Managing Your Practice

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

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

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

Medicare Enrollment and Billing Eligibility

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

PAs must have:

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

NPs must:

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

Independent Billing

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

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

Shared/Split Billing

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

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

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

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

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

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

Non-Medicare Claims

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

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

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

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

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

NPP Billing Reminders

Discharge Day Management Services

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

Admission Services

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

Consultation Services

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

References

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

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

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

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

Medicare Enrollment and Billing Eligibility

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

PAs must have:

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

NPs must:

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

Independent Billing

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

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

Shared/Split Billing

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

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

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

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

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

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

Non-Medicare Claims

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

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

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

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

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

NPP Billing Reminders

Discharge Day Management Services

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

Admission Services

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

Consultation Services

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

References

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

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

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

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

Medicare Enrollment and Billing Eligibility

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

PAs must have:

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

NPs must:

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

Independent Billing

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

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

Shared/Split Billing

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

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

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

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

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

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

Non-Medicare Claims

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

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

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

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

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

NPP Billing Reminders

Discharge Day Management Services

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

Admission Services

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

Consultation Services

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

References

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

Dr. Hospitalist

Balance Is Key to HM Group Leaders’ Clinical Load

Should the leader of my hospitalist group have a lighter clinical load?

Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.

Dr. Hospitalist responds:

This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.

For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.

The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.

The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.

Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.

On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.

Dr. Hospitalist

Balance Is Key to HM Group Leaders’ Clinical Load

Should the leader of my hospitalist group have a lighter clinical load?

Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.

Dr. Hospitalist responds:

This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.

For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.

The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.

The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.

Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.

On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.

Dr. Hospitalist

Balance Is Key to HM Group Leaders’ Clinical Load

Should the leader of my hospitalist group have a lighter clinical load?

Cheryl Clinkenbeard, DO, MPH, Bartlesville, Okla.

Dr. Hospitalist responds:

This is an incredibly tough question, and it applies to pretty much every hospitalist program in existence. Big, small, private, teaching—every program needs leaders.

For starters, being a hospitalist program leader is generally a thankless job. It involves a heck of a lot of meetings, administrative hassles, and parsing of complaints. In my experience, it also tends to be a horrifically underpaid position. There generally is no waiting list of clinicians begging to be the group leader. Given all the time demands, I think it is perfectly reasonable to expect a leader to have a lighter clinical load. There is no way to fulfill both clinical and administrative duties while working full time, unless the group is very small (less than six FTEs). On the other hand, having a leader do no clinical work is pretty much a recipe for disaster. If your group leader is a clinician and does a lot less, or no clinical work, they will lose credibility with colleagues quickly. Group leaders focused solely on administration also lose sight of the day-to-day morale and activem issues facing the group.

The crux is trying to find the balance between admin and clinical duties. I think it is preferable to have a leader work fewer shifts but take an equivalent clinical load on those days. That allows group leaders to be viewed as “one of the team,” with the same shift responsibilities as everyone else—just not as many shifts. It’s a better way to understand the day-to-day variations and concerns of the job.

The other option is to have the leader work the same number of shifts but take a smaller census. I think this is a bad idea, mainly from the standpoint that HM is nothing if not unpredictable, and trying to protect one person’s census on a busy day is an impossible task. Either the leader will end up taking on too much clinical work (to help even the census) or the rest of the group will feel bitter that the group leader is not always available to help. I’ve seen both sides of this equation, and it is just not a good working environment.

Another factor to consider are the “undesirable” shifts. Whether it is nights or weekends, there are always shifts that folks would rather not do. A leader should continue to work these shifts, even at a reduced number, for the same reasons. Becoming an HM leader is not an excuse to design the perfect, protected schedule at the expense of the other physicians.

On balance, I think the hospitalist group leader ends up with more work, similar schedule obligations, and an inadequate pay structure. That does not make the position particularly attractive, as has been my experience over the years. However, given the opportunity to modify those variables, I think the shifts should be kept “whole” and reduced only in number, with the remainder of the compensation for the work coming in the form of increased pay. How much, you ask? Well, have a seat; this could take a while.

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].

Obese mother gains another 60 lb before delivery

AN OBESE WOMAN with a family history of diabetes had previously given birth to a large baby. Even though she expressed her concern that this fetus would also be macrosomic, the ObGyn planned for spontaneous vaginal delivery. At 39 weeks’ gestation, after gaining 60 lb, she went to the hospital requesting induction of labor; the ObGyn reluctantly agreed. Labor was lengthy, forceps-assisted delivery was performed, and a shoulder dystocia was encountered. The baby was born with respiratory distress, a brachial plexus injury, bruises on his right cheek and both ears, and multiple rib fractures. After transfer to a children’s hospital, surgical exploration revealed avulsion of the C6 root nerve from the spinal cord and damage to C5, C7, and C8 nerve roots. Several surgical repairs and physical therapy have led to some improvement, but the child is permanently injured. His right arm is shorter than the left, his right hand is smaller, and he has less strength and range of motion in the right arm. He also has excessive tearing in the right eye and his right eyelid droops.

PARENTS’ CLAIM The ObGyn failed to recognize the risk of delivering a macrosomic baby and did not consider cesarean delivery. The brachial plexus injury was due to downward traction applied during delivery.

PHYSICIAN’S DEFENSE There was no negligence. The brachial plexus injury was not caused by downward traction.

VERDICT A $4.1 million Indiana verdict was returned, but was reduced to the state cap of $1.25 million.

Failure to follow-up on mass: $1.97M verdict

AFTER STAGE II OVARIAN CANCER was found in 1999, a woman underwent surgery and chemotherapy, and was told she was cancer-free. She had regular visits between 2000 and 2008 with another surgical oncologist after her first surgeon moved. In 2004, the oncologist documented finding a round fullness during a pelvic exam. A CT scan confirmed a mass in the pelvic cul-de-sac.

In August 2008, the patient was treated for deep venous thrombosis in her leg. The attending physician saw the pelvic mass on imaging, and a biopsy indicated a recurrence of ovarian cancer. After chemotherapy, the patient underwent surgery, but the tumor was unresectable. In early 2011, testing revealed metastasis to the spine, sternum, pelvic bone, arm, and lung.

PATIENT’S CLAIM The surgeon did not properly investigate the mass resulting in a delayed diagnosis of cancer recurrence. The patient alleged that the surgical oncologist repeatedly stated that the mass had not changed and was most likely fluid; it was nothing to worry about. Radiology reports indicated a suspicion of cancer.

DEFENDANTS’ DEFENSE The oncologist repeatedly told the patient that the mass should be biopsied, but the patient refused because she was dealing with other medical issues. The radiologist argued that reports to the oncologist included everything needed to diagnose the cancer.

VERDICT A Pennsylvania jury found the surgical oncologist fully at fault and returned a $1,971,455 verdict.

Incomplete tubal ligation

BEFORE DELIVERY OF HER THIRD CHILD, a 26-year-old woman requested sterilization using tubal ligation. After delivery, the ObGyn performed a bilateral tubal ligation. The pathologist’s report indicated that the ligation was incomplete: the left fallopian tube had not been fully removed. The ObGyn failed to note the report’s results in the patient’s record, nor did he advise the patient. Two years later, the patient delivered a fourth child.

PATIENT’S CLAIM The patient alleged wrongful birth against both the ObGyn and pathologist. The ObGyn was negligent for not reacting to the pathologist’s report of incomplete tubal ligation, and for not informing the patient. The pathologist should have verbally confirmed receipt of the report with the ObGyn.

PHYSICIANS’ DEFENSE The ObGyn settled before trial. The pathologist claimed he had properly interpreted the specimen and reported the results.

VERDICT A Louisiana jury found the ObGyn fully at fault and assessed additional damages of $56,252 to the $100,000 settlement.

Where did this foreign body come from?

A WOMAN SUFFERED FROM PELVIC PAIN caused by adhesions following two cesarean deliveries and a hysterectomy. In January 2003, her ObGyn performed laparotomy to reduce adhesions from prior surgeries and place Gore-Tex mesh to prevent future adhesions. In October 2010, the patient reported epigastric pain, and went to a different surgeon (her insurance changed). A CT scan identified a foreign body encapsulated in scar tissue in the patient’s lower abdomen/pelvis. The surgeon removed the foreign body.

PATIENT’S CLAIM The ObGyn and hospital were negligent in conducting the 2003 procedure; the foreign object was a retained surgical sponge.

DEFENDANTS’ DEFENSE The foreign body removed in 2010 was the Gore-Tex mesh placed in 2003. The mesh became encapsulated in scar tissue due to the patient’s propensity to develop adhesions, and then moved within the patient’s body. Surgical sponges have embedded radiopaque tracers; CT scans in 2003 and 2010 did not detect any radiopaque tracers.

VERDICT A California defense verdict was returned.

Massive bleed during sacrocolpopexy

AFTER A 72-YEAR-OLD WOMAN developed pelvic organ prolapse, her urologist performed an abdominal sacrocolpopexy. As the urologist attempted to gain access to the sacral prominence, a tear in the median sacral vein expanded to involve the inferior vena cava and left iliac vein. Massive bleeding occurred and multiple units of blood were transfused. A general surgeon successfully repaired the vascular injuries. The patient was hospitalized for 16 days, received home healthcare, and fully recovered.

PATIENT’S CLAIM The urologist was negligent in overaggressive manipulation of the median sacral vein, causing it to avulse.

PHYSICIAN’S DEFENSE Bleeds of this type are a known complication of the procedure.

VERDICT A Michigan defense verdict was returned.

Was it hypoxia or autism?

AFTER SEVERAL HOURS IN LABOR, a fetal heart-rate monitor indicated decreasing fetal heart rate that led to terminal bradycardia. The ObGyn was called and performed an emergency cesarean delivery. The child was diagnosed with brain damage at 2 years of age.

PARENTS’ CLAIM A cesarean delivery should have been planned because of the fetal weight (8 lb 11 oz). A hypoxic event occurred during labor. Ultrasonography would have shown that the fetus was inverted and that the baby’s face was covered by one of its hands. Delivery was not properly managed, and fetal distress was not reported to the ObGyn in a timely manner.

DEFENDANTS’ DEFENSE The infant’s weight was not sufficient to warrant a cesarean delivery. The infant did not suffer hypoxia. The child’s abnormalities only emerged in the second year of life. An MRI at that time did not indicate brain damage. The child’s development with subsequent regression suggests autism.

VERDICT A New York defense verdict was returned.

Should mammography have been diagnostic?

A 46-YEAR-OLD WOMAN with a family history of breast cancer had regular annual screenings. In December 2006, the patient reported pain, hardness, and burning in her left breast to her gynecologist. A radiologist interpreted the mammography as normal. In May 2007, the patient found a lump in her left breast. Testing indicated she had stage IV breast cancer. She died 2 months after the trial concluded.

PATIENT’S CLAIM The 2006 mammogram was performed as a screening mammography, but should have been diagnostic, considering her family history and reported symptoms. The radiologist improperly interpreted the films.

DEFENDANTS’ DEFENSE The hospital staff testified that the patient did not report pain, hardness, and burning in her left breast when she presented for the 2006 mammography. The radiologist claimed his screening and interpretation were appropriate.

VERDICT The Louisiana court granted the patient’s motion for judgment, and awarded $558,000 in medical costs and $1.3 million in noneconomic damages, totalling $1.808 million. This was reduced to the $500,000 statutory cap.

Obese mother gains another 60 lb before delivery

AN OBESE WOMAN with a family history of diabetes had previously given birth to a large baby. Even though she expressed her concern that this fetus would also be macrosomic, the ObGyn planned for spontaneous vaginal delivery. At 39 weeks’ gestation, after gaining 60 lb, she went to the hospital requesting induction of labor; the ObGyn reluctantly agreed. Labor was lengthy, forceps-assisted delivery was performed, and a shoulder dystocia was encountered. The baby was born with respiratory distress, a brachial plexus injury, bruises on his right cheek and both ears, and multiple rib fractures. After transfer to a children’s hospital, surgical exploration revealed avulsion of the C6 root nerve from the spinal cord and damage to C5, C7, and C8 nerve roots. Several surgical repairs and physical therapy have led to some improvement, but the child is permanently injured. His right arm is shorter than the left, his right hand is smaller, and he has less strength and range of motion in the right arm. He also has excessive tearing in the right eye and his right eyelid droops.

PARENTS’ CLAIM The ObGyn failed to recognize the risk of delivering a macrosomic baby and did not consider cesarean delivery. The brachial plexus injury was due to downward traction applied during delivery.

PHYSICIAN’S DEFENSE There was no negligence. The brachial plexus injury was not caused by downward traction.

VERDICT A $4.1 million Indiana verdict was returned, but was reduced to the state cap of $1.25 million.

Failure to follow-up on mass: $1.97M verdict

AFTER STAGE II OVARIAN CANCER was found in 1999, a woman underwent surgery and chemotherapy, and was told she was cancer-free. She had regular visits between 2000 and 2008 with another surgical oncologist after her first surgeon moved. In 2004, the oncologist documented finding a round fullness during a pelvic exam. A CT scan confirmed a mass in the pelvic cul-de-sac.

In August 2008, the patient was treated for deep venous thrombosis in her leg. The attending physician saw the pelvic mass on imaging, and a biopsy indicated a recurrence of ovarian cancer. After chemotherapy, the patient underwent surgery, but the tumor was unresectable. In early 2011, testing revealed metastasis to the spine, sternum, pelvic bone, arm, and lung.

PATIENT’S CLAIM The surgeon did not properly investigate the mass resulting in a delayed diagnosis of cancer recurrence. The patient alleged that the surgical oncologist repeatedly stated that the mass had not changed and was most likely fluid; it was nothing to worry about. Radiology reports indicated a suspicion of cancer.

DEFENDANTS’ DEFENSE The oncologist repeatedly told the patient that the mass should be biopsied, but the patient refused because she was dealing with other medical issues. The radiologist argued that reports to the oncologist included everything needed to diagnose the cancer.

VERDICT A Pennsylvania jury found the surgical oncologist fully at fault and returned a $1,971,455 verdict.

Incomplete tubal ligation

BEFORE DELIVERY OF HER THIRD CHILD, a 26-year-old woman requested sterilization using tubal ligation. After delivery, the ObGyn performed a bilateral tubal ligation. The pathologist’s report indicated that the ligation was incomplete: the left fallopian tube had not been fully removed. The ObGyn failed to note the report’s results in the patient’s record, nor did he advise the patient. Two years later, the patient delivered a fourth child.

PATIENT’S CLAIM The patient alleged wrongful birth against both the ObGyn and pathologist. The ObGyn was negligent for not reacting to the pathologist’s report of incomplete tubal ligation, and for not informing the patient. The pathologist should have verbally confirmed receipt of the report with the ObGyn.

PHYSICIANS’ DEFENSE The ObGyn settled before trial. The pathologist claimed he had properly interpreted the specimen and reported the results.

VERDICT A Louisiana jury found the ObGyn fully at fault and assessed additional damages of $56,252 to the $100,000 settlement.

Where did this foreign body come from?

A WOMAN SUFFERED FROM PELVIC PAIN caused by adhesions following two cesarean deliveries and a hysterectomy. In January 2003, her ObGyn performed laparotomy to reduce adhesions from prior surgeries and place Gore-Tex mesh to prevent future adhesions. In October 2010, the patient reported epigastric pain, and went to a different surgeon (her insurance changed). A CT scan identified a foreign body encapsulated in scar tissue in the patient’s lower abdomen/pelvis. The surgeon removed the foreign body.

PATIENT’S CLAIM The ObGyn and hospital were negligent in conducting the 2003 procedure; the foreign object was a retained surgical sponge.

DEFENDANTS’ DEFENSE The foreign body removed in 2010 was the Gore-Tex mesh placed in 2003. The mesh became encapsulated in scar tissue due to the patient’s propensity to develop adhesions, and then moved within the patient’s body. Surgical sponges have embedded radiopaque tracers; CT scans in 2003 and 2010 did not detect any radiopaque tracers.

VERDICT A California defense verdict was returned.

Massive bleed during sacrocolpopexy

AFTER A 72-YEAR-OLD WOMAN developed pelvic organ prolapse, her urologist performed an abdominal sacrocolpopexy. As the urologist attempted to gain access to the sacral prominence, a tear in the median sacral vein expanded to involve the inferior vena cava and left iliac vein. Massive bleeding occurred and multiple units of blood were transfused. A general surgeon successfully repaired the vascular injuries. The patient was hospitalized for 16 days, received home healthcare, and fully recovered.

PATIENT’S CLAIM The urologist was negligent in overaggressive manipulation of the median sacral vein, causing it to avulse.

PHYSICIAN’S DEFENSE Bleeds of this type are a known complication of the procedure.

VERDICT A Michigan defense verdict was returned.

Was it hypoxia or autism?

AFTER SEVERAL HOURS IN LABOR, a fetal heart-rate monitor indicated decreasing fetal heart rate that led to terminal bradycardia. The ObGyn was called and performed an emergency cesarean delivery. The child was diagnosed with brain damage at 2 years of age.

PARENTS’ CLAIM A cesarean delivery should have been planned because of the fetal weight (8 lb 11 oz). A hypoxic event occurred during labor. Ultrasonography would have shown that the fetus was inverted and that the baby’s face was covered by one of its hands. Delivery was not properly managed, and fetal distress was not reported to the ObGyn in a timely manner.

DEFENDANTS’ DEFENSE The infant’s weight was not sufficient to warrant a cesarean delivery. The infant did not suffer hypoxia. The child’s abnormalities only emerged in the second year of life. An MRI at that time did not indicate brain damage. The child’s development with subsequent regression suggests autism.

VERDICT A New York defense verdict was returned.

Should mammography have been diagnostic?

A 46-YEAR-OLD WOMAN with a family history of breast cancer had regular annual screenings. In December 2006, the patient reported pain, hardness, and burning in her left breast to her gynecologist. A radiologist interpreted the mammography as normal. In May 2007, the patient found a lump in her left breast. Testing indicated she had stage IV breast cancer. She died 2 months after the trial concluded.

PATIENT’S CLAIM The 2006 mammogram was performed as a screening mammography, but should have been diagnostic, considering her family history and reported symptoms. The radiologist improperly interpreted the films.

DEFENDANTS’ DEFENSE The hospital staff testified that the patient did not report pain, hardness, and burning in her left breast when she presented for the 2006 mammography. The radiologist claimed his screening and interpretation were appropriate.

VERDICT The Louisiana court granted the patient’s motion for judgment, and awarded $558,000 in medical costs and $1.3 million in noneconomic damages, totalling $1.808 million. This was reduced to the $500,000 statutory cap.

Obese mother gains another 60 lb before delivery

AN OBESE WOMAN with a family history of diabetes had previously given birth to a large baby. Even though she expressed her concern that this fetus would also be macrosomic, the ObGyn planned for spontaneous vaginal delivery. At 39 weeks’ gestation, after gaining 60 lb, she went to the hospital requesting induction of labor; the ObGyn reluctantly agreed. Labor was lengthy, forceps-assisted delivery was performed, and a shoulder dystocia was encountered. The baby was born with respiratory distress, a brachial plexus injury, bruises on his right cheek and both ears, and multiple rib fractures. After transfer to a children’s hospital, surgical exploration revealed avulsion of the C6 root nerve from the spinal cord and damage to C5, C7, and C8 nerve roots. Several surgical repairs and physical therapy have led to some improvement, but the child is permanently injured. His right arm is shorter than the left, his right hand is smaller, and he has less strength and range of motion in the right arm. He also has excessive tearing in the right eye and his right eyelid droops.

PARENTS’ CLAIM The ObGyn failed to recognize the risk of delivering a macrosomic baby and did not consider cesarean delivery. The brachial plexus injury was due to downward traction applied during delivery.

PHYSICIAN’S DEFENSE There was no negligence. The brachial plexus injury was not caused by downward traction.

VERDICT A $4.1 million Indiana verdict was returned, but was reduced to the state cap of $1.25 million.

Failure to follow-up on mass: $1.97M verdict

AFTER STAGE II OVARIAN CANCER was found in 1999, a woman underwent surgery and chemotherapy, and was told she was cancer-free. She had regular visits between 2000 and 2008 with another surgical oncologist after her first surgeon moved. In 2004, the oncologist documented finding a round fullness during a pelvic exam. A CT scan confirmed a mass in the pelvic cul-de-sac.

In August 2008, the patient was treated for deep venous thrombosis in her leg. The attending physician saw the pelvic mass on imaging, and a biopsy indicated a recurrence of ovarian cancer. After chemotherapy, the patient underwent surgery, but the tumor was unresectable. In early 2011, testing revealed metastasis to the spine, sternum, pelvic bone, arm, and lung.

PATIENT’S CLAIM The surgeon did not properly investigate the mass resulting in a delayed diagnosis of cancer recurrence. The patient alleged that the surgical oncologist repeatedly stated that the mass had not changed and was most likely fluid; it was nothing to worry about. Radiology reports indicated a suspicion of cancer.

DEFENDANTS’ DEFENSE The oncologist repeatedly told the patient that the mass should be biopsied, but the patient refused because she was dealing with other medical issues. The radiologist argued that reports to the oncologist included everything needed to diagnose the cancer.

VERDICT A Pennsylvania jury found the surgical oncologist fully at fault and returned a $1,971,455 verdict.

Incomplete tubal ligation

BEFORE DELIVERY OF HER THIRD CHILD, a 26-year-old woman requested sterilization using tubal ligation. After delivery, the ObGyn performed a bilateral tubal ligation. The pathologist’s report indicated that the ligation was incomplete: the left fallopian tube had not been fully removed. The ObGyn failed to note the report’s results in the patient’s record, nor did he advise the patient. Two years later, the patient delivered a fourth child.

PATIENT’S CLAIM The patient alleged wrongful birth against both the ObGyn and pathologist. The ObGyn was negligent for not reacting to the pathologist’s report of incomplete tubal ligation, and for not informing the patient. The pathologist should have verbally confirmed receipt of the report with the ObGyn.

PHYSICIANS’ DEFENSE The ObGyn settled before trial. The pathologist claimed he had properly interpreted the specimen and reported the results.

VERDICT A Louisiana jury found the ObGyn fully at fault and assessed additional damages of $56,252 to the $100,000 settlement.

Where did this foreign body come from?

A WOMAN SUFFERED FROM PELVIC PAIN caused by adhesions following two cesarean deliveries and a hysterectomy. In January 2003, her ObGyn performed laparotomy to reduce adhesions from prior surgeries and place Gore-Tex mesh to prevent future adhesions. In October 2010, the patient reported epigastric pain, and went to a different surgeon (her insurance changed). A CT scan identified a foreign body encapsulated in scar tissue in the patient’s lower abdomen/pelvis. The surgeon removed the foreign body.

PATIENT’S CLAIM The ObGyn and hospital were negligent in conducting the 2003 procedure; the foreign object was a retained surgical sponge.

DEFENDANTS’ DEFENSE The foreign body removed in 2010 was the Gore-Tex mesh placed in 2003. The mesh became encapsulated in scar tissue due to the patient’s propensity to develop adhesions, and then moved within the patient’s body. Surgical sponges have embedded radiopaque tracers; CT scans in 2003 and 2010 did not detect any radiopaque tracers.

VERDICT A California defense verdict was returned.

Massive bleed during sacrocolpopexy

AFTER A 72-YEAR-OLD WOMAN developed pelvic organ prolapse, her urologist performed an abdominal sacrocolpopexy. As the urologist attempted to gain access to the sacral prominence, a tear in the median sacral vein expanded to involve the inferior vena cava and left iliac vein. Massive bleeding occurred and multiple units of blood were transfused. A general surgeon successfully repaired the vascular injuries. The patient was hospitalized for 16 days, received home healthcare, and fully recovered.

PATIENT’S CLAIM The urologist was negligent in overaggressive manipulation of the median sacral vein, causing it to avulse.

PHYSICIAN’S DEFENSE Bleeds of this type are a known complication of the procedure.

VERDICT A Michigan defense verdict was returned.

Was it hypoxia or autism?

AFTER SEVERAL HOURS IN LABOR, a fetal heart-rate monitor indicated decreasing fetal heart rate that led to terminal bradycardia. The ObGyn was called and performed an emergency cesarean delivery. The child was diagnosed with brain damage at 2 years of age.

PARENTS’ CLAIM A cesarean delivery should have been planned because of the fetal weight (8 lb 11 oz). A hypoxic event occurred during labor. Ultrasonography would have shown that the fetus was inverted and that the baby’s face was covered by one of its hands. Delivery was not properly managed, and fetal distress was not reported to the ObGyn in a timely manner.

DEFENDANTS’ DEFENSE The infant’s weight was not sufficient to warrant a cesarean delivery. The infant did not suffer hypoxia. The child’s abnormalities only emerged in the second year of life. An MRI at that time did not indicate brain damage. The child’s development with subsequent regression suggests autism.

VERDICT A New York defense verdict was returned.

Should mammography have been diagnostic?

A 46-YEAR-OLD WOMAN with a family history of breast cancer had regular annual screenings. In December 2006, the patient reported pain, hardness, and burning in her left breast to her gynecologist. A radiologist interpreted the mammography as normal. In May 2007, the patient found a lump in her left breast. Testing indicated she had stage IV breast cancer. She died 2 months after the trial concluded.

PATIENT’S CLAIM The 2006 mammogram was performed as a screening mammography, but should have been diagnostic, considering her family history and reported symptoms. The radiologist improperly interpreted the films.

DEFENDANTS’ DEFENSE The hospital staff testified that the patient did not report pain, hardness, and burning in her left breast when she presented for the 2006 mammography. The radiologist claimed his screening and interpretation were appropriate.

VERDICT The Louisiana court granted the patient’s motion for judgment, and awarded $558,000 in medical costs and $1.3 million in noneconomic damages, totalling $1.808 million. This was reduced to the $500,000 statutory cap.

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.

Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?

Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:

• The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
• The unexpected occurs (i.e. a patient falls and breaks their hip); or
• The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).

A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”¹ Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.²

What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.

The Fundamentals

The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.

The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”

The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.

The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.

The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.

Take-Home Message

The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.

What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.

It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”

Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
2. Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.

Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?

Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:

• The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
• The unexpected occurs (i.e. a patient falls and breaks their hip); or
• The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).

A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”¹ Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.²

What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.

The Fundamentals

The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.

The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”

The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.

The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.

The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.

Take-Home Message

The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.

What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.

It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”

Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
2. Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.

Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?

Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:

• The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
• The unexpected occurs (i.e. a patient falls and breaks their hip); or
• The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).

A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”¹ Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.²

What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.

The Fundamentals

The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.

The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”

The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.

The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.

The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.

Take-Home Message

The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.

What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.

It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”

Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

References

1. Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
2. Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.

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.”

Dr. Alhadeff

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.’”

Dr. Kealey

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.”

Dr. Sloan

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.”

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. [Group leaders] need to understand the importance of [long-term analysis] and how all the pieces tie in together.

—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver

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.”

Dr. Alhadeff

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.’”

Dr. Kealey

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.”

Dr. Sloan

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.”

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. [Group leaders] need to understand the importance of [long-term analysis] and how all the pieces tie in together.

—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver

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.”

Dr. Alhadeff

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.’”

Dr. Kealey

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.”

Dr. Sloan

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.”

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. [Group leaders] need to understand the importance of [long-term analysis] and how all the pieces tie in together.

—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver

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.