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Why (and how) we must repeal the sustainable growth rate
Imagine this: Your 20-year-old daughter tells you she wants to attend an expensive school for 5 years of intensive postgraduate training, amassing tens of thousands of dollars of debt, to provide expert services to the US population. There is no good substitute for the services she hopes to provide, and they are vitally needed. The services also carry risk. Despite this, she tells you that her salary will not increase every year in tandem with the cost of living; in fact, she expects her salary to be cut by nearly one-third each year. Compensation in her chosen field hasn’t increased in real dollars for many years.
Sound like a good plan?
By now you have recognized this as your own story, at least if you’re among the 92% of ObGyns who participate in Medicare.
ObGyn participation in the Medicare program reflects ObGyn training and commitment to serve as lifelong principal care physicians for women of all ages, including women with disabilities. Fifty-six percent of all Medicare beneficiaries are women. With continuing shortages of primary care physicians and the transitioning of the Baby Boomer generation to Medicare, it is likely that ObGyns will become more involved in delivering health care to this population.
Medicare physician payments matter to ObGyns in other ways, too, because TRICARE and private payers often follow Medicare payment and coverage policies. Clearly, the Medicare program is a pretty big gorilla in every exam room. We all have much at stake in ensuring a stable Medicare system for years to come, starting with an improved physician payment system.
In 2011, Medicare paid $68 billion for physician care provided to nearly 50 million elderly and disabled individuals—about 12% of total Medicare spending—covering just over 1 billion distinct physician services. Physicians received a 10-month reprieve from a 27% cut in Medicare payments that had been scheduled for March 1, 2011, extending current payment rates through the end of this year. The agreement is part of a deal to extend a payroll tax cut and unemployment benefits. It is the 14th short-term patch to the sustainable growth rate (SGR) in the past 10 years. On January 1, 2013, we now face a 26.5% cut that Congress will have to find $245 billion to eliminate altogether.
How did we get here?
In 1997, Congress passed the Balanced Budget Act (BBA), at a time when many members of Congress were frustrated by continued increases in Medicare costs, fueled on the physician side, in part, by increases in the number of visits, tests, and procedures. To control these costs, Congress included in the BBA a complicated formula to peg Medicare physician payments to an economic growth target—the SGR. For the first few years, Medicare expenditures stayed within the target, and doctors received modest pay increases. But in 2002, expenditures rose faster than the SGR, and doctors were slated for a 4.8% pay cut.
Every year since, the SGR has signaled physician pay cuts, and every year, Congress has stopped the cuts from taking effect. But each deferral just made the next cut bigger and increased the price tag of stopping each pay cut. Today, the price of eliminating the SGR is $245 billion over the next 10 years. In these days of sequestration and deficit reduction, $245 billion is hard to find.
What now?
The good news is that support for eliminating the SGR is bicameral and bipartisan, rare in these hyperpartisan political days. Both Republicans and Democrats in the US House and Senate agree: The SGR has got to go. It’s a topic of conversation that wore out its welcome long ago.
The bad news? The $245 billion price tag. Remember, the SGR is in statute, so it requires an Act of Congress, signed by the President, to repeal it—and every Act is scored by the Congressional Budget Office.
The likeliest scenario is one we’ve seen many times before: Congress returns from a difficult election for a short, lame-duck session, during which it will have to address the cut before January 1. A real solution won’t be within reach, so Congress will likely kick that well-dented can a few more yards down the road, delaying the cut for yet another legislative cliffhanger.
In October 2012, the American Congress of Obstetricians and Gynecologists (ACOG) joined the American Medical Association (AMA) and 110 state and national medical societies in providing the US Congress with a clear and definitive document—Driving Principles and Core Elements—that describes a way to transition to a Medicare payment system that will endure and ensure high-quality care for the individuals who rely on that program, and for many millions more whose care is linked to Medicare payment policies.
This document is unique in many ways, perhaps especially in the unity it demonstrates among all physician organizations. It echoes ACOG’s earlier guidance to the US Congress on essential elements for a Medicare payment system that benefits women’s health. Among ACOG’s recommendations:
Make the new system simple, coordinated, and transparent. A new Medicare physician payment system should coordinate closely with other health-care programs; ensure that information technology is interoperable; and guarantee that quality-measurement programs are the same across all payers and rely on high-quality, risk-adjusted data.
Maintain the global obstetric care package. Medicare currently uses this package to reimburse for pregnancy. It works well and may be a model for global payment options for care provided by other physician types. The global obstetric care payment covers 10 months of care, from the first antepartum visit through the final postdelivery office visit.
Global payments allow a physician to manage costs and care for a patient’s course of treatment, rather than for a patient’s individual medical encounters.
Maintain fee for service for women’s health physicians who have small Medicare populations. Depending on the practice mix, type, and area, ObGyns and ObGyn subspecialists could see relatively few Medicare patients; unique Medicare requirements can pose significant administrative challenges and create inefficiencies with participation. Physicians who have small numbers of Medicare patients must be accommodated—and not penalized—in a new payment system.
Ensure that payment fairly and accurately reflects the cost of care. Medicare payments to obstetricians are already well below the cost of maternity care; no further cuts should be allowed for this care.
Support innovative care models, including a women’s medical home. These models should recognize the dual role that ObGyns may play as primary care and specialty care physicians.
Repeal the Independent Medicare Payment Advisory Board. Leaving Medicare payment decisions in the hands of an unelected, unaccountable body with minimal Congressional oversight is just a bad idea.
Pass medical liability reform. Congress must enact meaningful medical liability reform, which the Congressional Budget Office says could save $40 billion—enough for a small downpayment on SGR repeal.
A continuing promise
Rest assured that ACOG’s work to ensure appropriate Medicare payments to physicians, and to ensure that your patients have access to needed care, won’t stop until the job is done.
ACOG, AMA, and 110 state and national medical societies think so, and prescribe driving principles and core elements for the transition
In their letter to Congressional leaders, ACOG, AMA, and other societies acknowledged the “profound change” sweeping through the US health-care system, noting that it offers a “unique opportunity to improve and restructure how we deliver and pay for care.” When it comes to the SGR, however, these organizations conclude that it is “an enormous impediment to successful health-care delivery and payment reforms that can improve the quality of patient care while lowering growth in costs. Physicians facing the constant specter of severe cuts under the SGR cannot invest their time, energy, and resources in care redesign. The first step in moving to a higher-performing Medicare program must be the elimination of the SGR formula,” they write, based on the following principles, values, and key reforms.
Driving principles
- Successful delivery reform is an essential foundation for transitioning to a high-performing Medicare program that provides patient choice and meets the health-care needs of a diverse patient population.
- The Medicare program must invest in and support physician infrastructure that provides the platform for delivery and payment reform.
- Medicare payment updates should reflect the cost of providing services as well as efforts and progress on quality improvements and managing costs.
Core elements of reform
- Reflect the diversity of physician practices and provide opportunities for physicians to choose payment models that work for their patients, practice, specialty, and region.
- Encourage incremental changes with positive incentives and rewards during a defined timetable instead of using penalties to order abrupt changes in the delivery of care.
- Provide a way to measure progress and show policymakers that physicians are taking accountability for quality and costs.
Recommended structural improvements
- Reward physicians for savings achieved across the health-care spectrum.
- Enhance prospects for physicians adopting new models to achieve positive updates.
- Tie incentives to physicians’ own actions, rather than the actions of others or variables beyond their influence.
- Enhance prospects to harmonize measures and alter incentives in current law.
- Encourage systems of care, regional collaborative efforts, and primary care and specialist cooperation while preserving patient choice.
- Allow specialty and state society initiatives to be credited as delivering improvements (deeming authority) and recognize the central role of the profession in determining and measuring quality.
- Provide exemptions and alternative pathways for physicians in practice situations in which making or recovering the investments that may be needed to improve care delivery would constitute a hardship.
We want to hear from you! Tell us what you think.
Women’s health under the Affordable Care Act: What is covered?
(September 2012)
Lay midwives and the ObGyn: Is collaboration risky?
(May 2012)
How state budget crises are putting the squeeze on Medicaid (and you)
(February 2012)
Is private ObGyn practice on its way out?
(October 2011)
14 questions (and answers) about health reform and you
with Janelle Yates, Senior Editor (August 2010)
Lucia DiVenere, MA
Ms. DiVenere is Senior Director of Government Affairs at the American Congress of Obstetricians and Gynecologists in Washington, DC.
Ms. DiVenere reports no financial relationships relevant to this article.
Lucia DiVenere, MA
Ms. DiVenere is Senior Director of Government Affairs at the American Congress of Obstetricians and Gynecologists in Washington, DC.
Ms. DiVenere reports no financial relationships relevant to this article.
Lucia DiVenere, MA
Ms. DiVenere is Senior Director of Government Affairs at the American Congress of Obstetricians and Gynecologists in Washington, DC.
Ms. DiVenere reports no financial relationships relevant to this article.
Imagine this: Your 20-year-old daughter tells you she wants to attend an expensive school for 5 years of intensive postgraduate training, amassing tens of thousands of dollars of debt, to provide expert services to the US population. There is no good substitute for the services she hopes to provide, and they are vitally needed. The services also carry risk. Despite this, she tells you that her salary will not increase every year in tandem with the cost of living; in fact, she expects her salary to be cut by nearly one-third each year. Compensation in her chosen field hasn’t increased in real dollars for many years.
Sound like a good plan?
By now you have recognized this as your own story, at least if you’re among the 92% of ObGyns who participate in Medicare.
ObGyn participation in the Medicare program reflects ObGyn training and commitment to serve as lifelong principal care physicians for women of all ages, including women with disabilities. Fifty-six percent of all Medicare beneficiaries are women. With continuing shortages of primary care physicians and the transitioning of the Baby Boomer generation to Medicare, it is likely that ObGyns will become more involved in delivering health care to this population.
Medicare physician payments matter to ObGyns in other ways, too, because TRICARE and private payers often follow Medicare payment and coverage policies. Clearly, the Medicare program is a pretty big gorilla in every exam room. We all have much at stake in ensuring a stable Medicare system for years to come, starting with an improved physician payment system.
In 2011, Medicare paid $68 billion for physician care provided to nearly 50 million elderly and disabled individuals—about 12% of total Medicare spending—covering just over 1 billion distinct physician services. Physicians received a 10-month reprieve from a 27% cut in Medicare payments that had been scheduled for March 1, 2011, extending current payment rates through the end of this year. The agreement is part of a deal to extend a payroll tax cut and unemployment benefits. It is the 14th short-term patch to the sustainable growth rate (SGR) in the past 10 years. On January 1, 2013, we now face a 26.5% cut that Congress will have to find $245 billion to eliminate altogether.
How did we get here?
In 1997, Congress passed the Balanced Budget Act (BBA), at a time when many members of Congress were frustrated by continued increases in Medicare costs, fueled on the physician side, in part, by increases in the number of visits, tests, and procedures. To control these costs, Congress included in the BBA a complicated formula to peg Medicare physician payments to an economic growth target—the SGR. For the first few years, Medicare expenditures stayed within the target, and doctors received modest pay increases. But in 2002, expenditures rose faster than the SGR, and doctors were slated for a 4.8% pay cut.
Every year since, the SGR has signaled physician pay cuts, and every year, Congress has stopped the cuts from taking effect. But each deferral just made the next cut bigger and increased the price tag of stopping each pay cut. Today, the price of eliminating the SGR is $245 billion over the next 10 years. In these days of sequestration and deficit reduction, $245 billion is hard to find.
What now?
The good news is that support for eliminating the SGR is bicameral and bipartisan, rare in these hyperpartisan political days. Both Republicans and Democrats in the US House and Senate agree: The SGR has got to go. It’s a topic of conversation that wore out its welcome long ago.
The bad news? The $245 billion price tag. Remember, the SGR is in statute, so it requires an Act of Congress, signed by the President, to repeal it—and every Act is scored by the Congressional Budget Office.
The likeliest scenario is one we’ve seen many times before: Congress returns from a difficult election for a short, lame-duck session, during which it will have to address the cut before January 1. A real solution won’t be within reach, so Congress will likely kick that well-dented can a few more yards down the road, delaying the cut for yet another legislative cliffhanger.
In October 2012, the American Congress of Obstetricians and Gynecologists (ACOG) joined the American Medical Association (AMA) and 110 state and national medical societies in providing the US Congress with a clear and definitive document—Driving Principles and Core Elements—that describes a way to transition to a Medicare payment system that will endure and ensure high-quality care for the individuals who rely on that program, and for many millions more whose care is linked to Medicare payment policies.
This document is unique in many ways, perhaps especially in the unity it demonstrates among all physician organizations. It echoes ACOG’s earlier guidance to the US Congress on essential elements for a Medicare payment system that benefits women’s health. Among ACOG’s recommendations:
Make the new system simple, coordinated, and transparent. A new Medicare physician payment system should coordinate closely with other health-care programs; ensure that information technology is interoperable; and guarantee that quality-measurement programs are the same across all payers and rely on high-quality, risk-adjusted data.
Maintain the global obstetric care package. Medicare currently uses this package to reimburse for pregnancy. It works well and may be a model for global payment options for care provided by other physician types. The global obstetric care payment covers 10 months of care, from the first antepartum visit through the final postdelivery office visit.
Global payments allow a physician to manage costs and care for a patient’s course of treatment, rather than for a patient’s individual medical encounters.
Maintain fee for service for women’s health physicians who have small Medicare populations. Depending on the practice mix, type, and area, ObGyns and ObGyn subspecialists could see relatively few Medicare patients; unique Medicare requirements can pose significant administrative challenges and create inefficiencies with participation. Physicians who have small numbers of Medicare patients must be accommodated—and not penalized—in a new payment system.
Ensure that payment fairly and accurately reflects the cost of care. Medicare payments to obstetricians are already well below the cost of maternity care; no further cuts should be allowed for this care.
Support innovative care models, including a women’s medical home. These models should recognize the dual role that ObGyns may play as primary care and specialty care physicians.
Repeal the Independent Medicare Payment Advisory Board. Leaving Medicare payment decisions in the hands of an unelected, unaccountable body with minimal Congressional oversight is just a bad idea.
Pass medical liability reform. Congress must enact meaningful medical liability reform, which the Congressional Budget Office says could save $40 billion—enough for a small downpayment on SGR repeal.
A continuing promise
Rest assured that ACOG’s work to ensure appropriate Medicare payments to physicians, and to ensure that your patients have access to needed care, won’t stop until the job is done.
ACOG, AMA, and 110 state and national medical societies think so, and prescribe driving principles and core elements for the transition
In their letter to Congressional leaders, ACOG, AMA, and other societies acknowledged the “profound change” sweeping through the US health-care system, noting that it offers a “unique opportunity to improve and restructure how we deliver and pay for care.” When it comes to the SGR, however, these organizations conclude that it is “an enormous impediment to successful health-care delivery and payment reforms that can improve the quality of patient care while lowering growth in costs. Physicians facing the constant specter of severe cuts under the SGR cannot invest their time, energy, and resources in care redesign. The first step in moving to a higher-performing Medicare program must be the elimination of the SGR formula,” they write, based on the following principles, values, and key reforms.
Driving principles
- Successful delivery reform is an essential foundation for transitioning to a high-performing Medicare program that provides patient choice and meets the health-care needs of a diverse patient population.
- The Medicare program must invest in and support physician infrastructure that provides the platform for delivery and payment reform.
- Medicare payment updates should reflect the cost of providing services as well as efforts and progress on quality improvements and managing costs.
Core elements of reform
- Reflect the diversity of physician practices and provide opportunities for physicians to choose payment models that work for their patients, practice, specialty, and region.
- Encourage incremental changes with positive incentives and rewards during a defined timetable instead of using penalties to order abrupt changes in the delivery of care.
- Provide a way to measure progress and show policymakers that physicians are taking accountability for quality and costs.
Recommended structural improvements
- Reward physicians for savings achieved across the health-care spectrum.
- Enhance prospects for physicians adopting new models to achieve positive updates.
- Tie incentives to physicians’ own actions, rather than the actions of others or variables beyond their influence.
- Enhance prospects to harmonize measures and alter incentives in current law.
- Encourage systems of care, regional collaborative efforts, and primary care and specialist cooperation while preserving patient choice.
- Allow specialty and state society initiatives to be credited as delivering improvements (deeming authority) and recognize the central role of the profession in determining and measuring quality.
- Provide exemptions and alternative pathways for physicians in practice situations in which making or recovering the investments that may be needed to improve care delivery would constitute a hardship.
We want to hear from you! Tell us what you think.
Women’s health under the Affordable Care Act: What is covered?
(September 2012)
Lay midwives and the ObGyn: Is collaboration risky?
(May 2012)
How state budget crises are putting the squeeze on Medicaid (and you)
(February 2012)
Is private ObGyn practice on its way out?
(October 2011)
14 questions (and answers) about health reform and you
with Janelle Yates, Senior Editor (August 2010)
Imagine this: Your 20-year-old daughter tells you she wants to attend an expensive school for 5 years of intensive postgraduate training, amassing tens of thousands of dollars of debt, to provide expert services to the US population. There is no good substitute for the services she hopes to provide, and they are vitally needed. The services also carry risk. Despite this, she tells you that her salary will not increase every year in tandem with the cost of living; in fact, she expects her salary to be cut by nearly one-third each year. Compensation in her chosen field hasn’t increased in real dollars for many years.
Sound like a good plan?
By now you have recognized this as your own story, at least if you’re among the 92% of ObGyns who participate in Medicare.
ObGyn participation in the Medicare program reflects ObGyn training and commitment to serve as lifelong principal care physicians for women of all ages, including women with disabilities. Fifty-six percent of all Medicare beneficiaries are women. With continuing shortages of primary care physicians and the transitioning of the Baby Boomer generation to Medicare, it is likely that ObGyns will become more involved in delivering health care to this population.
Medicare physician payments matter to ObGyns in other ways, too, because TRICARE and private payers often follow Medicare payment and coverage policies. Clearly, the Medicare program is a pretty big gorilla in every exam room. We all have much at stake in ensuring a stable Medicare system for years to come, starting with an improved physician payment system.
In 2011, Medicare paid $68 billion for physician care provided to nearly 50 million elderly and disabled individuals—about 12% of total Medicare spending—covering just over 1 billion distinct physician services. Physicians received a 10-month reprieve from a 27% cut in Medicare payments that had been scheduled for March 1, 2011, extending current payment rates through the end of this year. The agreement is part of a deal to extend a payroll tax cut and unemployment benefits. It is the 14th short-term patch to the sustainable growth rate (SGR) in the past 10 years. On January 1, 2013, we now face a 26.5% cut that Congress will have to find $245 billion to eliminate altogether.
How did we get here?
In 1997, Congress passed the Balanced Budget Act (BBA), at a time when many members of Congress were frustrated by continued increases in Medicare costs, fueled on the physician side, in part, by increases in the number of visits, tests, and procedures. To control these costs, Congress included in the BBA a complicated formula to peg Medicare physician payments to an economic growth target—the SGR. For the first few years, Medicare expenditures stayed within the target, and doctors received modest pay increases. But in 2002, expenditures rose faster than the SGR, and doctors were slated for a 4.8% pay cut.
Every year since, the SGR has signaled physician pay cuts, and every year, Congress has stopped the cuts from taking effect. But each deferral just made the next cut bigger and increased the price tag of stopping each pay cut. Today, the price of eliminating the SGR is $245 billion over the next 10 years. In these days of sequestration and deficit reduction, $245 billion is hard to find.
What now?
The good news is that support for eliminating the SGR is bicameral and bipartisan, rare in these hyperpartisan political days. Both Republicans and Democrats in the US House and Senate agree: The SGR has got to go. It’s a topic of conversation that wore out its welcome long ago.
The bad news? The $245 billion price tag. Remember, the SGR is in statute, so it requires an Act of Congress, signed by the President, to repeal it—and every Act is scored by the Congressional Budget Office.
The likeliest scenario is one we’ve seen many times before: Congress returns from a difficult election for a short, lame-duck session, during which it will have to address the cut before January 1. A real solution won’t be within reach, so Congress will likely kick that well-dented can a few more yards down the road, delaying the cut for yet another legislative cliffhanger.
In October 2012, the American Congress of Obstetricians and Gynecologists (ACOG) joined the American Medical Association (AMA) and 110 state and national medical societies in providing the US Congress with a clear and definitive document—Driving Principles and Core Elements—that describes a way to transition to a Medicare payment system that will endure and ensure high-quality care for the individuals who rely on that program, and for many millions more whose care is linked to Medicare payment policies.
This document is unique in many ways, perhaps especially in the unity it demonstrates among all physician organizations. It echoes ACOG’s earlier guidance to the US Congress on essential elements for a Medicare payment system that benefits women’s health. Among ACOG’s recommendations:
Make the new system simple, coordinated, and transparent. A new Medicare physician payment system should coordinate closely with other health-care programs; ensure that information technology is interoperable; and guarantee that quality-measurement programs are the same across all payers and rely on high-quality, risk-adjusted data.
Maintain the global obstetric care package. Medicare currently uses this package to reimburse for pregnancy. It works well and may be a model for global payment options for care provided by other physician types. The global obstetric care payment covers 10 months of care, from the first antepartum visit through the final postdelivery office visit.
Global payments allow a physician to manage costs and care for a patient’s course of treatment, rather than for a patient’s individual medical encounters.
Maintain fee for service for women’s health physicians who have small Medicare populations. Depending on the practice mix, type, and area, ObGyns and ObGyn subspecialists could see relatively few Medicare patients; unique Medicare requirements can pose significant administrative challenges and create inefficiencies with participation. Physicians who have small numbers of Medicare patients must be accommodated—and not penalized—in a new payment system.
Ensure that payment fairly and accurately reflects the cost of care. Medicare payments to obstetricians are already well below the cost of maternity care; no further cuts should be allowed for this care.
Support innovative care models, including a women’s medical home. These models should recognize the dual role that ObGyns may play as primary care and specialty care physicians.
Repeal the Independent Medicare Payment Advisory Board. Leaving Medicare payment decisions in the hands of an unelected, unaccountable body with minimal Congressional oversight is just a bad idea.
Pass medical liability reform. Congress must enact meaningful medical liability reform, which the Congressional Budget Office says could save $40 billion—enough for a small downpayment on SGR repeal.
A continuing promise
Rest assured that ACOG’s work to ensure appropriate Medicare payments to physicians, and to ensure that your patients have access to needed care, won’t stop until the job is done.
ACOG, AMA, and 110 state and national medical societies think so, and prescribe driving principles and core elements for the transition
In their letter to Congressional leaders, ACOG, AMA, and other societies acknowledged the “profound change” sweeping through the US health-care system, noting that it offers a “unique opportunity to improve and restructure how we deliver and pay for care.” When it comes to the SGR, however, these organizations conclude that it is “an enormous impediment to successful health-care delivery and payment reforms that can improve the quality of patient care while lowering growth in costs. Physicians facing the constant specter of severe cuts under the SGR cannot invest their time, energy, and resources in care redesign. The first step in moving to a higher-performing Medicare program must be the elimination of the SGR formula,” they write, based on the following principles, values, and key reforms.
Driving principles
- Successful delivery reform is an essential foundation for transitioning to a high-performing Medicare program that provides patient choice and meets the health-care needs of a diverse patient population.
- The Medicare program must invest in and support physician infrastructure that provides the platform for delivery and payment reform.
- Medicare payment updates should reflect the cost of providing services as well as efforts and progress on quality improvements and managing costs.
Core elements of reform
- Reflect the diversity of physician practices and provide opportunities for physicians to choose payment models that work for their patients, practice, specialty, and region.
- Encourage incremental changes with positive incentives and rewards during a defined timetable instead of using penalties to order abrupt changes in the delivery of care.
- Provide a way to measure progress and show policymakers that physicians are taking accountability for quality and costs.
Recommended structural improvements
- Reward physicians for savings achieved across the health-care spectrum.
- Enhance prospects for physicians adopting new models to achieve positive updates.
- Tie incentives to physicians’ own actions, rather than the actions of others or variables beyond their influence.
- Enhance prospects to harmonize measures and alter incentives in current law.
- Encourage systems of care, regional collaborative efforts, and primary care and specialist cooperation while preserving patient choice.
- Allow specialty and state society initiatives to be credited as delivering improvements (deeming authority) and recognize the central role of the profession in determining and measuring quality.
- Provide exemptions and alternative pathways for physicians in practice situations in which making or recovering the investments that may be needed to improve care delivery would constitute a hardship.
We want to hear from you! Tell us what you think.
Women’s health under the Affordable Care Act: What is covered?
(September 2012)
Lay midwives and the ObGyn: Is collaboration risky?
(May 2012)
How state budget crises are putting the squeeze on Medicaid (and you)
(February 2012)
Is private ObGyn practice on its way out?
(October 2011)
14 questions (and answers) about health reform and you
with Janelle Yates, Senior Editor (August 2010)
Accountable-Care Organizations on the Horizon for Hospitalists
Every HM group should look into transitioning from a fee-for-service model to an accountable-care organization (ACO), a leading hospitalist told conference attendees recently at the Third National Accountable Care Organization Congress.
"You need to be tackling it now, but that doesn't mean you need to be aggressively doing it now," Edward Murphy, MD, chairman of Sound Physicians, told eWire days before he spoke at the ACO Congress on Oct. 31 in Los Angeles. "By tackling it, you need to be doing a hard-nosed assessment of what's best for your group and your patients."
Question: Why is the ACO model so difficult in some instances?
Answer: The problem with the healthcare system today is we’ve spent 100 years building up a system that is designed around, and competent at, delivering services for fees. We're really not set up to manage care.
Q: What is the No. 1 thing you want hospitalists to know about ACOs today?
A: Figure out every single day how to improve the care of your patients at a lower cost. And then, how you can demonstrate it in a quantitative and clear way. ACO-style payments are really only a value proposition centered on providing superior outcomes for patients at higher satisfaction for lower cost. That’s a fundamental value that will always be noteworthy.
Q: Is a hospitalist's job to lead the charge toward ACOs, or support those who do?
A: That's the sort of thing that people on the ground don't have to be told. They just know. If I were the leader of a hospitalist group someplace and really thought the smart thing to do was to think about how to move to an accountable-care model … I would know from my discussions with my colleagues, my discussions with hospital executives where everybody was.
Visit our website for more information about ACOs.
Every HM group should look into transitioning from a fee-for-service model to an accountable-care organization (ACO), a leading hospitalist told conference attendees recently at the Third National Accountable Care Organization Congress.
"You need to be tackling it now, but that doesn't mean you need to be aggressively doing it now," Edward Murphy, MD, chairman of Sound Physicians, told eWire days before he spoke at the ACO Congress on Oct. 31 in Los Angeles. "By tackling it, you need to be doing a hard-nosed assessment of what's best for your group and your patients."
Question: Why is the ACO model so difficult in some instances?
Answer: The problem with the healthcare system today is we’ve spent 100 years building up a system that is designed around, and competent at, delivering services for fees. We're really not set up to manage care.
Q: What is the No. 1 thing you want hospitalists to know about ACOs today?
A: Figure out every single day how to improve the care of your patients at a lower cost. And then, how you can demonstrate it in a quantitative and clear way. ACO-style payments are really only a value proposition centered on providing superior outcomes for patients at higher satisfaction for lower cost. That’s a fundamental value that will always be noteworthy.
Q: Is a hospitalist's job to lead the charge toward ACOs, or support those who do?
A: That's the sort of thing that people on the ground don't have to be told. They just know. If I were the leader of a hospitalist group someplace and really thought the smart thing to do was to think about how to move to an accountable-care model … I would know from my discussions with my colleagues, my discussions with hospital executives where everybody was.
Visit our website for more information about ACOs.
Every HM group should look into transitioning from a fee-for-service model to an accountable-care organization (ACO), a leading hospitalist told conference attendees recently at the Third National Accountable Care Organization Congress.
"You need to be tackling it now, but that doesn't mean you need to be aggressively doing it now," Edward Murphy, MD, chairman of Sound Physicians, told eWire days before he spoke at the ACO Congress on Oct. 31 in Los Angeles. "By tackling it, you need to be doing a hard-nosed assessment of what's best for your group and your patients."
Question: Why is the ACO model so difficult in some instances?
Answer: The problem with the healthcare system today is we’ve spent 100 years building up a system that is designed around, and competent at, delivering services for fees. We're really not set up to manage care.
Q: What is the No. 1 thing you want hospitalists to know about ACOs today?
A: Figure out every single day how to improve the care of your patients at a lower cost. And then, how you can demonstrate it in a quantitative and clear way. ACO-style payments are really only a value proposition centered on providing superior outcomes for patients at higher satisfaction for lower cost. That’s a fundamental value that will always be noteworthy.
Q: Is a hospitalist's job to lead the charge toward ACOs, or support those who do?
A: That's the sort of thing that people on the ground don't have to be told. They just know. If I were the leader of a hospitalist group someplace and really thought the smart thing to do was to think about how to move to an accountable-care model … I would know from my discussions with my colleagues, my discussions with hospital executives where everybody was.
Visit our website for more information about ACOs.
ONLINE EXCLUSIVE: SHM Board Member Eric Siegal Offers Advice to Manage Scope Creep
Holiday Bonuses Revisited
As I’ve been writing for several years, holiday bonuses have increasingly become a thing of the past in the business world. Most companies have replaced them with various types of structured, incentive-based reward systems.
Yet an informal poll of dermatologists around the country on the RxDerm-L listserv reveals that a substantial percentage of private practitioners continue to offer their employees no-strings-attached holiday bonuses. This is somewhat understandable in the sense that, once employees come to expect a particular benefit, it is difficult to take it away. Given the uncertainties of the fluctuating economy, though, and the impending changes in the status of health care in this country, many practices may have to follow the national trend and begin tying their awards programs to performance.
Holiday bonuses have been falling out of favor in the business world because companies face increased pressure to reduce costs and so have become more focused on growth and performance. Since this is also increasingly true in the world of private practice, it makes sense for medical practices to heed this trend.
Instead of giving arbitrary, across-the-board bonuses, you may want to find ways to appropriately reward your highest-performing employees. This can be done by reserving more bonus budgets (called "variable compensation" in business lingo, as opposed to guaranteed, salaried compensation) for bonuses that are based on performance and must be re-earned each year.
First, however, you must decide what targets and goals you wish your employees to achieve during the year. Specific performance goals will vary by the type of practice: Cosmetic practices might set financial goals, such as a profit and revenue targets, while offices primarily practicing medical dermatology might measure performance according to output and quality of work.
Whatever changes you decide to make, be sure to share them with your staff from the outset. Employees must be aware of what they need to accomplish to earn a performance-based bonus.
Commonly cited guidelines for effectively rewarding employees include the following:
• Reward your employees in ways that they find rewarding. (This does not necessarily mean cash.) The reward should be matched to the achievement, so bigger achievements earn bigger rewards.
• To be effective, rewards must be given as soon as possible after a specific laudable behavior or achievement, and the employee should always be told why he or she is receiving it. A reward coming weeks or months later – say, during the holiday season – has little or no effect as a performance incentive.
So how do you know what rewards your employees will find rewarding? Ask them! In my office, their ideas have been surprisingly creative – and cheap. For example, my employees are required to park their cars each day on the other side of the hospital campus from my office building. One of them suggested that a closer parking space would be a good reward, so I obtained an extra access card for the doctors’ lot right next to my building and each month one "Employee of the Month" gets to park there. This reward – which costs me nothing – has become the most hotly contested in the office.
One of the strongest motivators is the confidence that you, the boss, have taken the time to notice a job well done and praise it publicly, in a timely manner.
Time off is another powerful motivator: Who (including you) doesn’t appreciate a bit more free time?
This is not to say, of course, that you cannot also give your employees a gift at holiday time – as long as you (and they) understand that it is a one-time gift, with no guarantees or expectations of annual repetition. Such gifts usually consist of either cash (or gift certificates/cards) or a non-cash gift such as a fruit basket or baked goods.
Keep in mind that bonuses and gifts nearly always qualify as a tax write-off for employers, but they may or may not count as taxable income for employees. As a general rule, cash bonuses tend to be taxable while non-cash awards are not, but check your state’s applicable laws to be sure.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail him at our editorial offices at [email protected].
As I’ve been writing for several years, holiday bonuses have increasingly become a thing of the past in the business world. Most companies have replaced them with various types of structured, incentive-based reward systems.
Yet an informal poll of dermatologists around the country on the RxDerm-L listserv reveals that a substantial percentage of private practitioners continue to offer their employees no-strings-attached holiday bonuses. This is somewhat understandable in the sense that, once employees come to expect a particular benefit, it is difficult to take it away. Given the uncertainties of the fluctuating economy, though, and the impending changes in the status of health care in this country, many practices may have to follow the national trend and begin tying their awards programs to performance.
Holiday bonuses have been falling out of favor in the business world because companies face increased pressure to reduce costs and so have become more focused on growth and performance. Since this is also increasingly true in the world of private practice, it makes sense for medical practices to heed this trend.
Instead of giving arbitrary, across-the-board bonuses, you may want to find ways to appropriately reward your highest-performing employees. This can be done by reserving more bonus budgets (called "variable compensation" in business lingo, as opposed to guaranteed, salaried compensation) for bonuses that are based on performance and must be re-earned each year.
First, however, you must decide what targets and goals you wish your employees to achieve during the year. Specific performance goals will vary by the type of practice: Cosmetic practices might set financial goals, such as a profit and revenue targets, while offices primarily practicing medical dermatology might measure performance according to output and quality of work.
Whatever changes you decide to make, be sure to share them with your staff from the outset. Employees must be aware of what they need to accomplish to earn a performance-based bonus.
Commonly cited guidelines for effectively rewarding employees include the following:
• Reward your employees in ways that they find rewarding. (This does not necessarily mean cash.) The reward should be matched to the achievement, so bigger achievements earn bigger rewards.
• To be effective, rewards must be given as soon as possible after a specific laudable behavior or achievement, and the employee should always be told why he or she is receiving it. A reward coming weeks or months later – say, during the holiday season – has little or no effect as a performance incentive.
So how do you know what rewards your employees will find rewarding? Ask them! In my office, their ideas have been surprisingly creative – and cheap. For example, my employees are required to park their cars each day on the other side of the hospital campus from my office building. One of them suggested that a closer parking space would be a good reward, so I obtained an extra access card for the doctors’ lot right next to my building and each month one "Employee of the Month" gets to park there. This reward – which costs me nothing – has become the most hotly contested in the office.
One of the strongest motivators is the confidence that you, the boss, have taken the time to notice a job well done and praise it publicly, in a timely manner.
Time off is another powerful motivator: Who (including you) doesn’t appreciate a bit more free time?
This is not to say, of course, that you cannot also give your employees a gift at holiday time – as long as you (and they) understand that it is a one-time gift, with no guarantees or expectations of annual repetition. Such gifts usually consist of either cash (or gift certificates/cards) or a non-cash gift such as a fruit basket or baked goods.
Keep in mind that bonuses and gifts nearly always qualify as a tax write-off for employers, but they may or may not count as taxable income for employees. As a general rule, cash bonuses tend to be taxable while non-cash awards are not, but check your state’s applicable laws to be sure.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail him at our editorial offices at [email protected].
As I’ve been writing for several years, holiday bonuses have increasingly become a thing of the past in the business world. Most companies have replaced them with various types of structured, incentive-based reward systems.
Yet an informal poll of dermatologists around the country on the RxDerm-L listserv reveals that a substantial percentage of private practitioners continue to offer their employees no-strings-attached holiday bonuses. This is somewhat understandable in the sense that, once employees come to expect a particular benefit, it is difficult to take it away. Given the uncertainties of the fluctuating economy, though, and the impending changes in the status of health care in this country, many practices may have to follow the national trend and begin tying their awards programs to performance.
Holiday bonuses have been falling out of favor in the business world because companies face increased pressure to reduce costs and so have become more focused on growth and performance. Since this is also increasingly true in the world of private practice, it makes sense for medical practices to heed this trend.
Instead of giving arbitrary, across-the-board bonuses, you may want to find ways to appropriately reward your highest-performing employees. This can be done by reserving more bonus budgets (called "variable compensation" in business lingo, as opposed to guaranteed, salaried compensation) for bonuses that are based on performance and must be re-earned each year.
First, however, you must decide what targets and goals you wish your employees to achieve during the year. Specific performance goals will vary by the type of practice: Cosmetic practices might set financial goals, such as a profit and revenue targets, while offices primarily practicing medical dermatology might measure performance according to output and quality of work.
Whatever changes you decide to make, be sure to share them with your staff from the outset. Employees must be aware of what they need to accomplish to earn a performance-based bonus.
Commonly cited guidelines for effectively rewarding employees include the following:
• Reward your employees in ways that they find rewarding. (This does not necessarily mean cash.) The reward should be matched to the achievement, so bigger achievements earn bigger rewards.
• To be effective, rewards must be given as soon as possible after a specific laudable behavior or achievement, and the employee should always be told why he or she is receiving it. A reward coming weeks or months later – say, during the holiday season – has little or no effect as a performance incentive.
So how do you know what rewards your employees will find rewarding? Ask them! In my office, their ideas have been surprisingly creative – and cheap. For example, my employees are required to park their cars each day on the other side of the hospital campus from my office building. One of them suggested that a closer parking space would be a good reward, so I obtained an extra access card for the doctors’ lot right next to my building and each month one "Employee of the Month" gets to park there. This reward – which costs me nothing – has become the most hotly contested in the office.
One of the strongest motivators is the confidence that you, the boss, have taken the time to notice a job well done and praise it publicly, in a timely manner.
Time off is another powerful motivator: Who (including you) doesn’t appreciate a bit more free time?
This is not to say, of course, that you cannot also give your employees a gift at holiday time – as long as you (and they) understand that it is a one-time gift, with no guarantees or expectations of annual repetition. Such gifts usually consist of either cash (or gift certificates/cards) or a non-cash gift such as a fruit basket or baked goods.
Keep in mind that bonuses and gifts nearly always qualify as a tax write-off for employers, but they may or may not count as taxable income for employees. As a general rule, cash bonuses tend to be taxable while non-cash awards are not, but check your state’s applicable laws to be sure.
Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. To respond to this column, e-mail him at our editorial offices at [email protected].
U.S. Army Supports Rapid Deployment of Hospital Practice
A U.S. military combat-support hospital team based at Fort Polk near Leesville, La., works hard year-round to remain ready to erect a temporary, fully functioning tent hospital within 72 hours whenever and wherever it’s needed. That could mean an overseas war zone or closer to home for Americans hit by a tornado or hurricane.
The 115th Forward Support Battalion, led by Col. Kevin J. Stevens, has practiced assembling the temporary hospital three times this year, with another exercise planned for October. In its last run-through, a 24-hour acute-care hospital of 84 beds was erected in 66 hours. It included two operating rooms, two 24-bed ICUs with ventilators, patient wards, a six-bay ED, specialty clinics, and lab, pathology, biomedical, pharmacy, and blood services.
All of the needed equipment can be moved by truck, airplane, or boat in 32 20-foot-long vehicles, Stevens says. The staging team lays out the perimeter, perhaps in a parking lot or an existing structure, such as a school. Heating and cooling systems, water, oxygen, and power generators are brought in, and the team establishes a landing pad for helicopters.
“We bring all that wherever we go. But setting it up is the easy part,” Stevens says, adding that staffing and managing an acute-care hospital is the hard part.
When fully operational, the temporary hospital employs a professional staff of 75 to 80, including medical specialists. Some are based year-round at Fort Polk, keeping the equipment maintained. Others practice at hospitals across the country but are on the “call list” when a deployment is ordered. A new set of up-to-date, interlocking equipment for the temporary hospital was issued in March.
“Getting better at this is my mission,” says Stevens, a soldier since 1974 who has deployed with Forward Support Hospitals in both Iraq and Afghanistan. “We work to keep medical and deployment skills sharp at all times. Everything we do is meant to save soldier and civilian lives.”
Larry Beresford is a freelance writer in Oakland, Calif.
A U.S. military combat-support hospital team based at Fort Polk near Leesville, La., works hard year-round to remain ready to erect a temporary, fully functioning tent hospital within 72 hours whenever and wherever it’s needed. That could mean an overseas war zone or closer to home for Americans hit by a tornado or hurricane.
The 115th Forward Support Battalion, led by Col. Kevin J. Stevens, has practiced assembling the temporary hospital three times this year, with another exercise planned for October. In its last run-through, a 24-hour acute-care hospital of 84 beds was erected in 66 hours. It included two operating rooms, two 24-bed ICUs with ventilators, patient wards, a six-bay ED, specialty clinics, and lab, pathology, biomedical, pharmacy, and blood services.
All of the needed equipment can be moved by truck, airplane, or boat in 32 20-foot-long vehicles, Stevens says. The staging team lays out the perimeter, perhaps in a parking lot or an existing structure, such as a school. Heating and cooling systems, water, oxygen, and power generators are brought in, and the team establishes a landing pad for helicopters.
“We bring all that wherever we go. But setting it up is the easy part,” Stevens says, adding that staffing and managing an acute-care hospital is the hard part.
When fully operational, the temporary hospital employs a professional staff of 75 to 80, including medical specialists. Some are based year-round at Fort Polk, keeping the equipment maintained. Others practice at hospitals across the country but are on the “call list” when a deployment is ordered. A new set of up-to-date, interlocking equipment for the temporary hospital was issued in March.
“Getting better at this is my mission,” says Stevens, a soldier since 1974 who has deployed with Forward Support Hospitals in both Iraq and Afghanistan. “We work to keep medical and deployment skills sharp at all times. Everything we do is meant to save soldier and civilian lives.”
Larry Beresford is a freelance writer in Oakland, Calif.
A U.S. military combat-support hospital team based at Fort Polk near Leesville, La., works hard year-round to remain ready to erect a temporary, fully functioning tent hospital within 72 hours whenever and wherever it’s needed. That could mean an overseas war zone or closer to home for Americans hit by a tornado or hurricane.
The 115th Forward Support Battalion, led by Col. Kevin J. Stevens, has practiced assembling the temporary hospital three times this year, with another exercise planned for October. In its last run-through, a 24-hour acute-care hospital of 84 beds was erected in 66 hours. It included two operating rooms, two 24-bed ICUs with ventilators, patient wards, a six-bay ED, specialty clinics, and lab, pathology, biomedical, pharmacy, and blood services.
All of the needed equipment can be moved by truck, airplane, or boat in 32 20-foot-long vehicles, Stevens says. The staging team lays out the perimeter, perhaps in a parking lot or an existing structure, such as a school. Heating and cooling systems, water, oxygen, and power generators are brought in, and the team establishes a landing pad for helicopters.
“We bring all that wherever we go. But setting it up is the easy part,” Stevens says, adding that staffing and managing an acute-care hospital is the hard part.
When fully operational, the temporary hospital employs a professional staff of 75 to 80, including medical specialists. Some are based year-round at Fort Polk, keeping the equipment maintained. Others practice at hospitals across the country but are on the “call list” when a deployment is ordered. A new set of up-to-date, interlocking equipment for the temporary hospital was issued in March.
“Getting better at this is my mission,” says Stevens, a soldier since 1974 who has deployed with Forward Support Hospitals in both Iraq and Afghanistan. “We work to keep medical and deployment skills sharp at all times. Everything we do is meant to save soldier and civilian lives.”
Larry Beresford is a freelance writer in Oakland, Calif.
Five Ways Hospitalists Can Prevent Overextending Their Services
1. Do not feel sorry for yourself; it can become a self-fulfilling prophecy.
“Most of what is happening in medicine is outside of our control,” Dr. Nelson says. “We need to realize that our role is going to change, and we should not perceive ourselves as the low person on the totem pole.”
2. Increase “face time” with your specialist colleagues.
Join them for lunch in the physician’s lounge, call your colleagues by their first names, engage in meaningful discussions about cases, and show empathy for them and their patients. Look for opportunities to do mutual education with other services.
3. Know when to draw the line.
“HM leaders should have the skills to analyze an opportunity and assess whether their program has the staffing capacity and clinical skills to successfully deliver a requested service,” Dr. Simone says. “‘No’ is an acceptable answer, if there are clear and reasonable reasons that support that decision.”
4. Make it about the patient.
Whenever your HM service is approached about comanagement, phrase your decision within the context of ensuring patient safety and delivering quality care. In that way, Dr. Siy says, you will be on solid footing.
5. Openly promote strategic “yes” answers.
Instead of digging in their heels, HM groups can periodically examine all requests, pick one or two to begin with, then promote successful outcomes to boost the group’s value.
1. Do not feel sorry for yourself; it can become a self-fulfilling prophecy.
“Most of what is happening in medicine is outside of our control,” Dr. Nelson says. “We need to realize that our role is going to change, and we should not perceive ourselves as the low person on the totem pole.”
2. Increase “face time” with your specialist colleagues.
Join them for lunch in the physician’s lounge, call your colleagues by their first names, engage in meaningful discussions about cases, and show empathy for them and their patients. Look for opportunities to do mutual education with other services.
3. Know when to draw the line.
“HM leaders should have the skills to analyze an opportunity and assess whether their program has the staffing capacity and clinical skills to successfully deliver a requested service,” Dr. Simone says. “‘No’ is an acceptable answer, if there are clear and reasonable reasons that support that decision.”
4. Make it about the patient.
Whenever your HM service is approached about comanagement, phrase your decision within the context of ensuring patient safety and delivering quality care. In that way, Dr. Siy says, you will be on solid footing.
5. Openly promote strategic “yes” answers.
Instead of digging in their heels, HM groups can periodically examine all requests, pick one or two to begin with, then promote successful outcomes to boost the group’s value.
1. Do not feel sorry for yourself; it can become a self-fulfilling prophecy.
“Most of what is happening in medicine is outside of our control,” Dr. Nelson says. “We need to realize that our role is going to change, and we should not perceive ourselves as the low person on the totem pole.”
2. Increase “face time” with your specialist colleagues.
Join them for lunch in the physician’s lounge, call your colleagues by their first names, engage in meaningful discussions about cases, and show empathy for them and their patients. Look for opportunities to do mutual education with other services.
3. Know when to draw the line.
“HM leaders should have the skills to analyze an opportunity and assess whether their program has the staffing capacity and clinical skills to successfully deliver a requested service,” Dr. Simone says. “‘No’ is an acceptable answer, if there are clear and reasonable reasons that support that decision.”
4. Make it about the patient.
Whenever your HM service is approached about comanagement, phrase your decision within the context of ensuring patient safety and delivering quality care. In that way, Dr. Siy says, you will be on solid footing.
5. Openly promote strategic “yes” answers.
Instead of digging in their heels, HM groups can periodically examine all requests, pick one or two to begin with, then promote successful outcomes to boost the group’s value.
Why It's Hard for Healthcare Providers to Say I'm Sorry
It’s 1982, and in middle-school gyms across the country, among punch bowls and parental scrutiny, young girls and boys are slow-dancing with outstretched arms to a breathtaking song by the band Chicago. The song tells of the agonizing difficulty of apology, how despite the want and need to apologize, it is just too arduous.
Fast-forward 30 years, and it is hard to believe that cheesy No. 1 Billboard hit espoused the feelings that continue to haunt healthcare providers across the country: It’s hard for me to say I’m sorry.
Others Say It
If you look at the world around us, you see apology everywhere. Customer service representatives and customer-minded industries routinely let those words flow off their tongues with ease and grace.
While I was driving down the interstate last week, the number of traffic lanes shrunk from three to two to one. Anticipating widespread aggravation from weary travelers, the state transportation department deployed several large road signs every few miles; they read “WE APOLOGIZE FOR THE INCONVENIENCE … BEAR WITH US WHILE WE MAKE YOUR ROADS SMOOTHER AND SAFER.” Those simple messages made me feel like the congestion was not a senseless waste of time, that the state’s Department of Transportation was actually being strategic and thoughtful in their rationing of lanes during rush hour in the middle of the week.
Phone-based, customer-service departments figured out the simple apology a long time ago. While holding the line for a Lands’ End customer-service representative a few weeks ago, I heard, “We apologize for the delay. Your business is important to us. Please hold the line while we address callers ahead of you.” It validated for me that those phone representatives are not just sitting around eating lunch, completely ignoring my call, and that maybe there are others who procrastinated buying back-to-school backpacks until September—and just happened to call right before me.
I even got an apology at the dry cleaner. Amidst my last batch of clothes, my astute dry cleaner apparently found a very stubborn stain, which resisted all of their usual concoctions. It was on the back of a shirt and I probably would not have even noticed it was there. But nonetheless, they sent an apology tag, with a picture of a distraught butler who seemed to have struggled with that stain for hours.
Why Not Us?
So why is “sorry” so hard in healthcare? When things happen to patients, things that are inconvenient or downright dangerous, we have great difficulty in simply saying: “Hey, I am really sorry this happened to you,” or “I am so sorry you are still here. You must be really frustrated by our inefficiencies.”
I have the distinct pleasure of overseeing my hospital’s risk-management department for a few months. This means I get to see and hear what does and doesn’t happen to patients, which, at times, is misaligned with what should or shouldn’t happen to patients. When unanticipated events occur, the group launches into an investigation of what happened, why it happened, and the risk that it could happen again. After the initial dust settles and the facts are relayed from the care team to the risk-management team, the risk team always asks of those involved: “So what does the patient and their family know?” And we get a range of answers—some polished, some fumbled, some baffled.
The next question is: “Well, what should they know?” And that is always an easy question to answer. They should know the truth. Not just some of the truth, or half the truth, or a partial truth. Not what the care team thinks the patient “can handle.” They should just get the truth. To the best of the team’s ability, they should tell the patient:
- What (they think) happened;
- Why (they think) it happened;
- What it means for the patient; and
- What they are going to do to make it not happen again.
And then the patient (and family members) deserve an apology—sincere, compassionate, genuine. The apology should be the easy part, as most providers do not always know what happened, why it happened, or what they are going to do to prevent it from happening, but they usually truly do feel sorry that it happened at all.
“Sorry”=Positive Results
Patients are unanimous in their desire to be informed if a medical error has occurred; focus groups have found that patients believe such information would enhance their trust in their physicians and would reassure them that they were receiving complete information. And they want an apology.1
But interestingly, many physicians believe that full disclosure with apology is not warranted or appropriate, and that the apology could erode patient trust, might scare the patient, and might increase the risk of legal liability.1
There is little evidence that disclosure is harmful or detrimental, and there is some evidence that it is beneficial to the medical industry (i.e. reduces claims and litigation costs). A study published in 2010 from the University of Michigan Health System found a disclosure-with-compensation program was associated with a 36% reduction in new claims, a 65% reduction in lawsuits, and a 59% reduction in total liability cost.2
I have witnessed this phenomenon from both sides. My mother, who has Alzheimer’s and lives in an assisted-living facility, recently was given twice the dose of her medications one morning. She was “given” her night medications by being placed in her room, which she has no recollection of (the staff are supposed to watch her take her medications). The next morning, she saw the medications and took them, then took another dose when the nurse came by to give her morning medications. It was not realized until she’d already taken the medications and the staff noticed the medicine cup from the night before. My mom said she felt a little weak and dizzy for a few hours, but nothing significant, and she fully recovered. Interestingly, my mom mentioned it in passing, but no one called to let us know a medication error had occurred. Although she was not harmed, it made us, her family, lose a little trust in the facility because we found out about it indirectly, without any acknowledgement or apology.
On the other side of the equation, I have witnessed countless numbers of patient events in which providers feel worried and uncomfortable about the effects of disclosure with apology on themselves and their patients.
The bottom line is, disclosure with apology is needed and appreciated by patients, and it is absolutely the right thing to do. So download that cheesy Chicago song to your iPod and practice saying (or singing) “I’m sorry.” If the butler with chemicals can do it, so can we.
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
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
- Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-221.
It’s 1982, and in middle-school gyms across the country, among punch bowls and parental scrutiny, young girls and boys are slow-dancing with outstretched arms to a breathtaking song by the band Chicago. The song tells of the agonizing difficulty of apology, how despite the want and need to apologize, it is just too arduous.
Fast-forward 30 years, and it is hard to believe that cheesy No. 1 Billboard hit espoused the feelings that continue to haunt healthcare providers across the country: It’s hard for me to say I’m sorry.
Others Say It
If you look at the world around us, you see apology everywhere. Customer service representatives and customer-minded industries routinely let those words flow off their tongues with ease and grace.
While I was driving down the interstate last week, the number of traffic lanes shrunk from three to two to one. Anticipating widespread aggravation from weary travelers, the state transportation department deployed several large road signs every few miles; they read “WE APOLOGIZE FOR THE INCONVENIENCE … BEAR WITH US WHILE WE MAKE YOUR ROADS SMOOTHER AND SAFER.” Those simple messages made me feel like the congestion was not a senseless waste of time, that the state’s Department of Transportation was actually being strategic and thoughtful in their rationing of lanes during rush hour in the middle of the week.
Phone-based, customer-service departments figured out the simple apology a long time ago. While holding the line for a Lands’ End customer-service representative a few weeks ago, I heard, “We apologize for the delay. Your business is important to us. Please hold the line while we address callers ahead of you.” It validated for me that those phone representatives are not just sitting around eating lunch, completely ignoring my call, and that maybe there are others who procrastinated buying back-to-school backpacks until September—and just happened to call right before me.
I even got an apology at the dry cleaner. Amidst my last batch of clothes, my astute dry cleaner apparently found a very stubborn stain, which resisted all of their usual concoctions. It was on the back of a shirt and I probably would not have even noticed it was there. But nonetheless, they sent an apology tag, with a picture of a distraught butler who seemed to have struggled with that stain for hours.
Why Not Us?
So why is “sorry” so hard in healthcare? When things happen to patients, things that are inconvenient or downright dangerous, we have great difficulty in simply saying: “Hey, I am really sorry this happened to you,” or “I am so sorry you are still here. You must be really frustrated by our inefficiencies.”
I have the distinct pleasure of overseeing my hospital’s risk-management department for a few months. This means I get to see and hear what does and doesn’t happen to patients, which, at times, is misaligned with what should or shouldn’t happen to patients. When unanticipated events occur, the group launches into an investigation of what happened, why it happened, and the risk that it could happen again. After the initial dust settles and the facts are relayed from the care team to the risk-management team, the risk team always asks of those involved: “So what does the patient and their family know?” And we get a range of answers—some polished, some fumbled, some baffled.
The next question is: “Well, what should they know?” And that is always an easy question to answer. They should know the truth. Not just some of the truth, or half the truth, or a partial truth. Not what the care team thinks the patient “can handle.” They should just get the truth. To the best of the team’s ability, they should tell the patient:
- What (they think) happened;
- Why (they think) it happened;
- What it means for the patient; and
- What they are going to do to make it not happen again.
And then the patient (and family members) deserve an apology—sincere, compassionate, genuine. The apology should be the easy part, as most providers do not always know what happened, why it happened, or what they are going to do to prevent it from happening, but they usually truly do feel sorry that it happened at all.
“Sorry”=Positive Results
Patients are unanimous in their desire to be informed if a medical error has occurred; focus groups have found that patients believe such information would enhance their trust in their physicians and would reassure them that they were receiving complete information. And they want an apology.1
But interestingly, many physicians believe that full disclosure with apology is not warranted or appropriate, and that the apology could erode patient trust, might scare the patient, and might increase the risk of legal liability.1
There is little evidence that disclosure is harmful or detrimental, and there is some evidence that it is beneficial to the medical industry (i.e. reduces claims and litigation costs). A study published in 2010 from the University of Michigan Health System found a disclosure-with-compensation program was associated with a 36% reduction in new claims, a 65% reduction in lawsuits, and a 59% reduction in total liability cost.2
I have witnessed this phenomenon from both sides. My mother, who has Alzheimer’s and lives in an assisted-living facility, recently was given twice the dose of her medications one morning. She was “given” her night medications by being placed in her room, which she has no recollection of (the staff are supposed to watch her take her medications). The next morning, she saw the medications and took them, then took another dose when the nurse came by to give her morning medications. It was not realized until she’d already taken the medications and the staff noticed the medicine cup from the night before. My mom said she felt a little weak and dizzy for a few hours, but nothing significant, and she fully recovered. Interestingly, my mom mentioned it in passing, but no one called to let us know a medication error had occurred. Although she was not harmed, it made us, her family, lose a little trust in the facility because we found out about it indirectly, without any acknowledgement or apology.
On the other side of the equation, I have witnessed countless numbers of patient events in which providers feel worried and uncomfortable about the effects of disclosure with apology on themselves and their patients.
The bottom line is, disclosure with apology is needed and appreciated by patients, and it is absolutely the right thing to do. So download that cheesy Chicago song to your iPod and practice saying (or singing) “I’m sorry.” If the butler with chemicals can do it, so can we.
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
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
- Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-221.
It’s 1982, and in middle-school gyms across the country, among punch bowls and parental scrutiny, young girls and boys are slow-dancing with outstretched arms to a breathtaking song by the band Chicago. The song tells of the agonizing difficulty of apology, how despite the want and need to apologize, it is just too arduous.
Fast-forward 30 years, and it is hard to believe that cheesy No. 1 Billboard hit espoused the feelings that continue to haunt healthcare providers across the country: It’s hard for me to say I’m sorry.
Others Say It
If you look at the world around us, you see apology everywhere. Customer service representatives and customer-minded industries routinely let those words flow off their tongues with ease and grace.
While I was driving down the interstate last week, the number of traffic lanes shrunk from three to two to one. Anticipating widespread aggravation from weary travelers, the state transportation department deployed several large road signs every few miles; they read “WE APOLOGIZE FOR THE INCONVENIENCE … BEAR WITH US WHILE WE MAKE YOUR ROADS SMOOTHER AND SAFER.” Those simple messages made me feel like the congestion was not a senseless waste of time, that the state’s Department of Transportation was actually being strategic and thoughtful in their rationing of lanes during rush hour in the middle of the week.
Phone-based, customer-service departments figured out the simple apology a long time ago. While holding the line for a Lands’ End customer-service representative a few weeks ago, I heard, “We apologize for the delay. Your business is important to us. Please hold the line while we address callers ahead of you.” It validated for me that those phone representatives are not just sitting around eating lunch, completely ignoring my call, and that maybe there are others who procrastinated buying back-to-school backpacks until September—and just happened to call right before me.
I even got an apology at the dry cleaner. Amidst my last batch of clothes, my astute dry cleaner apparently found a very stubborn stain, which resisted all of their usual concoctions. It was on the back of a shirt and I probably would not have even noticed it was there. But nonetheless, they sent an apology tag, with a picture of a distraught butler who seemed to have struggled with that stain for hours.
Why Not Us?
So why is “sorry” so hard in healthcare? When things happen to patients, things that are inconvenient or downright dangerous, we have great difficulty in simply saying: “Hey, I am really sorry this happened to you,” or “I am so sorry you are still here. You must be really frustrated by our inefficiencies.”
I have the distinct pleasure of overseeing my hospital’s risk-management department for a few months. This means I get to see and hear what does and doesn’t happen to patients, which, at times, is misaligned with what should or shouldn’t happen to patients. When unanticipated events occur, the group launches into an investigation of what happened, why it happened, and the risk that it could happen again. After the initial dust settles and the facts are relayed from the care team to the risk-management team, the risk team always asks of those involved: “So what does the patient and their family know?” And we get a range of answers—some polished, some fumbled, some baffled.
The next question is: “Well, what should they know?” And that is always an easy question to answer. They should know the truth. Not just some of the truth, or half the truth, or a partial truth. Not what the care team thinks the patient “can handle.” They should just get the truth. To the best of the team’s ability, they should tell the patient:
- What (they think) happened;
- Why (they think) it happened;
- What it means for the patient; and
- What they are going to do to make it not happen again.
And then the patient (and family members) deserve an apology—sincere, compassionate, genuine. The apology should be the easy part, as most providers do not always know what happened, why it happened, or what they are going to do to prevent it from happening, but they usually truly do feel sorry that it happened at all.
“Sorry”=Positive Results
Patients are unanimous in their desire to be informed if a medical error has occurred; focus groups have found that patients believe such information would enhance their trust in their physicians and would reassure them that they were receiving complete information. And they want an apology.1
But interestingly, many physicians believe that full disclosure with apology is not warranted or appropriate, and that the apology could erode patient trust, might scare the patient, and might increase the risk of legal liability.1
There is little evidence that disclosure is harmful or detrimental, and there is some evidence that it is beneficial to the medical industry (i.e. reduces claims and litigation costs). A study published in 2010 from the University of Michigan Health System found a disclosure-with-compensation program was associated with a 36% reduction in new claims, a 65% reduction in lawsuits, and a 59% reduction in total liability cost.2
I have witnessed this phenomenon from both sides. My mother, who has Alzheimer’s and lives in an assisted-living facility, recently was given twice the dose of her medications one morning. She was “given” her night medications by being placed in her room, which she has no recollection of (the staff are supposed to watch her take her medications). The next morning, she saw the medications and took them, then took another dose when the nurse came by to give her morning medications. It was not realized until she’d already taken the medications and the staff noticed the medicine cup from the night before. My mom said she felt a little weak and dizzy for a few hours, but nothing significant, and she fully recovered. Interestingly, my mom mentioned it in passing, but no one called to let us know a medication error had occurred. Although she was not harmed, it made us, her family, lose a little trust in the facility because we found out about it indirectly, without any acknowledgement or apology.
On the other side of the equation, I have witnessed countless numbers of patient events in which providers feel worried and uncomfortable about the effects of disclosure with apology on themselves and their patients.
The bottom line is, disclosure with apology is needed and appreciated by patients, and it is absolutely the right thing to do. So download that cheesy Chicago song to your iPod and practice saying (or singing) “I’m sorry.” If the butler with chemicals can do it, so can we.
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
- Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levinson W. Patients’ and physicians’ attitudes regarding the disclosure of medical errors. JAMA. 2003;289(8):1001-1007.
- Kachalia A, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med. 2010;153(4):213-221.
Why It's Hard for Healthcare Providers to Say I'm Sorry
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John Nelson: Heavy Workloads
Now that HM is moving (or has moved?) from infancy to adolescence or even maturity, you might think that we would have reached some sort of consensus on what a reasonable workload—or patient volume—for a hospitalist is. My sense is that conventional wisdom says a reasonable average daily workload for a daytime rounding/admitting hospitalist is in the range of 12 to 17 billed encounters. And to average this volume, the doctor will have a number of days with more or fewer patients.
After thinking about average workload, the next question is: What is a reasonable upper limit for patient volume on a single day? Here, opinion seems to be a little fuzzier, but I think most would say a hospitalist should be expected to see more than 20 patients in a single day only on rare occasions and on, say, no more than 10 days annually. Keep in mind that a hospitalist who has 22 patients today still has a pretty good chance they will have 20 or more tomorrow, and the day after. High volumes are not a single-day phenomenon, either, because it usually takes a number of days for those patients to reach discharge—and the doctor to realize a decline in workload.
But these numbers are only conventional wisdom. There are little research data to guide our thinking about patient volumes, and thoughtful people sometimes arrive at very different conclusions. As I’ve written in this space previously, I think each individual hospitalist should have significant influence or autonomy to decide the appropriate or optimal patient volume for themselves or their group. This usually requires that doctors are connected to the economic and quality-of-care effects of their patient volume choices, something many hospitalists resist.
Divergence of Opinion
But given lots of autonomy, some hospitalists could make poor choices. I have had the experience of working with hospitalists in three practices around the country who are confident that, at least for themselves, very high patient volumes are safe and reasonable. These high-energy hospitalists see as many as 30 or 40 patients per day, day after day.
At one of these practices, I sat down with the doctors on duty that day at 1 p.m. and talked uninterrupted by pager or patient-care issues for nearly three hours. It was only at the end of the meeting that they explained each of them was seeing around 30 patients that day but had nearly finished rounds before our meeting started. I was stunned. (I probably wouldn’t stop for lunch, to say nothing of a three-hour meeting, to see just 20 patients in a day.)
So I asked just what they saw as an excessive daily patient volume. One of them seemed to deliberate carefully and said, “I probably need help when I have more than 35 patients to see in a day, but I’m OK with anything less than that.”
But the record goes to a really nice, spirited hospitalist who told me that, in addition to his usual workload, he occasionally covered weekends for an internal-medicine group. On a recent weekend, he had 88 patients to see each day, he said. Yes, you read that correctly: 88! (Fortunately, he did see that as a problem and was working to decrease the number.)
Potential Risks
I want to be clear that my own opinion is that the volumes above are unacceptable and dangerous. I think that, in most settings, routinely seeing more than 20 patients in a day probably degrades performance and increases the risk of burnout. While I think most knowledgeable people in our field share this opinion, none of us can point to compelling, generalizable research data to support our opinion.
The way I see it, excessively high workloads risk:
- Adverse patient outcomes due to increased potential for clinical errors and accompanying poor documentation;
- Failure of hospitalists to meet performance and citizenship expectations, such as length of stay (LOS), resource utilization, use of standardized order sets, attention to early discharge times, etc.;
- Lack of any excess capacity to handle transient increases in workload;
- Recruiting and/or retention challenges for hospitalists who might not want to work so hard;
- High risk of hospitalist stress and burnout, which over time could negatively impact a person’s well-being, as well as their attitudes and interactions with other members of the patient care team;
- Overdependence on a few very-hard-working doctors; if one doctor gets sick or has to stop working for a period of time, the hospital must find the equivalent of one-and-a-half doctors to replace him or her; and
- Increased malpractice risk.
Limited Data
There is some research to guide the thinking about workload. I recall one or two abstracts presented at past SHM annual meetings in which doctors in a single practice showed that LOS increased when their patient volume was high. And some sharp hospitalist researchers at Christiana Care Health System in Wilmington, Del., conducted a more robust retrospective cohort study of thousands of non-ICU adult admissions to their 1,100-bed hospital over a three-year period. Their data, which they intend to publish, showed LOS rises as hospitalist workload increases.
Others have assessed the connection between workload and well-being or burnout. Surprisingly, it has been hard to document in the peer-reviewed literature that increasing workloads are associated with increased burnout. Studies of hospitalists published in 2001 and 2011 failed to show a connection between self-reported workload and burnout.1,2 A 2009 systemic review of literature on all physician specialties concluded that “an imbalance between expected and experienced … workload is moderately associated with dissatisfaction, but there is less evidence of a significant association with objective workload.”3 (Emphasis mine.)
Rather than workload, both of the hospitalist studies found that such attributes as organizational solidarity, climate, and fairness; the feeling of being valued by the whole healthcare team; personal time; and compensation were more tightly correlated with whether hospitalists would thrive than workload.
Unfortunately, I’m not aware of any robust studies showing the relationship between hospitalist workload and quality of care (please email me if you know of any). I think the burden of proof is on those who support high workloads to show they don’t adversely affect patient incomes.
If you’d like to discuss workload further, I’ll be moderating a session titled “Who Says 15 is the Right Number?” during HM13, May 17-19, 2013, in Washington, D.C. (www.hospitalmedicine2013.org). I hope to see you there.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
2. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
3. Scheurer D, McKean S, Miller J, Wetterneck T. U.S. physician satisfaction: a systematic review. J Hosp Med. 2009;4(9):560-568.
Now that HM is moving (or has moved?) from infancy to adolescence or even maturity, you might think that we would have reached some sort of consensus on what a reasonable workload—or patient volume—for a hospitalist is. My sense is that conventional wisdom says a reasonable average daily workload for a daytime rounding/admitting hospitalist is in the range of 12 to 17 billed encounters. And to average this volume, the doctor will have a number of days with more or fewer patients.
After thinking about average workload, the next question is: What is a reasonable upper limit for patient volume on a single day? Here, opinion seems to be a little fuzzier, but I think most would say a hospitalist should be expected to see more than 20 patients in a single day only on rare occasions and on, say, no more than 10 days annually. Keep in mind that a hospitalist who has 22 patients today still has a pretty good chance they will have 20 or more tomorrow, and the day after. High volumes are not a single-day phenomenon, either, because it usually takes a number of days for those patients to reach discharge—and the doctor to realize a decline in workload.
But these numbers are only conventional wisdom. There are little research data to guide our thinking about patient volumes, and thoughtful people sometimes arrive at very different conclusions. As I’ve written in this space previously, I think each individual hospitalist should have significant influence or autonomy to decide the appropriate or optimal patient volume for themselves or their group. This usually requires that doctors are connected to the economic and quality-of-care effects of their patient volume choices, something many hospitalists resist.
Divergence of Opinion
But given lots of autonomy, some hospitalists could make poor choices. I have had the experience of working with hospitalists in three practices around the country who are confident that, at least for themselves, very high patient volumes are safe and reasonable. These high-energy hospitalists see as many as 30 or 40 patients per day, day after day.
At one of these practices, I sat down with the doctors on duty that day at 1 p.m. and talked uninterrupted by pager or patient-care issues for nearly three hours. It was only at the end of the meeting that they explained each of them was seeing around 30 patients that day but had nearly finished rounds before our meeting started. I was stunned. (I probably wouldn’t stop for lunch, to say nothing of a three-hour meeting, to see just 20 patients in a day.)
So I asked just what they saw as an excessive daily patient volume. One of them seemed to deliberate carefully and said, “I probably need help when I have more than 35 patients to see in a day, but I’m OK with anything less than that.”
But the record goes to a really nice, spirited hospitalist who told me that, in addition to his usual workload, he occasionally covered weekends for an internal-medicine group. On a recent weekend, he had 88 patients to see each day, he said. Yes, you read that correctly: 88! (Fortunately, he did see that as a problem and was working to decrease the number.)
Potential Risks
I want to be clear that my own opinion is that the volumes above are unacceptable and dangerous. I think that, in most settings, routinely seeing more than 20 patients in a day probably degrades performance and increases the risk of burnout. While I think most knowledgeable people in our field share this opinion, none of us can point to compelling, generalizable research data to support our opinion.
The way I see it, excessively high workloads risk:
- Adverse patient outcomes due to increased potential for clinical errors and accompanying poor documentation;
- Failure of hospitalists to meet performance and citizenship expectations, such as length of stay (LOS), resource utilization, use of standardized order sets, attention to early discharge times, etc.;
- Lack of any excess capacity to handle transient increases in workload;
- Recruiting and/or retention challenges for hospitalists who might not want to work so hard;
- High risk of hospitalist stress and burnout, which over time could negatively impact a person’s well-being, as well as their attitudes and interactions with other members of the patient care team;
- Overdependence on a few very-hard-working doctors; if one doctor gets sick or has to stop working for a period of time, the hospital must find the equivalent of one-and-a-half doctors to replace him or her; and
- Increased malpractice risk.
Limited Data
There is some research to guide the thinking about workload. I recall one or two abstracts presented at past SHM annual meetings in which doctors in a single practice showed that LOS increased when their patient volume was high. And some sharp hospitalist researchers at Christiana Care Health System in Wilmington, Del., conducted a more robust retrospective cohort study of thousands of non-ICU adult admissions to their 1,100-bed hospital over a three-year period. Their data, which they intend to publish, showed LOS rises as hospitalist workload increases.
Others have assessed the connection between workload and well-being or burnout. Surprisingly, it has been hard to document in the peer-reviewed literature that increasing workloads are associated with increased burnout. Studies of hospitalists published in 2001 and 2011 failed to show a connection between self-reported workload and burnout.1,2 A 2009 systemic review of literature on all physician specialties concluded that “an imbalance between expected and experienced … workload is moderately associated with dissatisfaction, but there is less evidence of a significant association with objective workload.”3 (Emphasis mine.)
Rather than workload, both of the hospitalist studies found that such attributes as organizational solidarity, climate, and fairness; the feeling of being valued by the whole healthcare team; personal time; and compensation were more tightly correlated with whether hospitalists would thrive than workload.
Unfortunately, I’m not aware of any robust studies showing the relationship between hospitalist workload and quality of care (please email me if you know of any). I think the burden of proof is on those who support high workloads to show they don’t adversely affect patient incomes.
If you’d like to discuss workload further, I’ll be moderating a session titled “Who Says 15 is the Right Number?” during HM13, May 17-19, 2013, in Washington, D.C. (www.hospitalmedicine2013.org). I hope to see you there.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
2. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
3. Scheurer D, McKean S, Miller J, Wetterneck T. U.S. physician satisfaction: a systematic review. J Hosp Med. 2009;4(9):560-568.
Now that HM is moving (or has moved?) from infancy to adolescence or even maturity, you might think that we would have reached some sort of consensus on what a reasonable workload—or patient volume—for a hospitalist is. My sense is that conventional wisdom says a reasonable average daily workload for a daytime rounding/admitting hospitalist is in the range of 12 to 17 billed encounters. And to average this volume, the doctor will have a number of days with more or fewer patients.
After thinking about average workload, the next question is: What is a reasonable upper limit for patient volume on a single day? Here, opinion seems to be a little fuzzier, but I think most would say a hospitalist should be expected to see more than 20 patients in a single day only on rare occasions and on, say, no more than 10 days annually. Keep in mind that a hospitalist who has 22 patients today still has a pretty good chance they will have 20 or more tomorrow, and the day after. High volumes are not a single-day phenomenon, either, because it usually takes a number of days for those patients to reach discharge—and the doctor to realize a decline in workload.
But these numbers are only conventional wisdom. There are little research data to guide our thinking about patient volumes, and thoughtful people sometimes arrive at very different conclusions. As I’ve written in this space previously, I think each individual hospitalist should have significant influence or autonomy to decide the appropriate or optimal patient volume for themselves or their group. This usually requires that doctors are connected to the economic and quality-of-care effects of their patient volume choices, something many hospitalists resist.
Divergence of Opinion
But given lots of autonomy, some hospitalists could make poor choices. I have had the experience of working with hospitalists in three practices around the country who are confident that, at least for themselves, very high patient volumes are safe and reasonable. These high-energy hospitalists see as many as 30 or 40 patients per day, day after day.
At one of these practices, I sat down with the doctors on duty that day at 1 p.m. and talked uninterrupted by pager or patient-care issues for nearly three hours. It was only at the end of the meeting that they explained each of them was seeing around 30 patients that day but had nearly finished rounds before our meeting started. I was stunned. (I probably wouldn’t stop for lunch, to say nothing of a three-hour meeting, to see just 20 patients in a day.)
So I asked just what they saw as an excessive daily patient volume. One of them seemed to deliberate carefully and said, “I probably need help when I have more than 35 patients to see in a day, but I’m OK with anything less than that.”
But the record goes to a really nice, spirited hospitalist who told me that, in addition to his usual workload, he occasionally covered weekends for an internal-medicine group. On a recent weekend, he had 88 patients to see each day, he said. Yes, you read that correctly: 88! (Fortunately, he did see that as a problem and was working to decrease the number.)
Potential Risks
I want to be clear that my own opinion is that the volumes above are unacceptable and dangerous. I think that, in most settings, routinely seeing more than 20 patients in a day probably degrades performance and increases the risk of burnout. While I think most knowledgeable people in our field share this opinion, none of us can point to compelling, generalizable research data to support our opinion.
The way I see it, excessively high workloads risk:
- Adverse patient outcomes due to increased potential for clinical errors and accompanying poor documentation;
- Failure of hospitalists to meet performance and citizenship expectations, such as length of stay (LOS), resource utilization, use of standardized order sets, attention to early discharge times, etc.;
- Lack of any excess capacity to handle transient increases in workload;
- Recruiting and/or retention challenges for hospitalists who might not want to work so hard;
- High risk of hospitalist stress and burnout, which over time could negatively impact a person’s well-being, as well as their attitudes and interactions with other members of the patient care team;
- Overdependence on a few very-hard-working doctors; if one doctor gets sick or has to stop working for a period of time, the hospital must find the equivalent of one-and-a-half doctors to replace him or her; and
- Increased malpractice risk.
Limited Data
There is some research to guide the thinking about workload. I recall one or two abstracts presented at past SHM annual meetings in which doctors in a single practice showed that LOS increased when their patient volume was high. And some sharp hospitalist researchers at Christiana Care Health System in Wilmington, Del., conducted a more robust retrospective cohort study of thousands of non-ICU adult admissions to their 1,100-bed hospital over a three-year period. Their data, which they intend to publish, showed LOS rises as hospitalist workload increases.
Others have assessed the connection between workload and well-being or burnout. Surprisingly, it has been hard to document in the peer-reviewed literature that increasing workloads are associated with increased burnout. Studies of hospitalists published in 2001 and 2011 failed to show a connection between self-reported workload and burnout.1,2 A 2009 systemic review of literature on all physician specialties concluded that “an imbalance between expected and experienced … workload is moderately associated with dissatisfaction, but there is less evidence of a significant association with objective workload.”3 (Emphasis mine.)
Rather than workload, both of the hospitalist studies found that such attributes as organizational solidarity, climate, and fairness; the feeling of being valued by the whole healthcare team; personal time; and compensation were more tightly correlated with whether hospitalists would thrive than workload.
Unfortunately, I’m not aware of any robust studies showing the relationship between hospitalist workload and quality of care (please email me if you know of any). I think the burden of proof is on those who support high workloads to show they don’t adversely affect patient incomes.
If you’d like to discuss workload further, I’ll be moderating a session titled “Who Says 15 is the Right Number?” during HM13, May 17-19, 2013, in Washington, D.C. (www.hospitalmedicine2013.org). I hope to see you there.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
References
2. Hinami K, Whelan CT, Wolosin RJ, Miller JA, Wetterneck TB. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28-36.
3. Scheurer D, McKean S, Miller J, Wetterneck T. U.S. physician satisfaction: a systematic review. J Hosp Med. 2009;4(9):560-568.
Five Ways to Enhance Your Hospital Medicine Group's Efficiency
Is there a role in HM for industrial engineering or industrial efficiency models? Jonathan Turner, PhD, thinks so. He is an industrial-engineer-turned-hospital-engineer whose job is to help make hospital care safer, faster, less costly, and more satisfying. He has few peers in this role, although any hospitalist group in the vicinity of a college department of engineering could seek out similar expertise there. Real-world problems make the best research projects, he says.
“I wrote my thesis on how a vascular surgery department could use computer simulation models to help balance multiple objectives in scheduling residents,” says Turner, who earned his doctorate at Northwestern University in Evanston, Ill.
His thesis examined, among other things, the need for pre-operative continuity of care and resident exposure to a variety of surgical experiences. He also found himself hanging around Northwestern’s Feinberg School of Medicine in Chicago at a time when Mark Williams, MD, MHM, chief of the division of hospital medicine, was looking for ways to build collaboration between Northwestern’s medical school, hospital, and department of engineering.
“Our objectives were the same,” says Turner, who was hired by Dr. Williams in May 2011.
Turner says many of the challenges of managing an HM group—making patient rounds better, improving length of stay (LOS) and throughput, or deciding how to incorporate technology into practice—can be scrutinized with an efficiency lens. At Northwestern, he optimized the HM group schedule and made it more appealing to the physicians. He examined the incremental costs incurred by patient handoffs and the effectiveness of consultations with medical specialists. He tackled technology, teamwork, and wait-time issues. He even helped surgeons standardize their instrument trays.
But every hospitalist group—from the three-FTE teams covering rural hospitals to high-volume groups with dozens of moving parts—has developed inefficient habits. Experts say most groups have never even thought of the problems, let alone the solutions—for example, regularly inputting data into spreadsheets that no one ever looks at.
Efficiency is an essential target for quality initiatives in the hospital, although the word means different things to different people. It typically involves trade-offs that need to be balanced if the system as a whole is to benefit. What makes an individual practice more efficient could make a group’s less so—and vice versa. What helps one department’s bottom line can harm another’s. Enhancing hospitalists’ work-life balance through schedule modification could make life harder for nurses.
-Jonathan Turner, PhD
One current example that cuts across HM groups of all shapes and sizes is the discharge process. Hospitalist groups speeding up discharges might lead to inadequately prepared patients leaving the hospital, which could mean post-discharge crises, which could lead to unnecessary readmissions, which certainly will mean government penalties. Pure efficiency, in terms of maximizing caseloads, also can conflict with patient safety or patient satisfaction. In many healthcare settings, approaching 100% of capacity limits the ability to respond to surges in demand, Turner says. That usually leads to backups, long waits, dissatisfaction, and even diversions from the ED, he explains.
HM groups have pursued a variety of tools and strategies to enhance efficiency. “One of the things we try to show is that you use these methods every day—but you can be more systematic in how you apply them,” Turner says. The character and personality of practicing hospitalists, who tend to be more quality-minded and focused on systems, might make them more open to becoming efficiency experts and willing to try new approaches.
Still, when engineers talk about efficiency, hospital professionals might feel that it cramps their practice style. “I need to be willing to listen to their concerns,” says Turner, who in September began a new position as director of systems engineering at University Hospital in Augusta, Ga.
“I don’t want to turn patients into widgets. I’d rather be thought of as an axe sharpener—helping people do their work more easily,” he says. “You can’t satisfy everybody, but you at least need to listen to everybody when you try to make their work lives more efficient.”
Following are some examples of how hospitalist groups have improved the efficiency of important aspects of their practice.
1. Specialized Care Plans
It is well known that some of the most challenging hospital patients consume a disproportionate share of costs and resources, says Rick Hilger, MD, SFHM, a hospitalist with HealthPartners at Regions Hospital in St. Paul, Minn. It can be controversial to suggest that these difficult patients should receive special handling, but Dr. Hilger, who presented a poster on the topic at HM12, says the current system isn’t safe for patients or sustainable in the long run.3
At Regions, about 70 high-utilizing patients have been given an ongoing, specialized care plan that is easily accessible in their electronic health record (EHR) whenever they present at a HealthPartners clinic, ED, or hospital. Patients include those with a history of drug-seeking behaviors, antisocial behavior disorders, aggression or noncompliance in the hospital, and a variety of traumatic brain injuries or memory deficits that might cause them to give a different story to every medical provider. They also include patients who simply have very complex medical conditions.
Referrals for a specialized care plan can come from any hospital staff member. A care-planning committee representing HM, case management, social work, emergency medicine, and administrative staffs meets monthly to review cases and decide if each patient would benefit from a specialized care plan. It offers quick access in the EHR to a cover page with common clinical scenarios, recent tests and procedures, and a template for optimal care that can save a lot of time and prevent duplicative or uncoordinated treatments, Dr. Hilger says. It also ensures that clinicians give a consistent message to the patient.
“Our mantra is that we want care plans that are easy to create, easy to find, easy to use, and likely to lead to better coordination of care,” he says. “We also say that if everybody has a specialized care plan, then nobody does. We want the provider—whether physician, case manager, or nurse—to walk away saying that the care plan saved them time and led to safer care.”
In its first two months, Regions saw a 68% reduction in total ED visits and hospital admissions for the 43 patients with specialized care plans.
2. Scheduling Models
A number of scheduling models are used for deploying hospitalists in larger groups, including seven on/seven off, five on/five off, weekdays versus weekends, zoned staffing, and admitters versus rounders. Research has shown an incremental cost for every handoff, and creating a work schedule that results in fewer handoffs might make patients more satisfied. But that goal needs to be balanced against provider schedules with an eye toward keeping caseloads localized in the hospital.
Shalini Chandra, MD, MS, FHM, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore, was co-presenter of a HM12 workshop on how to use performance-improvement principles to improve HM group schedules. She says the schedule needs to account for such variables as when hospitalists are assigned new patients, are required to interact with the ED, and are devoted to patient contact versus paperwork, which normally is greater at admission and discharge.
“You need to find the sweet spot between the hospital’s needs, the patient’s needs, and the doctor’s needs,” she says. “Our physicians felt they were being penalized for discharging patients in a timely manner [by receiving more new cases]. We had to go back and say, ‘OK, if somebody is doing a four-day stretch, how can we distribute patients more equitably?’”
Dr. Chandra’s quality team mapped out the entire admissions process and identified key metrics, then devised a model called CICLE (Creating Incentives and Continuity Leading to Efficiency in Hospital Medicine) for its four-day shift. The first day, which can be a long one, is front-loaded with new admissions. But on Day Two and Day Three, the hospitalist is largely protected from new admissions, thereby preserving the incentive to discharge patients when they are ready.
CICLE also results in fewer handoffs, with a third of patients seen by only one hospitalist, Dr. Chandra explains. That in turn translates into decreased LOS and cost.
The four-day schedule at Hopkins is complicated by the need to respond to other demands on the system, and Dr. Chandra says only 60 percent of the hospitalist caseload is scheduled this way.
—Rick Hilger, MD, SFHM
3. Individual Flexibility
The best schedule in the world can be turned upside down by vacations, sickness, or an open position that goes unfilled for months. Accounting for the nuances can be a full-time job.
At Northwestern, the hospitalist group is converting to scheduling software called Lightning Bolt (www.lightning-bolt.com) that provides flexibility to respond to varying needs among the 70-plus members of the group, including such needs as attending their children’s soccer games, says Charlotta Weaver, MD, assistant professor of medicine.
“An enormous amount of time, both administrative and medical, gets devoted to scheduling,” she says.
Each hospital and HM group is different, and each physician has varying desires from the schedule. “Things are constantly changing,” Dr. Weaver says. “People come and go or need to change jobs, there are changes in FTE allocations, physicians may get research grants, and there can be changes in hospital structure or service lines.”
The schedule also needs to facilitate “day trading” between members of the group, and Northwestern is experimenting with some new approaches, including pairing up two physicians on one service line and letting them work out their own schedules.
The group also needs a way to respond to admission surges beyond the capacity of scheduled physicians, which can be hard to predict, and the days when physicians call in sick.
“We have tried to develop a robust system of ‘jeopardy’ for first- and second-line backup,” Dr. Weaver says. Everyone in the hospitalist group has jeopardy one or two weeks per year, where they are in line to be called in if needed.
Franziska Jovin, MD, FHM, a hospitalist at the University of Pittsburgh Medical Center, says her group struggles with predicting patient peaks and valleys.
“One of our hospitalist teams is responsible for the transitional-care unit, and not every patient on that unit has to be seen every day,” Dr. Jovin says. “This person is already scheduled to work, but the responsibilities are not time-dependent. So we can pull in that doctor as needed to cover higher demand on the acute side.”
As most hospitalists know the winter months are busier, “and we staff accordingly,” she says, in response to higher incidence of flu, pneumonia, and the like.
4. Structured Rounds
Another challenge to scheduling is the rounding model used for daily care planning in the hospital. Various models have tried to address competing concerns of geography, schedule efficiency, and the needs of hospitalists, nurses, and other staff. At Emory Healthcare in Atlanta, an approach called Structured Interdisciplinary Bedside Rounds (SIBR) was described during an HM12 workshop and in a prize-winning poster presented by Christina Payne, MD (see “The Innovation Express,” May 2012, p. 27).
Dr. Payne described how SIBR works with two teaching hospitalist services on a 24-bed “accountable-care unit” at Emory University Hospital. Each team has a resident, three interns, a social worker, and the patient’s nurse, with the attending standing by.
“We round on each patient every day—beginning and ending on time,” 12 patients per hour, with five brisk minutes to report on each patient, she says. Rounding starts when the patient’s primary intern and nurse are both present in the patient’s room, and only ends when a plan of care for the day has been articulated—using a standardized script with safety and discharge planning checklists. The second intern enters the plan, in real time, into the EHR.
In addition to the time efficiency, this approach has posted positive outcomes, namely a 53% reduction in in-hospital mortality on the unit and an 11% reduction in LOS. With new residents and interns rotating through the unit every month, “We acknowledge to them that this will be difficult and they will be uncomfortable at first,” Dr. Payne says, “but by Week Two, we’re a well-oiled machine.”
Similar approaches have been implemented at other Emory hospitals.
5. NPP Mobilization
Many hospitalist groups have integrated nonphysician providers (NPPs, or nurse practitioners and physician assistants) into the group’s practice or are considering such a move. Tracy Cardin, ACNP-BC, a nurse practitioner in hospital practice at the University of Chicago Medical Center, says it’s important to ask why a group is considering a role for NPPs.
“Is it to promote efficiency? Is it because you can’t attract enough physicians?” she says. “Clarify your hopes for the position and how you will define success.” She also says HM group leaders need to factor in the time needed to hire, orient, and train an NPP, with mentoring that includes structured teaching and feedback.
There are a lot of models for deploying NPPs, says Cardin, a Team Hospitalist member.
“We utilize shared billing and teams of a hospitalist and nurse practitioner. This allows the physician to see a larger number of patients and brings more than one set of eyes and ears to the complex patient,” she says. “We’ve developed a process over the past six years where the hospitalist and NPP together go over the patient list every day. Both will see the patient, but the NPP commonly writes the notes and orders.”
Cardin emphasizes NPPs cost less than physicians and “can do many of the same things,” but “they are not free.” The most resourceful HM group’s use NPPs to extend the physician’s practice. “They can carry a pager and respond to small crises that come up, or see the patient on discharge day,” she says. “In other settings, the NPP does admissions, serves on quality projects, takes on a patient cohort based on diagnosis, or calls the primary-care physician at discharge.”
Efficiency can be a tough nut to crack in the hospital. Turner, the engineer, says HM groups need to “remember that the hospital is a very complex environment, with cascades of reactions and downstream effects.”
Hospitalists need the support of other professionals, and quality-improvement (QI) initiatives need sufficient time and resources to succeed.
One way to start advancing the efficiency agenda is to look for bright spots among the hospitalist group’s members. “Talk to them,” Turner says. “Find out how they do their jobs. Learn from them.”
Larry Beresford is a freelance author in Oakland, Calif.
References
- Yu D, Sanches S. Lean inpatient unit base care model [abstract]. J Hosp Med. 2012;7(Suppl 2):S107.
- Payne C, Odetoyinbo D, Castle B, et al. A dual hospital care and training model: structured interdisciplinary team rounds in an accountable care unit [abstract]. J Hosp Med. 2012;7(Suppl 2):S125.
- Hilger R, Quirk R, Dahms R. Use of restriction care plans to decrease medically unnecessary admissions and emergency department visits [abstract]. J Hosp Med. 2012;7(Suppl 2):S2.
- Premier. Year Three: QUEST Collaborative Findings. Premier website. Available at: http://www.premierinc.com/quality-safety/tools-services/quest/year3/quest-year-3-collaborative-findings.pdf. Accessed Sept. 26, 2012.
Is there a role in HM for industrial engineering or industrial efficiency models? Jonathan Turner, PhD, thinks so. He is an industrial-engineer-turned-hospital-engineer whose job is to help make hospital care safer, faster, less costly, and more satisfying. He has few peers in this role, although any hospitalist group in the vicinity of a college department of engineering could seek out similar expertise there. Real-world problems make the best research projects, he says.
“I wrote my thesis on how a vascular surgery department could use computer simulation models to help balance multiple objectives in scheduling residents,” says Turner, who earned his doctorate at Northwestern University in Evanston, Ill.
His thesis examined, among other things, the need for pre-operative continuity of care and resident exposure to a variety of surgical experiences. He also found himself hanging around Northwestern’s Feinberg School of Medicine in Chicago at a time when Mark Williams, MD, MHM, chief of the division of hospital medicine, was looking for ways to build collaboration between Northwestern’s medical school, hospital, and department of engineering.
“Our objectives were the same,” says Turner, who was hired by Dr. Williams in May 2011.
Turner says many of the challenges of managing an HM group—making patient rounds better, improving length of stay (LOS) and throughput, or deciding how to incorporate technology into practice—can be scrutinized with an efficiency lens. At Northwestern, he optimized the HM group schedule and made it more appealing to the physicians. He examined the incremental costs incurred by patient handoffs and the effectiveness of consultations with medical specialists. He tackled technology, teamwork, and wait-time issues. He even helped surgeons standardize their instrument trays.
But every hospitalist group—from the three-FTE teams covering rural hospitals to high-volume groups with dozens of moving parts—has developed inefficient habits. Experts say most groups have never even thought of the problems, let alone the solutions—for example, regularly inputting data into spreadsheets that no one ever looks at.
Efficiency is an essential target for quality initiatives in the hospital, although the word means different things to different people. It typically involves trade-offs that need to be balanced if the system as a whole is to benefit. What makes an individual practice more efficient could make a group’s less so—and vice versa. What helps one department’s bottom line can harm another’s. Enhancing hospitalists’ work-life balance through schedule modification could make life harder for nurses.
-Jonathan Turner, PhD
One current example that cuts across HM groups of all shapes and sizes is the discharge process. Hospitalist groups speeding up discharges might lead to inadequately prepared patients leaving the hospital, which could mean post-discharge crises, which could lead to unnecessary readmissions, which certainly will mean government penalties. Pure efficiency, in terms of maximizing caseloads, also can conflict with patient safety or patient satisfaction. In many healthcare settings, approaching 100% of capacity limits the ability to respond to surges in demand, Turner says. That usually leads to backups, long waits, dissatisfaction, and even diversions from the ED, he explains.
HM groups have pursued a variety of tools and strategies to enhance efficiency. “One of the things we try to show is that you use these methods every day—but you can be more systematic in how you apply them,” Turner says. The character and personality of practicing hospitalists, who tend to be more quality-minded and focused on systems, might make them more open to becoming efficiency experts and willing to try new approaches.
Still, when engineers talk about efficiency, hospital professionals might feel that it cramps their practice style. “I need to be willing to listen to their concerns,” says Turner, who in September began a new position as director of systems engineering at University Hospital in Augusta, Ga.
“I don’t want to turn patients into widgets. I’d rather be thought of as an axe sharpener—helping people do their work more easily,” he says. “You can’t satisfy everybody, but you at least need to listen to everybody when you try to make their work lives more efficient.”
Following are some examples of how hospitalist groups have improved the efficiency of important aspects of their practice.
1. Specialized Care Plans
It is well known that some of the most challenging hospital patients consume a disproportionate share of costs and resources, says Rick Hilger, MD, SFHM, a hospitalist with HealthPartners at Regions Hospital in St. Paul, Minn. It can be controversial to suggest that these difficult patients should receive special handling, but Dr. Hilger, who presented a poster on the topic at HM12, says the current system isn’t safe for patients or sustainable in the long run.3
At Regions, about 70 high-utilizing patients have been given an ongoing, specialized care plan that is easily accessible in their electronic health record (EHR) whenever they present at a HealthPartners clinic, ED, or hospital. Patients include those with a history of drug-seeking behaviors, antisocial behavior disorders, aggression or noncompliance in the hospital, and a variety of traumatic brain injuries or memory deficits that might cause them to give a different story to every medical provider. They also include patients who simply have very complex medical conditions.
Referrals for a specialized care plan can come from any hospital staff member. A care-planning committee representing HM, case management, social work, emergency medicine, and administrative staffs meets monthly to review cases and decide if each patient would benefit from a specialized care plan. It offers quick access in the EHR to a cover page with common clinical scenarios, recent tests and procedures, and a template for optimal care that can save a lot of time and prevent duplicative or uncoordinated treatments, Dr. Hilger says. It also ensures that clinicians give a consistent message to the patient.
“Our mantra is that we want care plans that are easy to create, easy to find, easy to use, and likely to lead to better coordination of care,” he says. “We also say that if everybody has a specialized care plan, then nobody does. We want the provider—whether physician, case manager, or nurse—to walk away saying that the care plan saved them time and led to safer care.”
In its first two months, Regions saw a 68% reduction in total ED visits and hospital admissions for the 43 patients with specialized care plans.
2. Scheduling Models
A number of scheduling models are used for deploying hospitalists in larger groups, including seven on/seven off, five on/five off, weekdays versus weekends, zoned staffing, and admitters versus rounders. Research has shown an incremental cost for every handoff, and creating a work schedule that results in fewer handoffs might make patients more satisfied. But that goal needs to be balanced against provider schedules with an eye toward keeping caseloads localized in the hospital.
Shalini Chandra, MD, MS, FHM, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore, was co-presenter of a HM12 workshop on how to use performance-improvement principles to improve HM group schedules. She says the schedule needs to account for such variables as when hospitalists are assigned new patients, are required to interact with the ED, and are devoted to patient contact versus paperwork, which normally is greater at admission and discharge.
“You need to find the sweet spot between the hospital’s needs, the patient’s needs, and the doctor’s needs,” she says. “Our physicians felt they were being penalized for discharging patients in a timely manner [by receiving more new cases]. We had to go back and say, ‘OK, if somebody is doing a four-day stretch, how can we distribute patients more equitably?’”
Dr. Chandra’s quality team mapped out the entire admissions process and identified key metrics, then devised a model called CICLE (Creating Incentives and Continuity Leading to Efficiency in Hospital Medicine) for its four-day shift. The first day, which can be a long one, is front-loaded with new admissions. But on Day Two and Day Three, the hospitalist is largely protected from new admissions, thereby preserving the incentive to discharge patients when they are ready.
CICLE also results in fewer handoffs, with a third of patients seen by only one hospitalist, Dr. Chandra explains. That in turn translates into decreased LOS and cost.
The four-day schedule at Hopkins is complicated by the need to respond to other demands on the system, and Dr. Chandra says only 60 percent of the hospitalist caseload is scheduled this way.
—Rick Hilger, MD, SFHM
3. Individual Flexibility
The best schedule in the world can be turned upside down by vacations, sickness, or an open position that goes unfilled for months. Accounting for the nuances can be a full-time job.
At Northwestern, the hospitalist group is converting to scheduling software called Lightning Bolt (www.lightning-bolt.com) that provides flexibility to respond to varying needs among the 70-plus members of the group, including such needs as attending their children’s soccer games, says Charlotta Weaver, MD, assistant professor of medicine.
“An enormous amount of time, both administrative and medical, gets devoted to scheduling,” she says.
Each hospital and HM group is different, and each physician has varying desires from the schedule. “Things are constantly changing,” Dr. Weaver says. “People come and go or need to change jobs, there are changes in FTE allocations, physicians may get research grants, and there can be changes in hospital structure or service lines.”
The schedule also needs to facilitate “day trading” between members of the group, and Northwestern is experimenting with some new approaches, including pairing up two physicians on one service line and letting them work out their own schedules.
The group also needs a way to respond to admission surges beyond the capacity of scheduled physicians, which can be hard to predict, and the days when physicians call in sick.
“We have tried to develop a robust system of ‘jeopardy’ for first- and second-line backup,” Dr. Weaver says. Everyone in the hospitalist group has jeopardy one or two weeks per year, where they are in line to be called in if needed.
Franziska Jovin, MD, FHM, a hospitalist at the University of Pittsburgh Medical Center, says her group struggles with predicting patient peaks and valleys.
“One of our hospitalist teams is responsible for the transitional-care unit, and not every patient on that unit has to be seen every day,” Dr. Jovin says. “This person is already scheduled to work, but the responsibilities are not time-dependent. So we can pull in that doctor as needed to cover higher demand on the acute side.”
As most hospitalists know the winter months are busier, “and we staff accordingly,” she says, in response to higher incidence of flu, pneumonia, and the like.
4. Structured Rounds
Another challenge to scheduling is the rounding model used for daily care planning in the hospital. Various models have tried to address competing concerns of geography, schedule efficiency, and the needs of hospitalists, nurses, and other staff. At Emory Healthcare in Atlanta, an approach called Structured Interdisciplinary Bedside Rounds (SIBR) was described during an HM12 workshop and in a prize-winning poster presented by Christina Payne, MD (see “The Innovation Express,” May 2012, p. 27).
Dr. Payne described how SIBR works with two teaching hospitalist services on a 24-bed “accountable-care unit” at Emory University Hospital. Each team has a resident, three interns, a social worker, and the patient’s nurse, with the attending standing by.
“We round on each patient every day—beginning and ending on time,” 12 patients per hour, with five brisk minutes to report on each patient, she says. Rounding starts when the patient’s primary intern and nurse are both present in the patient’s room, and only ends when a plan of care for the day has been articulated—using a standardized script with safety and discharge planning checklists. The second intern enters the plan, in real time, into the EHR.
In addition to the time efficiency, this approach has posted positive outcomes, namely a 53% reduction in in-hospital mortality on the unit and an 11% reduction in LOS. With new residents and interns rotating through the unit every month, “We acknowledge to them that this will be difficult and they will be uncomfortable at first,” Dr. Payne says, “but by Week Two, we’re a well-oiled machine.”
Similar approaches have been implemented at other Emory hospitals.
5. NPP Mobilization
Many hospitalist groups have integrated nonphysician providers (NPPs, or nurse practitioners and physician assistants) into the group’s practice or are considering such a move. Tracy Cardin, ACNP-BC, a nurse practitioner in hospital practice at the University of Chicago Medical Center, says it’s important to ask why a group is considering a role for NPPs.
“Is it to promote efficiency? Is it because you can’t attract enough physicians?” she says. “Clarify your hopes for the position and how you will define success.” She also says HM group leaders need to factor in the time needed to hire, orient, and train an NPP, with mentoring that includes structured teaching and feedback.
There are a lot of models for deploying NPPs, says Cardin, a Team Hospitalist member.
“We utilize shared billing and teams of a hospitalist and nurse practitioner. This allows the physician to see a larger number of patients and brings more than one set of eyes and ears to the complex patient,” she says. “We’ve developed a process over the past six years where the hospitalist and NPP together go over the patient list every day. Both will see the patient, but the NPP commonly writes the notes and orders.”
Cardin emphasizes NPPs cost less than physicians and “can do many of the same things,” but “they are not free.” The most resourceful HM group’s use NPPs to extend the physician’s practice. “They can carry a pager and respond to small crises that come up, or see the patient on discharge day,” she says. “In other settings, the NPP does admissions, serves on quality projects, takes on a patient cohort based on diagnosis, or calls the primary-care physician at discharge.”
Efficiency can be a tough nut to crack in the hospital. Turner, the engineer, says HM groups need to “remember that the hospital is a very complex environment, with cascades of reactions and downstream effects.”
Hospitalists need the support of other professionals, and quality-improvement (QI) initiatives need sufficient time and resources to succeed.
One way to start advancing the efficiency agenda is to look for bright spots among the hospitalist group’s members. “Talk to them,” Turner says. “Find out how they do their jobs. Learn from them.”
Larry Beresford is a freelance author in Oakland, Calif.
References
- Yu D, Sanches S. Lean inpatient unit base care model [abstract]. J Hosp Med. 2012;7(Suppl 2):S107.
- Payne C, Odetoyinbo D, Castle B, et al. A dual hospital care and training model: structured interdisciplinary team rounds in an accountable care unit [abstract]. J Hosp Med. 2012;7(Suppl 2):S125.
- Hilger R, Quirk R, Dahms R. Use of restriction care plans to decrease medically unnecessary admissions and emergency department visits [abstract]. J Hosp Med. 2012;7(Suppl 2):S2.
- Premier. Year Three: QUEST Collaborative Findings. Premier website. Available at: http://www.premierinc.com/quality-safety/tools-services/quest/year3/quest-year-3-collaborative-findings.pdf. Accessed Sept. 26, 2012.
Is there a role in HM for industrial engineering or industrial efficiency models? Jonathan Turner, PhD, thinks so. He is an industrial-engineer-turned-hospital-engineer whose job is to help make hospital care safer, faster, less costly, and more satisfying. He has few peers in this role, although any hospitalist group in the vicinity of a college department of engineering could seek out similar expertise there. Real-world problems make the best research projects, he says.
“I wrote my thesis on how a vascular surgery department could use computer simulation models to help balance multiple objectives in scheduling residents,” says Turner, who earned his doctorate at Northwestern University in Evanston, Ill.
His thesis examined, among other things, the need for pre-operative continuity of care and resident exposure to a variety of surgical experiences. He also found himself hanging around Northwestern’s Feinberg School of Medicine in Chicago at a time when Mark Williams, MD, MHM, chief of the division of hospital medicine, was looking for ways to build collaboration between Northwestern’s medical school, hospital, and department of engineering.
“Our objectives were the same,” says Turner, who was hired by Dr. Williams in May 2011.
Turner says many of the challenges of managing an HM group—making patient rounds better, improving length of stay (LOS) and throughput, or deciding how to incorporate technology into practice—can be scrutinized with an efficiency lens. At Northwestern, he optimized the HM group schedule and made it more appealing to the physicians. He examined the incremental costs incurred by patient handoffs and the effectiveness of consultations with medical specialists. He tackled technology, teamwork, and wait-time issues. He even helped surgeons standardize their instrument trays.
But every hospitalist group—from the three-FTE teams covering rural hospitals to high-volume groups with dozens of moving parts—has developed inefficient habits. Experts say most groups have never even thought of the problems, let alone the solutions—for example, regularly inputting data into spreadsheets that no one ever looks at.
Efficiency is an essential target for quality initiatives in the hospital, although the word means different things to different people. It typically involves trade-offs that need to be balanced if the system as a whole is to benefit. What makes an individual practice more efficient could make a group’s less so—and vice versa. What helps one department’s bottom line can harm another’s. Enhancing hospitalists’ work-life balance through schedule modification could make life harder for nurses.
-Jonathan Turner, PhD
One current example that cuts across HM groups of all shapes and sizes is the discharge process. Hospitalist groups speeding up discharges might lead to inadequately prepared patients leaving the hospital, which could mean post-discharge crises, which could lead to unnecessary readmissions, which certainly will mean government penalties. Pure efficiency, in terms of maximizing caseloads, also can conflict with patient safety or patient satisfaction. In many healthcare settings, approaching 100% of capacity limits the ability to respond to surges in demand, Turner says. That usually leads to backups, long waits, dissatisfaction, and even diversions from the ED, he explains.
HM groups have pursued a variety of tools and strategies to enhance efficiency. “One of the things we try to show is that you use these methods every day—but you can be more systematic in how you apply them,” Turner says. The character and personality of practicing hospitalists, who tend to be more quality-minded and focused on systems, might make them more open to becoming efficiency experts and willing to try new approaches.
Still, when engineers talk about efficiency, hospital professionals might feel that it cramps their practice style. “I need to be willing to listen to their concerns,” says Turner, who in September began a new position as director of systems engineering at University Hospital in Augusta, Ga.
“I don’t want to turn patients into widgets. I’d rather be thought of as an axe sharpener—helping people do their work more easily,” he says. “You can’t satisfy everybody, but you at least need to listen to everybody when you try to make their work lives more efficient.”
Following are some examples of how hospitalist groups have improved the efficiency of important aspects of their practice.
1. Specialized Care Plans
It is well known that some of the most challenging hospital patients consume a disproportionate share of costs and resources, says Rick Hilger, MD, SFHM, a hospitalist with HealthPartners at Regions Hospital in St. Paul, Minn. It can be controversial to suggest that these difficult patients should receive special handling, but Dr. Hilger, who presented a poster on the topic at HM12, says the current system isn’t safe for patients or sustainable in the long run.3
At Regions, about 70 high-utilizing patients have been given an ongoing, specialized care plan that is easily accessible in their electronic health record (EHR) whenever they present at a HealthPartners clinic, ED, or hospital. Patients include those with a history of drug-seeking behaviors, antisocial behavior disorders, aggression or noncompliance in the hospital, and a variety of traumatic brain injuries or memory deficits that might cause them to give a different story to every medical provider. They also include patients who simply have very complex medical conditions.
Referrals for a specialized care plan can come from any hospital staff member. A care-planning committee representing HM, case management, social work, emergency medicine, and administrative staffs meets monthly to review cases and decide if each patient would benefit from a specialized care plan. It offers quick access in the EHR to a cover page with common clinical scenarios, recent tests and procedures, and a template for optimal care that can save a lot of time and prevent duplicative or uncoordinated treatments, Dr. Hilger says. It also ensures that clinicians give a consistent message to the patient.
“Our mantra is that we want care plans that are easy to create, easy to find, easy to use, and likely to lead to better coordination of care,” he says. “We also say that if everybody has a specialized care plan, then nobody does. We want the provider—whether physician, case manager, or nurse—to walk away saying that the care plan saved them time and led to safer care.”
In its first two months, Regions saw a 68% reduction in total ED visits and hospital admissions for the 43 patients with specialized care plans.
2. Scheduling Models
A number of scheduling models are used for deploying hospitalists in larger groups, including seven on/seven off, five on/five off, weekdays versus weekends, zoned staffing, and admitters versus rounders. Research has shown an incremental cost for every handoff, and creating a work schedule that results in fewer handoffs might make patients more satisfied. But that goal needs to be balanced against provider schedules with an eye toward keeping caseloads localized in the hospital.
Shalini Chandra, MD, MS, FHM, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore, was co-presenter of a HM12 workshop on how to use performance-improvement principles to improve HM group schedules. She says the schedule needs to account for such variables as when hospitalists are assigned new patients, are required to interact with the ED, and are devoted to patient contact versus paperwork, which normally is greater at admission and discharge.
“You need to find the sweet spot between the hospital’s needs, the patient’s needs, and the doctor’s needs,” she says. “Our physicians felt they were being penalized for discharging patients in a timely manner [by receiving more new cases]. We had to go back and say, ‘OK, if somebody is doing a four-day stretch, how can we distribute patients more equitably?’”
Dr. Chandra’s quality team mapped out the entire admissions process and identified key metrics, then devised a model called CICLE (Creating Incentives and Continuity Leading to Efficiency in Hospital Medicine) for its four-day shift. The first day, which can be a long one, is front-loaded with new admissions. But on Day Two and Day Three, the hospitalist is largely protected from new admissions, thereby preserving the incentive to discharge patients when they are ready.
CICLE also results in fewer handoffs, with a third of patients seen by only one hospitalist, Dr. Chandra explains. That in turn translates into decreased LOS and cost.
The four-day schedule at Hopkins is complicated by the need to respond to other demands on the system, and Dr. Chandra says only 60 percent of the hospitalist caseload is scheduled this way.
—Rick Hilger, MD, SFHM
3. Individual Flexibility
The best schedule in the world can be turned upside down by vacations, sickness, or an open position that goes unfilled for months. Accounting for the nuances can be a full-time job.
At Northwestern, the hospitalist group is converting to scheduling software called Lightning Bolt (www.lightning-bolt.com) that provides flexibility to respond to varying needs among the 70-plus members of the group, including such needs as attending their children’s soccer games, says Charlotta Weaver, MD, assistant professor of medicine.
“An enormous amount of time, both administrative and medical, gets devoted to scheduling,” she says.
Each hospital and HM group is different, and each physician has varying desires from the schedule. “Things are constantly changing,” Dr. Weaver says. “People come and go or need to change jobs, there are changes in FTE allocations, physicians may get research grants, and there can be changes in hospital structure or service lines.”
The schedule also needs to facilitate “day trading” between members of the group, and Northwestern is experimenting with some new approaches, including pairing up two physicians on one service line and letting them work out their own schedules.
The group also needs a way to respond to admission surges beyond the capacity of scheduled physicians, which can be hard to predict, and the days when physicians call in sick.
“We have tried to develop a robust system of ‘jeopardy’ for first- and second-line backup,” Dr. Weaver says. Everyone in the hospitalist group has jeopardy one or two weeks per year, where they are in line to be called in if needed.
Franziska Jovin, MD, FHM, a hospitalist at the University of Pittsburgh Medical Center, says her group struggles with predicting patient peaks and valleys.
“One of our hospitalist teams is responsible for the transitional-care unit, and not every patient on that unit has to be seen every day,” Dr. Jovin says. “This person is already scheduled to work, but the responsibilities are not time-dependent. So we can pull in that doctor as needed to cover higher demand on the acute side.”
As most hospitalists know the winter months are busier, “and we staff accordingly,” she says, in response to higher incidence of flu, pneumonia, and the like.
4. Structured Rounds
Another challenge to scheduling is the rounding model used for daily care planning in the hospital. Various models have tried to address competing concerns of geography, schedule efficiency, and the needs of hospitalists, nurses, and other staff. At Emory Healthcare in Atlanta, an approach called Structured Interdisciplinary Bedside Rounds (SIBR) was described during an HM12 workshop and in a prize-winning poster presented by Christina Payne, MD (see “The Innovation Express,” May 2012, p. 27).
Dr. Payne described how SIBR works with two teaching hospitalist services on a 24-bed “accountable-care unit” at Emory University Hospital. Each team has a resident, three interns, a social worker, and the patient’s nurse, with the attending standing by.
“We round on each patient every day—beginning and ending on time,” 12 patients per hour, with five brisk minutes to report on each patient, she says. Rounding starts when the patient’s primary intern and nurse are both present in the patient’s room, and only ends when a plan of care for the day has been articulated—using a standardized script with safety and discharge planning checklists. The second intern enters the plan, in real time, into the EHR.
In addition to the time efficiency, this approach has posted positive outcomes, namely a 53% reduction in in-hospital mortality on the unit and an 11% reduction in LOS. With new residents and interns rotating through the unit every month, “We acknowledge to them that this will be difficult and they will be uncomfortable at first,” Dr. Payne says, “but by Week Two, we’re a well-oiled machine.”
Similar approaches have been implemented at other Emory hospitals.
5. NPP Mobilization
Many hospitalist groups have integrated nonphysician providers (NPPs, or nurse practitioners and physician assistants) into the group’s practice or are considering such a move. Tracy Cardin, ACNP-BC, a nurse practitioner in hospital practice at the University of Chicago Medical Center, says it’s important to ask why a group is considering a role for NPPs.
“Is it to promote efficiency? Is it because you can’t attract enough physicians?” she says. “Clarify your hopes for the position and how you will define success.” She also says HM group leaders need to factor in the time needed to hire, orient, and train an NPP, with mentoring that includes structured teaching and feedback.
There are a lot of models for deploying NPPs, says Cardin, a Team Hospitalist member.
“We utilize shared billing and teams of a hospitalist and nurse practitioner. This allows the physician to see a larger number of patients and brings more than one set of eyes and ears to the complex patient,” she says. “We’ve developed a process over the past six years where the hospitalist and NPP together go over the patient list every day. Both will see the patient, but the NPP commonly writes the notes and orders.”
Cardin emphasizes NPPs cost less than physicians and “can do many of the same things,” but “they are not free.” The most resourceful HM group’s use NPPs to extend the physician’s practice. “They can carry a pager and respond to small crises that come up, or see the patient on discharge day,” she says. “In other settings, the NPP does admissions, serves on quality projects, takes on a patient cohort based on diagnosis, or calls the primary-care physician at discharge.”
Efficiency can be a tough nut to crack in the hospital. Turner, the engineer, says HM groups need to “remember that the hospital is a very complex environment, with cascades of reactions and downstream effects.”
Hospitalists need the support of other professionals, and quality-improvement (QI) initiatives need sufficient time and resources to succeed.
One way to start advancing the efficiency agenda is to look for bright spots among the hospitalist group’s members. “Talk to them,” Turner says. “Find out how they do their jobs. Learn from them.”
Larry Beresford is a freelance author in Oakland, Calif.
References
- Yu D, Sanches S. Lean inpatient unit base care model [abstract]. J Hosp Med. 2012;7(Suppl 2):S107.
- Payne C, Odetoyinbo D, Castle B, et al. A dual hospital care and training model: structured interdisciplinary team rounds in an accountable care unit [abstract]. J Hosp Med. 2012;7(Suppl 2):S125.
- Hilger R, Quirk R, Dahms R. Use of restriction care plans to decrease medically unnecessary admissions and emergency department visits [abstract]. J Hosp Med. 2012;7(Suppl 2):S2.
- Premier. Year Three: QUEST Collaborative Findings. Premier website. Available at: http://www.premierinc.com/quality-safety/tools-services/quest/year3/quest-year-3-collaborative-findings.pdf. Accessed Sept. 26, 2012.