on the number of shifts (or some other metric) that a doctor is to work each year.

Tenure-based salary increases. It makes a lot of sense to pay doctors in most specialties an increasing salary based on his or her tenure with the practice. As they build a patient population and a referral stream, they generate more revenue and should benefit accordingly. But a new hospitalist who joins an existing group almost never has to build the referrals. In most cases, the group hired the doctor because the referrals are already coming and the practice needs more help, or the new doctor is replacing a departing one. So paying a new hospitalist a lower salary that increases automatically every few years isn’t really a raise earned by the doctor’s improved financial performance. Usually it’s just a system of withholding money that could be available for compensation for the doctor’s first few years in the practice. This lower starting salary might adversely impact recruiting. For more, see “Compensation Conundrum” from December 2009.

Poor roles for nonphysician providers (NPPs). I’ve worked with a lot of practices that have NPs and PAs (and, in some cases, RNs) who are doing what amounts to clerical work. They’re faxing discharge summaries, making calls to schedule patient appointments, dividing up the overnight admissions for the day rounders, etc.

Don’t make this mistake. Hire a secretary for that sort of work. And be sure that the roles occupied by trained clinicians (PAs, NPs, RNs, etc.) are professionally satisfying and will position them to make an effective contribution to the practice.

For more on this topic, see “The 411 on NPPs” from September 2008 and “Role Refinement” from September 2009; the latter features the perspective of Ryan Genzink, a thoughtful PA-C from Michigan.

Blinded performance reporting. First, make sure your practice provides regular, meaningful reports on each doctor’s performance and the group as a whole. This usually takes the form of a dashboard or report card. In my experience, too few practices do this. Make sure your group isn’t in that category.

Groups that do provide performance data often allow each doctor to see only his or her data. If data about other individuals in the group are provided, the names have often been removed. With exception of certain human resources issues (e.g. counseling a doctor to prevent termination), I think all performance data in the group should be shared by name with the whole group. In most practices, everyone should know by name which doctors are the high and low producers, each doctor’s compensation, and CPT coding practices (e.g. the portion of discharges coded at the high level).

When clinical performance can be attributed to individual providers, report those metrics openly, too. This usually creates greater cohesion within the group and helps foster a mentality of practice ownership. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I’m often asked about the attributes associated with high-functioning practices, so I thought I’d offer a list of them in this column. I’ve written entire columns about some of them in prior issues of The Hospitalist, so I will provide only brief commentary about each of them here.

I think this list can serve as a valuable frame of reference for any hospitalist practice, though it is geared more toward nonacademic settings. It is based on my own career as a hospitalist, which spans more than 20 years, and 15 years’ work as a consultant with nearly 300 institutions around the country. While I think my experience has given me a valuable perspective, others might reasonably omit some attributes listed here or add others.

I believe the single most important measure of a practice is excellent outcomes for its patients. That said, all of the attributes I describe here have more to do with excellent operational, or business, performance. It is possible for a practice to have all of these attributes and still provide disappointing clinical quality for its patients, but that seems really unlikely to me. And even a practice that provides superior clinical care probably won’t be able to do so for long without high-functioning business operations.

I think each of these attributes might be a cause of a practice’s excellent performance, but it is possible that some are a result of it. They are listed in no particular order.

A culture of practice ownership. The most important attribute associated with a high-functioning practice is that the providers in the group maintain a mindset of practice ownership. Even if you are employees of a hospital or other organization, you should think of yourselves as owners of the practice’s performance. When problems arise, you shouldn’t simply assume it is up to the practice leader alone, or an administrator outside of the practice to solve it. Instead, each doctor should always be thinking about how to improve the practice and taking action to make it happen. For more, see “Foster Ownership Culture” in the August 2008 issue, or visit my website and take a quiz (http://nelsonflores.com/html/quiz.html) to assess your ownership culture.

An effective group leader. All groups need a leader who takes the role seriously and doesn’t just view the job description as making the work schedule and attending more meetings than the other hospitalists. (Unfortunately, my experience is that this is precisely what a lot of leaders think.) Of the many markers that effective leaders display, one that seems pretty reliable to me is whether the group has routinely scheduled meetings, with an agenda provided in advance and minutes circulated a few days later. I wrote about effective group leaders in a June 2008 column titled “Follow the Money.”

Autonomy in making decisions. Even when you are an employee of a larger entity, the practice should be structured so that hospitalists have as much autonomy in decision-making as possible. For example, you should always be able to adjust the group’s work schedule (e.g. when shifts start and stop). You also should have a lot of say about your staffing and workload. The latter typically requires that the group is connected to the financial consequences of its choices, which usually means a compensation system based, to a significant degree, on productivity.

While still common for hospitalists, when the largest salary component is fixed, it will always follow that someone outside the group (e.g. an administrator at the hospital) will end up deciding how hard you will have to work to justify the promised salary. And the hospitalists will almost always find fault with that person’s decision—a recipe for constant frustration that inhibits the development of an ownership culture, among other things.

Each doctor sees the job as more than just providing care to patients. In addition to providing quality care for your patients, each hospitalist in the group must work to improve the performance of the hospital. This means work on clinical protocols, medical staff functions (e.g. credentials committee), documentation and coding for both CPT and DRG billing, etc.

Strong social connections. Every high-performing practice I’ve worked with is notable for the social connections between the hospitalists themselves, as well as between hospitalists and other physicians, nursing staff, and administrators. This shouldn’t be taken lightly. Social connections matter—a lot. And while the hospitalists in most groups feel reasonably connected with one another, too often they feel isolated from the other doctors and administrators at the hospital. I wrote some more thoughts about this in a June 2010 column, “Square Peg, Square Hole.”

Hospitalists actively involved in recruiting for their practice. The hospitalists themselves—at a minimum, the group leader—should be very involved in recruiting new members for the group. Professional recruiters are very valuable but can be a lot more effective if the hospitalists themselves participate in the process. The group will land better candidates that way. For more, see “We’re Hiring,” from July 2008.

Hospitalists know data about their performance. Too many practices fail to provide routine data about each provider’s clinical and financial performance. Make sure your group isn’t in this category. Develop a routine report of key metrics for your practice. Usually it is fine, and best, to provide to the whole group unblinded performance data about each individual hospitalist. For more information, check out “Measuring Hospitalist Performance: Metrics, Reports, and Dashboards” on the SHM website.

Don’t rely solely on consensus-based decision-making. Relying on consensus is reasonable for most decisions, if a group has about eight to 10 members. Larger groups need to decide how they’ll make decisions if consensus can’t be reached easily. And they need to have the discipline to stick to their agreed upon process, usually a vote. For more on this subject, see “Play by the Rules” in the December 2007 issue. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I like to ask laypeople what they think “hospitalist” means. For years, I was confident that they had never heard the term, but now my question is more often met with an accurate response.

A hotel desk clerk in 1998 actually made one of the cleverest guesses I’ve ever heard. For the whole day, she and her colleagues had in front of them a sign that read “Hospitalist Meeting in the Ballroom,” which got them talking about what in the world a hospitalist is. Seeing from my badge that I was attending that meeting, she asked me what the term meant, but she first gamely provided her best guess: “Someone who makes lists of hospitals.”

There seems to be no end to the number of healthcare-related nouns and verbs to which someone attaches the suffix “ist.” Some days I request so many consults that I’m just a “referralist” (one who refers patients; surely this is a term we can do without). But don’t let the headline of this column confuse you: I really am addressing the lists used to determine which doctor to refer patients to.

Hospitalist Referrals

The first of two common referral lists for hospitalists is a directory of primary-care physicians (PCPs) and clinics, as well as some other providers that refer patients to the hospitalist. Nearly all hospitalist groups maintain such a list, and they might apply a variety of terms such as “subscriber” (which refers to hospitalists) and “nonsubscriber” physicians.

Because most HM groups care for patients who come from all or nearly all of the PCPs in an area, it is often simpler to just create a short list of those providers who don’t refer to the hospitalists. In many hospitals, there are just four or five providers on that list. ED providers are the ones who most often access this list. When visiting other hospitals, I often see a paper copy of the list taped up at the provider workstations in the ED.

Consult Who?

The other, and much less common, type of referral list governs which doctors the hospitalists are to consult. There are two strategies that come up when thinking about this kind of list.

Do what the ED doctors do. ED physicians typically are constrained by the list of on-call physicians for each specialty, and are to always consult that doctor rather than another. For example, the ED doctor is required to consult Dr. Taylor for any patient in need of a general surgeon and doesn’t have a prior relationship with one. Tomorrow, the ED doctor is required to consult Dr. Simon. Dr. Taylor and Dr. Simon are to be contacted because they are the ones on call for the ED those days. Even if the ED doctor would rather consult Dr. Simon today (maybe she is more able, affable, and available than Dr. Taylor), that isn’t an option, because it is Dr. Taylor’s name on the ED on-call roster today.

Each PCP creates a referral list for hospitalists to follow. New hospitalist practices often agree to follow the consulting patterns of each referring PCP. This can increase PCP acceptance of the HM model, and after all, the GI doctor consulted by the hospitalist during the few days in the hospital is the same one who will be working with the PCP when the patient has outpatient issues requiring GI specialty care. This usually means that the hospitalist carries a list of each PCP, and which GI doctor, orthopedist, etc., that particular PCP likes to consult. When the hospitalist needs an ortho consult, she first verifies the PCP this patient sees, then pulls out the list to see the orthopedist(s) that PCP prefers.

In most settings, either form of a mandated referral list is a poor system for hospitalists and is best avoided. Instead, the hospitalists should be free to deviate from the ED call list as they see fit. And while they should be attentive to the consulting preferences of each PCP, it is best not to promise the PCPs that their preference will always be followed. Providing the hospitalists this latitude means they can tailor the choice of consultant to the patient’s needs and the level of service (i.e. able, affable, available) each provides. And, at least in theory, when there are competing providers in a given specialty, they will have an incentive to provide better service to the hospitalist as a way of ensuring future referrals.

Practical Considerations

Even though I think it is optimal for hospitalists to have a lot of latitude in which doctors they consult, there are some practical considerations to keep in mind. For example, if the patient’s PCP is in a group that also has surgeons, it will be best to call one of them, and not a competing surgeon, when the patient has surgical needs. And the hospitalists as a group should usually make some effort to avoid never consulting a particular provider or group, as that could lead the “blackballed” doctor or group to complain enough that the medical staff or hospital leadership might force the hospitalists to follow the ED call roster when choosing referrals.

The number of physicians seeking hospital employment, which is steadily increasing these days, will in many settings increase sensitivities around referral patterns. For example, if your hospital has had three competing general surgery groups and one chooses to become hospital-employed, then the other two groups are likely to worry a lot that the hospitalists might be directed by the hospital to preferentially refer to the newly employed surgeons. Even if your hospitalist group has never had any sort of encouragement to do this, it could be very hard to convince the non-hospital-employed surgeons of this. This could become such a sensitive issue that it might be necessary to carefully track the number of referrals to each surgical group.

And to prevent arguments like “You just consult us on the bad or uninsured patients,” you might also need to track the nature of the patient’s problem and insurance status, and whether the referral led to a procedure. The best approach will be to try to prevent these sorts of things from coming up by maintaining good communication and relations with other physician groups and thinking deliberately about your referral patterns. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.

I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.

The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.

Levels of Complexity

Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.

While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.

The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.

EHR: A Tipping Point

The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.

I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.

The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.

I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.

Rethink New Employee Orientation

I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.

My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.

And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.

Hospital-Certified?

If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?

Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.

Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.

It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.

But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.

The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.

Levels of Complexity

Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.

While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.

The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.

EHR: A Tipping Point

The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.

I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.

The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.

I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.

Rethink New Employee Orientation

I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.

My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.

And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.

Hospital-Certified?

If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?

Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.

Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.

It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.

But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

I rent cars regularly, and only occasionally do I get the same model twice. I’m ready to roll after spending a couple of minutes becoming familiar with a car that is new to me. I adjust the seat and climate control, etc. I resist fiddling with the radio until later. This seems OK to me.

The last time I started clinical practice in a new hospital, I did almost the same thing: I jumped right in and started seeing patients. Other than being provided with my password to the computer system and a dictation code, I had no orientation at all, not even to the hospital floor plan. This, too, seemed reasonable to me at the time. Now I see it differently.

Levels of Complexity

Years ago, learning a new hospital might not have been a lot more difficult than familiarizing yourself with a new rental car, so there didn’t seem to be much need for a detailed orientation. I’m generalizing here, but if you go back far enough in time, the general idea was that it was almost entirely up to the hospital and its staff to get to know the new doctor and how he or she practiced, rather than the doctor adapting to the hospital’s way of doing things.

While at one time hospitals and their systems might have been as similar to one another as a four-door Chevy is to a four-door Ford, today’s hospitals are far more complex. The appropriate transportation analogy might be one type of airplane to another.

The basics of what keeps a two-seat Cessna and a huge 747 flying are the same, but there are so many critical differences that specific training and certification are required for each. Even an accomplished professional pilot who is an ace in a 747 isn’t automatically certified to pilot a smaller 737. In fact, few professional pilots are certified to fly more than one type of commercial airplane at a time. One way to look at this is that the orientation to the plane is so complex that one person can’t be expected to maintain a high level of familiarity with the systems and operation of more than one at a time.

EHR: A Tipping Point

The complexity and unique attributes of hospitals have been increasing steadily for decades, but it seems to me that electronic health records (EHR) represent a huge increase in complexity. No longer can a doctor simply arrive at the hospital confident in her ability to fly this new plane. She will require a reasonably detailed introduction to the hospital’s EHR as part of an orientation that should ideally take place prior to seeing patients.

I worry that it will be increasingly difficult, and potentially unwise, for a doctor in any specialty to practice at more than one or two hospitals that don’t share the same EHR. If a doctor is not proficient in the use of the EHR at a particular site, two things are likely to happen: First, and most alarmingly, the new doctor would probably unintentionally miss important information in the EHR, or might not have time to contemplate the series of buttons to click to check all potentially relevant information. For example, he might not realize the patient already had a series of blood tests, because accessing them requires some unfamiliar clicks of the mouse.

The other thing that might happen if a doctor is not proficient in the use of the hospital’s EHR is that he might be inclined to consult the hospitalist “just to cover all the bases.” In this case, that might be the same as asking the hospitalist to be involved as an EHR expert, rather than for medical expertise that the patient needs.

I practice at a hospital that recently installed a new information system, and some doctors have joked that if they can’t figure out how to use it, they will just consult a hospitalist to look up historical data, etc. I’m not aware of any study looking at this issue, but I suspect “soft” hospitalist consults increase when a hospital installs a new information system.

Rethink New Employee Orientation

I’m convinced that new doctors in all specialties that anticipate having a hospital patient volume above a predetermined threshold should be required to have a formal orientation to the hospital, especially for its information system. This is really important for hospitalists. Every practice should think carefully about a meaningful process of orientation to the hospital and the hospitalist practice itself. The latter would include things like scheduling issues, training in CPT coding, group governance and culture, etc.

My experience is that multistate hospitalist companies have pretty detailed orientation programs; for one thing, they can use this as a differentiator when marketing their services. But private hospitalist practices and groups employed by a single hospital usually have a pretty loose orientation process. It is tricky to find the sweet spot between valuable orientation activities and so much detail that the new doctor is overwhelmed or bored, and unlikely to remember much of what is presented.

And there certainly is a role for waiting to learn some things as the new doctor begins seeing patients. For example, my feeling is that a general orientation to the floor plan is sufficient and the new hire can best learn the details independently during the course of patient care. However, all hospitalists should have some reasonable level of proficiency in the EHR before seeing their first patients.

Hospital-Certified?

If you accept my premise that hospitals were once reasonably similar, like one rental car to another, but have now become as complex and different as jumbo jets, then we’re led to another question: Will we one day decide that a doctor must be certified to practice in a particular hospital by demonstrating knowledge and competence in that particular hospital’s systems and procedures?

Nearly all present-day credentialing and privileging related to a doctor’s work in a hospital focus on that doctor’s prior training and experience. In the case of pilots, there is a requirement to demonstrate proficiency when making a transition to a new airplane.

Maybe an analogous system of certification for a doctor to “fly” each hospital would be valuable for our patients. If training might not make sense for all doctors, then perhaps limit it to those, such as hospitalists, who will have a really high patient volume at the facility.

It would be dizzyingly complex to create and referee such a certification system, so I’m not sure anything like this will happen in my career. And the last thing I want is another set of bureaucratic hurdles.

But it might be worth thinking about how to ensure doctors at a particular hospital are expert enough in that hospital’s unique systems and operations. Start with your group’s orientation process. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is cofounder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.