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Hospital Medicine Leaders Set to Converge for HM13
Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.
And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.
And enjoy all the amenities of a first-class hotel and conference center under one roof.
And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.
But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.
Choosing Wisely
Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.
Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.
On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”
New Featured Speaker
Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.
Get Your Conference In Hand
Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.
The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.
For links to download the HM13 app, visit www.hospitalmedicine.org.
Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.
And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.
And enjoy all the amenities of a first-class hotel and conference center under one roof.
And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.
But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.
Choosing Wisely
Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.
Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.
On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”
New Featured Speaker
Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.
Get Your Conference In Hand
Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.
The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.
For links to download the HM13 app, visit www.hospitalmedicine.org.
Every year, thousands of hospitalists gather to share their experiences, challenges, and energy with each other at SHM’s annual meeting. In 2013, hospitalists can do all of that while visiting the nation’s capital.
And make a real difference by advocating on Capitol Hill for quality improvement and safety in hospitals.
And enjoy all the amenities of a first-class hotel and conference center under one roof.
And get ahead of the curve on some of the most pressing topics in healthcare, such as the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign.
But in order to do all of that, hospitalists have to register for HM13, and must do so quickly to save $50. The early registration deadline is March 19, earlier than in prior years. So don’t wait—sign up now at www.hospitalmedicine2013.org.
Choosing Wisely
Are you ready to make wise choices? HM13 provides unprecedented access to the hospitalist experts who developed the lists of recommendations for the Choosing Wisely campaign with two educational sessions and a pre-course.
Before HM13 kicks off, hospitalists John Bulger, DO, FACP, SFHM, and Ian Jenkins, MD, will direct a full-day Choosing Wisely pre-course on Thursday, May 16, featuring didactic sessions in the morning with national experts in QI on such topics as teambuilding and making the case for quality. The afternoon session will encompass highly interactive workgroups utilizing skills learned in the morning to develop a plan for how to “choose wisely.” Attendees will apply quality methodologies to frequently overutilized tests or procedures, resulting in an actual plan for embedding “avoids” or “never-dos” into their own practice in their own institutions.
On Saturday, May 18, Douglas Carlson, MD, and Ricardo Quinonez, MD, FAAP, FHM, will present “Addressing Overuse in Pediatric Hospital Medicine: The ABIM Choosing Wisely Campaign—PHM Recommendations,” and on Sunday, May 19, Drs. Bulger and Jenkins will present “Choosing Wisely: 5 Things Physicians and Patients Should Question.”
New Featured Speaker
Back by popular demand, hospitalist Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer and the director of the Office of Clinical Standards and Quality Centers for the Centers for Medicare & Medicaid Services (CMS), will speak on the role hospitalists will play as change agents for healthcare reform and patient safety in the years to come. Dr. Conway replaces quality expert Peter Pronovost, MD, who had a scheduling conflict and will not be able to speak at HM13.
Get Your Conference In Hand
Hospitalists continue to be ahead of the curve, and the technology at HM13 is no exception. This year’s HM13 At Hand conference app for smartphones and tablets enables conference-goers to plan their schedule ahead of time, download meeting content, play a scavenger hunt for prizes, and socialize with other attendees.
The app’s scheduling feature offers attendees the chance to explore their options ahead of time or make changes on the fly to their HM13 experience.
For links to download the HM13 app, visit www.hospitalmedicine.org.
Experts Debate Pros and Cons of Seven Days On, Seven Days Off Work Schedule
—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.
Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.
Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.
Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.
And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.
“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”
Viewpoints Vary
The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”
SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.
Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.
“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”
Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.
In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.
“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”
Cost Concerns
How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.
Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.
—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member
“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.
Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.
“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”
IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”
John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.
“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”
Practice Concerns
Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.
“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”
Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.
Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.
“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”
Richard Quinn is a freelance writer in New Jersey.
—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.
Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.
Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.
Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.
And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.
“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”
Viewpoints Vary
The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”
SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.
Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.
“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”
Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.
In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.
“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”
Cost Concerns
How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.
Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.
—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member
“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.
Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.
“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”
IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”
John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.
“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”
Practice Concerns
Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.
“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”
Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.
Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.
“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”
Richard Quinn is a freelance writer in New Jersey.
—Jeff Taylor, president, chief operating officer, IPC: The Hospitalist Co., North Hollywood, Calif.
Robert Houser, MD, MBA, co-medical director of Rapid City Regional Hospital in Rapid City, S.D., left his primary-care practice a little more than 10 years ago to become a hospitalist. At the time, his new schedule—working seven days in a row, then taking off seven days in a row—struck him as odd. But the idea of being able to throw himself completely and alternately into both his job and his family appealed to him. More than a decade later, he still believes his schedule is a perfect mix of personal and professional time.
Bradley Eshbaugh, MBA, FACMPE, chief administrator of Hospitalists of Northern Michigan (HNM) in Traverse City, Mich., and a SHM Administrators’ Committee member, doesn’t see it that way. His hospitalists tell him the work-a-week, skip-a-week schedule is too inflexible for the work-life balance they crave. Even when newly hired physicians accustomed to the week-on/week-off schedule ask if they can continue it, Eshbaugh says, most quickly realize the flexible-schedule option that HNM utilizes offers them a more balanced approach to time off work.
Welcome to the world of seven-on/seven-off scheduling, where detractors and supporters often have the same reasons for their differing viewpoints. Those who favor the model say that its simple-to-implement block approach to scheduling allows physicians to know far in advance when their time off is. That allows clinicians to plan their lives way in advance, a carrot hospitalist groups have used for more than a decade to attract new hires. Those who prefer other scheduling methods say the seven-on/seven-off model’s rigidity leaves little flexibility to deal with the unscheduled inevitabilities of life (sickness, personal time, maternity leave, resignations, etc.) and is not the best construct to match staffing to the busiest admissions periods.
And while everyone agrees that the seven-on/seven-off model is among the most popular, there is as yet no clinical data that show whether its practitioners are more or less likely to provide higher-quality care. So the oft-asked question of whether the schedule is sustainable comes down not to care delivery but financial pressure. Three-quarters of HM groups (HMGs) rely on their host hospitals for financial support, and that support-per-FTE at nonacademic groups serving only adults rose to an median of $140,204 this year, according to SHM’s 2012 State of Hospital Medicine report—a 40% increase over data in the 2010 SHM/MGMA‐ACMPE survey.
“When we started in this business 15 years ago, the average hospital might have three to five hospitalists, maybe a subsidy of $300,000 to $500,000,” says Martin Buser, a partner in Hospitalist Management Resources of Del Mar, Calif. “That same program today is probably running 15 to 20 hospitalists, a subsidy of $3 million-plus. It’s really strongly on the radar screen for administrators to look at, ‘Can I keep affording this, or do I need to find less expensive ways to get the same result?’”
Viewpoints Vary
The origins of the seven-on/seven-off schedule are a bit murky. Some believe it was borrowed from the shift-work model in the ED. Others think it has roots in the nursing ranks. Still others think that in the nascent days of HM, two- and three-physician groups developed the schedule by simply splitting monthly schedules by weeks. Regardless of pedigree, the model has grown to be just about the most common schedule for HMGs serving adults only. The State of Hospital Medicine report reported that 41.9% of adult groups use the seven-on/seven-off schedule, with 41.6% reporting their schedule as “variable” and “other.”
SHM has never queried hospitalists specifically about their schedules before, so no comparative data are available for information. Interestingly, the State of Hospital Medicine report found that hospitalist management companies and private HM groups were less likely to use the seven-on/seven-off schedule than hospital-owned or academic groups.
Jeff Taylor, president and chief operating officer of IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., says just 10% of his 1,400 providers nationwide uses the seven-on/seven-off construct. He argues the model “is economically inefficient.” For example, he says, take a hospital with a census of around 60 inpatients per day. An HM group that wants to limit daily censuses to about 15 patients would need four doctors to staff that patient load. Using the seven-on/seven-off schedule, the group would need eight dayside hospitalists (not counting nocturnists). In a more traditional staffing model of a five-day workweek and call coverage, a group likely could handle the same workload with five FTE hospitalists, Taylor says.
“We have been doing some education with hospitals over the last three or four years of just doing the math,” he adds. “How many doctors would you need to staff this census? … We often give a dual proposal. This is how much it will cost for seven-on/seven-off; this is how much it will cost with the Monday-through-Friday model. Obviously, the Monday-through-Friday model is a lower cost, but it may take a little bit longer to get it staffed.”
Staffing difficulties—particularly recruitment and retention—are a major driver of the popularity of the seven-on/seven-off schedule, says Gregory Martinek, DO, FHM, medical director of Lexington Hospitalists in Altoona, Pa. He says it’s tough to recruit hospitalists to work in a small town in central Pennsylvania, so offering a schedule those physicians want to work is helpful.
In fact, Dr. Martinek offers his hospitalists an extra week of vacation in addition to the 26 weeks they don’t work. That allows some of his foreign-born physicians to take a three-week break from work, which many use as a chance to return to their birth countries.
“We had trouble recruiting when we had a different model,” Dr. Martinek says. “This has really worked for us. It’s allowed us to recruit.”
Cost Concerns
How do HM group leaders answer C-suite questions about whether the expenses associated with the seven-on/seven-off model are worth it? The short answer is data. Know basic metrics on length of stay, cost of care, etc., before having that conversation. For example, a traditional 40-hour workweek is 2,080 hours per annum (and probably less with vacation time). And while some might think that 26 weeks off a year equates to fewer hours, 26 weeks of 12-hour shifts totals 2,184 hours.
Per Danielsson, MD, medical director of Swedish Hospital Medicine in Seattle, says his group uses a hybrid seven-on/seven-off schedule that has demonstrated that their cost-of-care delivery is consistently $1,000 to $1,500 less per case than other physicians’ cases at Swedish Medical Center—and those other physicians often take care of patients with the same diagnoses.
—Kristi Gylten, MBA, director, hospitalist services, Rapid City (S.D.) Regional Hospital, SHM Administrators’ Committee member
“When you have those kinds of numbers, and you’re doing 7,000 admissions per year, the numbers add up quickly,” Dr. Danielsson says.
Kristi Gylten, MBA, director of hospitalist services at Rapid City Regional Hospital and a member of SHM’s Administrators’ Committee, says hospitalist group leaders should urge their administrations to look at more than just financial statements when judging the value of an HM group, particularly in rural areas.
“Our program started with three physicians in 2004 and has grown to over 30 in 2012,” she says. “There has been such great value brought to our community and our medical staff and our patients, just over and above what the bottom line would show on a monthly operational statement, that we don’t have the bean-counters knocking on our door.”
IPC’s Taylor says a complicating factor in moving away from the seven-on/seven-off format is the passion physicians have for their schedules. Or, to use his words: “You make major changes to schedules at great peril.”
John Frehse, managing partner of Core Practice, a Chicago consultancy that designs and implements labor strategies for shift-work operations, says that managers and administrators looking to change schedules often shy away from the upheaval.
“This emotional and potentially disruptive environment is something that makes them say, ‘We’re getting away with it now, so let’s not change it. Why rock the boat?’” Frehse explains. “They should be saying, ‘What is the methodology to get this out of here and put in something that’s financially responsible for the organization?’”
Practice Concerns
Ten years ago, Dr. Houser found the seven-on/seven-off schedule “a little bit unusual.” Now, his workweek of seven 10-hour days in a row seems natural. Even so, he understands those who voice concerns about hospitalized patients who would not be happy to know their hospitalist was on his 60th, 70th, or 80th hour of work that week.
“The physician’s side of me stays in a mode where I know I have to be a resource to the patient and I have to be a resource to my colleagues, and so I don’t think terms of being mentally drained,” he says. “Whether I’m starting or finishing, I just want to be as fresh as I can to approach those problems and mentally stay in the game that way. If I start thinking about being fatigued or tired, I feel like I won’t be able to provide the type of care that I can for that patient.”
Some groups using the seven-on/seven-off model allow physicians to leave the hospital at slow times while requiring they be on call. That allows hospitalists to recharge a bit midweek while ensuring that there is enough staff to provide coverage. Dr. Martinek says there’s no need to “hold them in the hospital if there is no work to do.” Daytime hospitalists also split admission to lighten the workload, he says.
Taylor says another practical concern for hospitalists working the seven-on/seven-off schedule is how engaged they can be with their institutions, particularly when they aren’t there half the year for committee meetings, staff gatherings—even water cooler conversation.
“I just have difficulty understanding how if half your workforce is gone every other week, how that group of doctors can become as integrated and ingrained and as part of the fabric of that facility as people who are there every week,” he says. “There are people who disagree with me on that, obviously.”
Richard Quinn is a freelance writer in New Jersey.
Hospitalwide Reductions in Pediatric Patient Harm are Achievable
Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?
Study design: Single-institution quality-improvement initiative.
Setting: Cincinnati Children’s Hospital Medical Center.
Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.
SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).
This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.
Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.
Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.
Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.
Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?
Study design: Single-institution quality-improvement initiative.
Setting: Cincinnati Children’s Hospital Medical Center.
Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.
SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).
This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.
Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.
Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.
Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.
Clinical question: Can a broadly constructed improvement initiative significantly reduce serious safety events (SSEs)?
Study design: Single-institution quality-improvement initiative.
Setting: Cincinnati Children’s Hospital Medical Center.
Synopsis: A multidisciplinary team supported by leadership was formed to reduce SSEs across the hospital by 80% within four years. A consulting firm with expertise in the field was also engaged for this process. Multifaceted interventions were clustered according to perceived key drivers of change in the institution: error prevention systems, improved safety governance, cause analysis programs, lessons-learned programs, and specific tactical interventions.
SSEs per 10,000 adjusted patient-days decreased significantly, to a mean of 0.3 from 0.9 (P<0.0001) after implementation, while days between SSEs increased to a mean of 55.2 from 19.4 (P<0.0001).
This work represents one of the most robust single-center approaches to improving patient safety that has been published to date. The authors attribute much of their success to culture change, which required “relentless clarity of vision by the organization.” Although this substantially limits immediate generalizability of any of the specific interventions, the work stands on its own as a prime example of what may be accomplished through focused dedication to reducing patient harm.
Bottom line: Patient harm is preventable through a widespread and multifaceted institutional initiative.
Citation: Muething SE, Goudie A, Schoettker PJ, et al. Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics. 2012;130:e423-431.
Reviewed by Pediatric Editor Mark Shen, MD, SFHM, medical director of hospital medicine at Dell Children's Medical Center, Austin, Texas.
Multiple Patient-Safety Events Affect 1 in 1000 Hospitalizations
Patients who experienced multiple patient-safety events—co-occurring iatrogenic events during a single stay in a U.S. hospital in 2004.6 This represents 1 out of every 1,000 hospitalizations. These patients experienced four times greater average lengths of stay and eight times greater average charges per admission.
Patients who experienced multiple patient-safety events—co-occurring iatrogenic events during a single stay in a U.S. hospital in 2004.6 This represents 1 out of every 1,000 hospitalizations. These patients experienced four times greater average lengths of stay and eight times greater average charges per admission.
Patients who experienced multiple patient-safety events—co-occurring iatrogenic events during a single stay in a U.S. hospital in 2004.6 This represents 1 out of every 1,000 hospitalizations. These patients experienced four times greater average lengths of stay and eight times greater average charges per admission.
Special Interest Groups Target Healthcare Waste
As HM ramps up its efforts to eliminate wasteful and unnecessary medical treatments through its participation in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely Campaign (choosingwisely.org), two new policy reports help to delineate the problem of waste in healthcare.
The Health Affairs health policy brief “Reducing Waste in Health Care” concludes that a third or more of U.S. healthcare spending could be considered wasteful.4 Its categories of waste include unnecessary services, inefficiently delivered services, excessive prices and administrative costs, fraud, and abuse—along with a handful of categories familiar to hospitalists: failures of care coordination, avoidable hospital readmissions, and missed prevention opportunities.
The policy brief offers potential solutions, including increased provider use of digital data to improve care coordination and delivery, and heightened transparency of provider performance for consumers.
On Jan. 10, the Commonwealth Fund proposed a new set of strategies to slow health spending growth by $2 trillion dollars over the next 10 years.5 The report outlines a broad set of policies to change the way healthcare is paid for, accelerating a variety of delivery system innovations already under way; disseminate better quality and cost information to enhance consumers’ ability to choose high-value care; and address the market forces that drive up costs.
“We know that by innovating and coordinating care, our healthcare system can provide better care at lower cost,” Commonwealth Fund president David Blumenthal, MD, said in the report.
References
- Health Affairs. Health Policy Brief: Reducing Waste in Health Care. Health Affairs website. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82. Accessed Jan. 10, 2013.
- The Commonwealth Fund Commission on a High Performance Health System. Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jan/Confronting-Costs.aspx?page=all. Accessed Feb. 2, 2013.
As HM ramps up its efforts to eliminate wasteful and unnecessary medical treatments through its participation in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely Campaign (choosingwisely.org), two new policy reports help to delineate the problem of waste in healthcare.
The Health Affairs health policy brief “Reducing Waste in Health Care” concludes that a third or more of U.S. healthcare spending could be considered wasteful.4 Its categories of waste include unnecessary services, inefficiently delivered services, excessive prices and administrative costs, fraud, and abuse—along with a handful of categories familiar to hospitalists: failures of care coordination, avoidable hospital readmissions, and missed prevention opportunities.
The policy brief offers potential solutions, including increased provider use of digital data to improve care coordination and delivery, and heightened transparency of provider performance for consumers.
On Jan. 10, the Commonwealth Fund proposed a new set of strategies to slow health spending growth by $2 trillion dollars over the next 10 years.5 The report outlines a broad set of policies to change the way healthcare is paid for, accelerating a variety of delivery system innovations already under way; disseminate better quality and cost information to enhance consumers’ ability to choose high-value care; and address the market forces that drive up costs.
“We know that by innovating and coordinating care, our healthcare system can provide better care at lower cost,” Commonwealth Fund president David Blumenthal, MD, said in the report.
References
- Health Affairs. Health Policy Brief: Reducing Waste in Health Care. Health Affairs website. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82. Accessed Jan. 10, 2013.
- The Commonwealth Fund Commission on a High Performance Health System. Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jan/Confronting-Costs.aspx?page=all. Accessed Feb. 2, 2013.
As HM ramps up its efforts to eliminate wasteful and unnecessary medical treatments through its participation in the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely Campaign (choosingwisely.org), two new policy reports help to delineate the problem of waste in healthcare.
The Health Affairs health policy brief “Reducing Waste in Health Care” concludes that a third or more of U.S. healthcare spending could be considered wasteful.4 Its categories of waste include unnecessary services, inefficiently delivered services, excessive prices and administrative costs, fraud, and abuse—along with a handful of categories familiar to hospitalists: failures of care coordination, avoidable hospital readmissions, and missed prevention opportunities.
The policy brief offers potential solutions, including increased provider use of digital data to improve care coordination and delivery, and heightened transparency of provider performance for consumers.
On Jan. 10, the Commonwealth Fund proposed a new set of strategies to slow health spending growth by $2 trillion dollars over the next 10 years.5 The report outlines a broad set of policies to change the way healthcare is paid for, accelerating a variety of delivery system innovations already under way; disseminate better quality and cost information to enhance consumers’ ability to choose high-value care; and address the market forces that drive up costs.
“We know that by innovating and coordinating care, our healthcare system can provide better care at lower cost,” Commonwealth Fund president David Blumenthal, MD, said in the report.
References
- Health Affairs. Health Policy Brief: Reducing Waste in Health Care. Health Affairs website. Available at: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=82. Accessed Jan. 10, 2013.
- The Commonwealth Fund Commission on a High Performance Health System. Confronting Costs: Stabilizing U.S. Health Spending While Moving Toward a High Performance Health Care System. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Jan/Confronting-Costs.aspx?page=all. Accessed Feb. 2, 2013.
Post-Hospital Syndrome Contributes to Readmission Risk for Elderly
Post-hospital syndrome, as labeled in a recent, widely publicized opinion piece in the New England Journal of Medicine, is not a new concept, according to one hospitalist pioneer.1
Harlan Krumholz, MD, of the Yale School of Medicine in New Haven, Conn., writes in NEJM what others previously have described as “hospitalization-associated disability,” says Mark Williams, MD, MHM, chief of hospital medicine at Northwestern University School of Medicine and principal investigator of SHM’s Project BOOST (www.hospitalmedicine.org/boost).2
Dr. Krumholz found that the majority of 30-day readmissions for elderly patients with heart failure, pneumonia, or chronic obstructive pulmonary disease are for conditions other than the diagnosis named at discharge. He attributes this phenomenon to hospitalization-related sleep deprivation, malnourishment, pain and discomfort, cognition- and physical function-altering medications, deconditioning from bed rest or inactivity, and the experience of confronting stressful, mentally challenging situations in the hospital.1 Such stressors leave elderly patients with post-hospitalization disabilities comparable to a bad case of jet lag.
For Dr. Williams, the physical deterioration leading to rehospitalizations is better attributed to the underlying serious illness and comorbidities experienced by elderly patients—a kind of high-risk, post-illness syndrome. Prior research also has demonstrated the effects of bed rest for hospitalized elderly patients.
Regardless of the origins, is there anything hospitalists can do about this syndrome? “Absolutely,” Dr. Williams says. “Get elderly, hospitalized patients out of bed as quickly as possible, and be mindful of medications and their effects on elderly patients. But most hospitalists already think about these things when managing elderly patients.”
References
Post-hospital syndrome, as labeled in a recent, widely publicized opinion piece in the New England Journal of Medicine, is not a new concept, according to one hospitalist pioneer.1
Harlan Krumholz, MD, of the Yale School of Medicine in New Haven, Conn., writes in NEJM what others previously have described as “hospitalization-associated disability,” says Mark Williams, MD, MHM, chief of hospital medicine at Northwestern University School of Medicine and principal investigator of SHM’s Project BOOST (www.hospitalmedicine.org/boost).2
Dr. Krumholz found that the majority of 30-day readmissions for elderly patients with heart failure, pneumonia, or chronic obstructive pulmonary disease are for conditions other than the diagnosis named at discharge. He attributes this phenomenon to hospitalization-related sleep deprivation, malnourishment, pain and discomfort, cognition- and physical function-altering medications, deconditioning from bed rest or inactivity, and the experience of confronting stressful, mentally challenging situations in the hospital.1 Such stressors leave elderly patients with post-hospitalization disabilities comparable to a bad case of jet lag.
For Dr. Williams, the physical deterioration leading to rehospitalizations is better attributed to the underlying serious illness and comorbidities experienced by elderly patients—a kind of high-risk, post-illness syndrome. Prior research also has demonstrated the effects of bed rest for hospitalized elderly patients.
Regardless of the origins, is there anything hospitalists can do about this syndrome? “Absolutely,” Dr. Williams says. “Get elderly, hospitalized patients out of bed as quickly as possible, and be mindful of medications and their effects on elderly patients. But most hospitalists already think about these things when managing elderly patients.”
References
Post-hospital syndrome, as labeled in a recent, widely publicized opinion piece in the New England Journal of Medicine, is not a new concept, according to one hospitalist pioneer.1
Harlan Krumholz, MD, of the Yale School of Medicine in New Haven, Conn., writes in NEJM what others previously have described as “hospitalization-associated disability,” says Mark Williams, MD, MHM, chief of hospital medicine at Northwestern University School of Medicine and principal investigator of SHM’s Project BOOST (www.hospitalmedicine.org/boost).2
Dr. Krumholz found that the majority of 30-day readmissions for elderly patients with heart failure, pneumonia, or chronic obstructive pulmonary disease are for conditions other than the diagnosis named at discharge. He attributes this phenomenon to hospitalization-related sleep deprivation, malnourishment, pain and discomfort, cognition- and physical function-altering medications, deconditioning from bed rest or inactivity, and the experience of confronting stressful, mentally challenging situations in the hospital.1 Such stressors leave elderly patients with post-hospitalization disabilities comparable to a bad case of jet lag.
For Dr. Williams, the physical deterioration leading to rehospitalizations is better attributed to the underlying serious illness and comorbidities experienced by elderly patients—a kind of high-risk, post-illness syndrome. Prior research also has demonstrated the effects of bed rest for hospitalized elderly patients.
Regardless of the origins, is there anything hospitalists can do about this syndrome? “Absolutely,” Dr. Williams says. “Get elderly, hospitalized patients out of bed as quickly as possible, and be mindful of medications and their effects on elderly patients. But most hospitalists already think about these things when managing elderly patients.”
References
Houston Hospitalists Create Direct-Admit System
Two hospitalists in the greater Houston area have developed a computer application that streamlines the hospital admission process—a major frustration for busy, office-based primary-care physicians (PCPs).
Mujtaba Ali-Khan, DO, who has practiced at Conroe Regional Medical Center since 2009, is president of Streamlined Medical Solutions (www.streamlinedmedical.com), a company incorporated in July 2011 to market the Direct Admit System for Hospitals, or DASH.1 DASH allows referring physicians to access and submit a direct-admit form, upload medical records, and order preliminary medications and tests for the patient. Once the on-call hospitalist accepts the submitted referral, a “boarding pass” with assigned hospitalist and room number is generated for the patient to take to the hospital’s admissions department. Patients bypass the ED and avoid duplicative medical tests. The process also sends a confirmation to the PCP.
With the support of Hospital Corporation of America (HCA), Dr. Ali-Khan and his business partner, hospitalist Ali Bhuriwala, MD, piloted DASH at two HCA hospitals in Texas. It’s now on the market and has been implemented or is in the works at several others.
“When we started using DASH, we found ourselves getting all sorts of data: Who are the referring physicians, the patients’ ZIP codes, how long do admissions take?” says Dr. Ali-Khan, who adds plans are under way to expand the software’s capacity to allow PCPs to upload tests and place medical orders from the field. “We’re also developing a full suite of hospitalist communication and coordination functions on a dashboard, accessible from smartphones and text alerts, dispensing with pagers entirely.”
Watch a video about DASH at www.youtube.com/watch?v=HUG_vQgKvE0.
Reference
Two hospitalists in the greater Houston area have developed a computer application that streamlines the hospital admission process—a major frustration for busy, office-based primary-care physicians (PCPs).
Mujtaba Ali-Khan, DO, who has practiced at Conroe Regional Medical Center since 2009, is president of Streamlined Medical Solutions (www.streamlinedmedical.com), a company incorporated in July 2011 to market the Direct Admit System for Hospitals, or DASH.1 DASH allows referring physicians to access and submit a direct-admit form, upload medical records, and order preliminary medications and tests for the patient. Once the on-call hospitalist accepts the submitted referral, a “boarding pass” with assigned hospitalist and room number is generated for the patient to take to the hospital’s admissions department. Patients bypass the ED and avoid duplicative medical tests. The process also sends a confirmation to the PCP.
With the support of Hospital Corporation of America (HCA), Dr. Ali-Khan and his business partner, hospitalist Ali Bhuriwala, MD, piloted DASH at two HCA hospitals in Texas. It’s now on the market and has been implemented or is in the works at several others.
“When we started using DASH, we found ourselves getting all sorts of data: Who are the referring physicians, the patients’ ZIP codes, how long do admissions take?” says Dr. Ali-Khan, who adds plans are under way to expand the software’s capacity to allow PCPs to upload tests and place medical orders from the field. “We’re also developing a full suite of hospitalist communication and coordination functions on a dashboard, accessible from smartphones and text alerts, dispensing with pagers entirely.”
Watch a video about DASH at www.youtube.com/watch?v=HUG_vQgKvE0.
Reference
Two hospitalists in the greater Houston area have developed a computer application that streamlines the hospital admission process—a major frustration for busy, office-based primary-care physicians (PCPs).
Mujtaba Ali-Khan, DO, who has practiced at Conroe Regional Medical Center since 2009, is president of Streamlined Medical Solutions (www.streamlinedmedical.com), a company incorporated in July 2011 to market the Direct Admit System for Hospitals, or DASH.1 DASH allows referring physicians to access and submit a direct-admit form, upload medical records, and order preliminary medications and tests for the patient. Once the on-call hospitalist accepts the submitted referral, a “boarding pass” with assigned hospitalist and room number is generated for the patient to take to the hospital’s admissions department. Patients bypass the ED and avoid duplicative medical tests. The process also sends a confirmation to the PCP.
With the support of Hospital Corporation of America (HCA), Dr. Ali-Khan and his business partner, hospitalist Ali Bhuriwala, MD, piloted DASH at two HCA hospitals in Texas. It’s now on the market and has been implemented or is in the works at several others.
“When we started using DASH, we found ourselves getting all sorts of data: Who are the referring physicians, the patients’ ZIP codes, how long do admissions take?” says Dr. Ali-Khan, who adds plans are under way to expand the software’s capacity to allow PCPs to upload tests and place medical orders from the field. “We’re also developing a full suite of hospitalist communication and coordination functions on a dashboard, accessible from smartphones and text alerts, dispensing with pagers entirely.”
Watch a video about DASH at www.youtube.com/watch?v=HUG_vQgKvE0.
Reference
Southern Hospital Medicine Conference Drives Home the Value of Hospitalists
More than 300 hospitalists and other clinicians recently attended the 13th annual Southern Hospital Medicine Conference in Atlanta. The conference is a joint collaboration between the Emory University School of Medicine in Atlanta and Ochsner Health System New Orleans. The meeting site has alternated between the two cities each year since 2005.
The prevailing conference theme in 2012 was “Value and Values in Hospital Medicine,” alluding to the value that hospitalists bring to the medical community and hospitals and the values shared by hospitalists. The conference offered five pre-courses and more than 50 sessions focused on educating hospitalists on current best practices within core topic areas, including clinical care, quality improvement, healthcare information technology, innovative care models, systems of care, and transitions of care. A judged poster competition featured research and clinical vignettes abstracts, with interesting clinical cases as well as new research in hospital medicine.
One of the highlights of this year’s conference was the keynote address delivered by Dr. William A. Bornstein, chief quality and medical officer of Emory Healthcare. Dr. Bornstein discussed the various aspects of quality and cost in hospital care. He described the challenges in defining quality and measuring cost when trying to calculate the “value” equation in medicine (value=quality/cost). He outlined the Institute of Medicine’s previously described STEEEP (safe, timely, effective, efficient, equitable, patient-centered) aims of quality in 2001.
Dr. Bornstein’s own definition for quality is “partnering with patients and families to reliably, 100% of the time, deliver when, where, and how they want it—and with minimal waste—care based on the best available evidence and consistent with patient and family values and preferences.” To measure outcome, he said, we need to address system structure (what’s in place before the patient arrives), process (what we do for the patient), and culture (how we can get the buy-in from all stakeholders). The sum of these factors achieves outcome, which requires risk adjustment and, ideally, long-term follow-up data, he said.
Dr. Bornstein also discussed the need to develop standard processes whereby equivalent clinicians can follow similar processes to achieve the same results. When physicians “do it the same” (i.e. standardized protocols), error rates and cost decrease, he explained.
Dr. Bornstein also focused on transformative solutions to address problems in healthcare as a whole, rather than attempting to fix problems piecemeal.
Jason Stein, MD, SFHM, offered another conference highlight: a pre-conference program and plenary session on an innovative approach to improve hospital outcomes through implementation of the accountable-care unit (ACU). Dr. Stein, director of the clinical research program at Emory School of Medicine, described the current state of hospital care as asynchronous, with various providers caring for the patient without much coordination. For example, the physician sees the patient at 9 a.m., followed by the nurse at 10 a.m., and then finally the visiting family at 11 a.m. The ACU model of care would involve all the providers rounding with the patient and family at a scheduled time daily to provide synchronous care.
Dr. Stein described an ACU as a geographic inpatient area consistently responsible for the clinical, service, and cost outcomes it produces. Features of this unit include:
- Assignment of physicians by units to enhance predictability;
- Cohesiveness and communication;
- Structured interdisciplinary bedside rounds to consistently deliver evidence-based, patient-centered care;
- Evaluation of performance data by unit instead of facility or service line; and
- A dyad partnership involving a nurse unit director and a physician unit medical director.
ACU implementation at Emory has led to decreased mortality, reduced length of stay, and improved patient satisfaction compared to traditional units, according to Dr. Stein. While the ACU might not be suited for all, he said, all hospitals can learn from various components of this innovative approach to deliver better patient care.
The ever-changing state of HM in the U.S. remains a challenge, but it continues to generate innovation and excitement. The high number of engaged participants from 30 different states attending the 13th annual Southern Hospital Medicine Conference demonstrates that hospitalists are eager to learn and ready to improve their practice in order to provide high-value healthcare in U.S. hospitals today.
Dr. Lee is vice chairman in the department of hospital medicine at Ochsner Health System. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory University. Dr. Deitelzweig is system chairman in the department of hospital medicine and medical director for regional business development at Ochsner Health System. Dr. Wang is the division director of hospital medicine at Emory University. Dr. Dressler is director for education in the division of hospital medicine and an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University.
More than 300 hospitalists and other clinicians recently attended the 13th annual Southern Hospital Medicine Conference in Atlanta. The conference is a joint collaboration between the Emory University School of Medicine in Atlanta and Ochsner Health System New Orleans. The meeting site has alternated between the two cities each year since 2005.
The prevailing conference theme in 2012 was “Value and Values in Hospital Medicine,” alluding to the value that hospitalists bring to the medical community and hospitals and the values shared by hospitalists. The conference offered five pre-courses and more than 50 sessions focused on educating hospitalists on current best practices within core topic areas, including clinical care, quality improvement, healthcare information technology, innovative care models, systems of care, and transitions of care. A judged poster competition featured research and clinical vignettes abstracts, with interesting clinical cases as well as new research in hospital medicine.
One of the highlights of this year’s conference was the keynote address delivered by Dr. William A. Bornstein, chief quality and medical officer of Emory Healthcare. Dr. Bornstein discussed the various aspects of quality and cost in hospital care. He described the challenges in defining quality and measuring cost when trying to calculate the “value” equation in medicine (value=quality/cost). He outlined the Institute of Medicine’s previously described STEEEP (safe, timely, effective, efficient, equitable, patient-centered) aims of quality in 2001.
Dr. Bornstein’s own definition for quality is “partnering with patients and families to reliably, 100% of the time, deliver when, where, and how they want it—and with minimal waste—care based on the best available evidence and consistent with patient and family values and preferences.” To measure outcome, he said, we need to address system structure (what’s in place before the patient arrives), process (what we do for the patient), and culture (how we can get the buy-in from all stakeholders). The sum of these factors achieves outcome, which requires risk adjustment and, ideally, long-term follow-up data, he said.
Dr. Bornstein also discussed the need to develop standard processes whereby equivalent clinicians can follow similar processes to achieve the same results. When physicians “do it the same” (i.e. standardized protocols), error rates and cost decrease, he explained.
Dr. Bornstein also focused on transformative solutions to address problems in healthcare as a whole, rather than attempting to fix problems piecemeal.
Jason Stein, MD, SFHM, offered another conference highlight: a pre-conference program and plenary session on an innovative approach to improve hospital outcomes through implementation of the accountable-care unit (ACU). Dr. Stein, director of the clinical research program at Emory School of Medicine, described the current state of hospital care as asynchronous, with various providers caring for the patient without much coordination. For example, the physician sees the patient at 9 a.m., followed by the nurse at 10 a.m., and then finally the visiting family at 11 a.m. The ACU model of care would involve all the providers rounding with the patient and family at a scheduled time daily to provide synchronous care.
Dr. Stein described an ACU as a geographic inpatient area consistently responsible for the clinical, service, and cost outcomes it produces. Features of this unit include:
- Assignment of physicians by units to enhance predictability;
- Cohesiveness and communication;
- Structured interdisciplinary bedside rounds to consistently deliver evidence-based, patient-centered care;
- Evaluation of performance data by unit instead of facility or service line; and
- A dyad partnership involving a nurse unit director and a physician unit medical director.
ACU implementation at Emory has led to decreased mortality, reduced length of stay, and improved patient satisfaction compared to traditional units, according to Dr. Stein. While the ACU might not be suited for all, he said, all hospitals can learn from various components of this innovative approach to deliver better patient care.
The ever-changing state of HM in the U.S. remains a challenge, but it continues to generate innovation and excitement. The high number of engaged participants from 30 different states attending the 13th annual Southern Hospital Medicine Conference demonstrates that hospitalists are eager to learn and ready to improve their practice in order to provide high-value healthcare in U.S. hospitals today.
Dr. Lee is vice chairman in the department of hospital medicine at Ochsner Health System. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory University. Dr. Deitelzweig is system chairman in the department of hospital medicine and medical director for regional business development at Ochsner Health System. Dr. Wang is the division director of hospital medicine at Emory University. Dr. Dressler is director for education in the division of hospital medicine and an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University.
More than 300 hospitalists and other clinicians recently attended the 13th annual Southern Hospital Medicine Conference in Atlanta. The conference is a joint collaboration between the Emory University School of Medicine in Atlanta and Ochsner Health System New Orleans. The meeting site has alternated between the two cities each year since 2005.
The prevailing conference theme in 2012 was “Value and Values in Hospital Medicine,” alluding to the value that hospitalists bring to the medical community and hospitals and the values shared by hospitalists. The conference offered five pre-courses and more than 50 sessions focused on educating hospitalists on current best practices within core topic areas, including clinical care, quality improvement, healthcare information technology, innovative care models, systems of care, and transitions of care. A judged poster competition featured research and clinical vignettes abstracts, with interesting clinical cases as well as new research in hospital medicine.
One of the highlights of this year’s conference was the keynote address delivered by Dr. William A. Bornstein, chief quality and medical officer of Emory Healthcare. Dr. Bornstein discussed the various aspects of quality and cost in hospital care. He described the challenges in defining quality and measuring cost when trying to calculate the “value” equation in medicine (value=quality/cost). He outlined the Institute of Medicine’s previously described STEEEP (safe, timely, effective, efficient, equitable, patient-centered) aims of quality in 2001.
Dr. Bornstein’s own definition for quality is “partnering with patients and families to reliably, 100% of the time, deliver when, where, and how they want it—and with minimal waste—care based on the best available evidence and consistent with patient and family values and preferences.” To measure outcome, he said, we need to address system structure (what’s in place before the patient arrives), process (what we do for the patient), and culture (how we can get the buy-in from all stakeholders). The sum of these factors achieves outcome, which requires risk adjustment and, ideally, long-term follow-up data, he said.
Dr. Bornstein also discussed the need to develop standard processes whereby equivalent clinicians can follow similar processes to achieve the same results. When physicians “do it the same” (i.e. standardized protocols), error rates and cost decrease, he explained.
Dr. Bornstein also focused on transformative solutions to address problems in healthcare as a whole, rather than attempting to fix problems piecemeal.
Jason Stein, MD, SFHM, offered another conference highlight: a pre-conference program and plenary session on an innovative approach to improve hospital outcomes through implementation of the accountable-care unit (ACU). Dr. Stein, director of the clinical research program at Emory School of Medicine, described the current state of hospital care as asynchronous, with various providers caring for the patient without much coordination. For example, the physician sees the patient at 9 a.m., followed by the nurse at 10 a.m., and then finally the visiting family at 11 a.m. The ACU model of care would involve all the providers rounding with the patient and family at a scheduled time daily to provide synchronous care.
Dr. Stein described an ACU as a geographic inpatient area consistently responsible for the clinical, service, and cost outcomes it produces. Features of this unit include:
- Assignment of physicians by units to enhance predictability;
- Cohesiveness and communication;
- Structured interdisciplinary bedside rounds to consistently deliver evidence-based, patient-centered care;
- Evaluation of performance data by unit instead of facility or service line; and
- A dyad partnership involving a nurse unit director and a physician unit medical director.
ACU implementation at Emory has led to decreased mortality, reduced length of stay, and improved patient satisfaction compared to traditional units, according to Dr. Stein. While the ACU might not be suited for all, he said, all hospitals can learn from various components of this innovative approach to deliver better patient care.
The ever-changing state of HM in the U.S. remains a challenge, but it continues to generate innovation and excitement. The high number of engaged participants from 30 different states attending the 13th annual Southern Hospital Medicine Conference demonstrates that hospitalists are eager to learn and ready to improve their practice in order to provide high-value healthcare in U.S. hospitals today.
Dr. Lee is vice chairman in the department of hospital medicine at Ochsner Health System. Dr. Smith is an assistant director for education in the division of hospital medicine at Emory University. Dr. Deitelzweig is system chairman in the department of hospital medicine and medical director for regional business development at Ochsner Health System. Dr. Wang is the division director of hospital medicine at Emory University. Dr. Dressler is director for education in the division of hospital medicine and an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory University.
Fundamentals of Highly Reliable Organizations Could Benefit Hospitalists
Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?
Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:
- The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
- The unexpected occurs (i.e. a patient falls and breaks their hip); or
- The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).
A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”1 Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.2
What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.
The Fundamentals
The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.
The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”
The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.
The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.
The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.
Take-Home Message
The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.
What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.
It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”
Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
References
- Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
- Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.
Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?
Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:
- The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
- The unexpected occurs (i.e. a patient falls and breaks their hip); or
- The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).
A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”1 Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.2
What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.
The Fundamentals
The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.
The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”
The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.
The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.
The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.
Take-Home Message
The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.
What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.
It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”
Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
References
- Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
- Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.
Reliability. This sounds like a decent trait. Who wouldn’t want to be described as “reliable”? It sounds reputable whether you’re a person, a car, or a dishwasher. So how does one become or emulate the trait of being reliable, one who is predictable, punctua—“reproducible,” if you will?
Organizational reliability has received a fair bit of press these days. The industries that have come to embrace reliability concepts are those in which failure is easy to come by, and those in which failure is likely to be catastrophic if it occurs. In the medical industry, failure occurs to people, not widgets or machines, so by definition it tends to be catastrophic. These failures generally come in three flavors:
- The expected fails to occur (i.e. a patient with pneumonia does not receive their antibiotics on time);
- The unexpected occurs (i.e. a patient falls and breaks their hip); or
- The unexpected was not previously thought of (i.e. low-risk patient has a PEA arrest).
A fair bit of research has been done on how organizations can become more reliable. In their book “Managing the Unexpected: Assuring High Performance in an Age of Complexity,”1 Karl Weick and Kathleen Sutcliffe studied firefighting, workers on aircraft carriers, and nuclear power plant employees. They all have in common the fundamental similarity that failure in their workplace is catastrophically dangerous, and that they must continuously strive to reduce the risk and/or mitigate effectively. The Agency for Healthcare Research and Quality (AHRQ) specifically studied, through case studies and site visits, how some healthcare organizations have achieved some success in the different domains of reliability.2
What both studies found is that there are five prerequisites that, if done well, lead to an organizational “state of mindfulness.” What they and others have found in their research of highly reliable organizations (HROs) is not that they have failure-free operations, but that they continuously and “mindfully” think about how to be failure-free. Inattention and complacency are the biggest threats to reliability.
The Fundamentals
The first prerequisite is sensitivity to operations. This refers to actively seeking information on how things actually are working, instead of how they are supposed to be working. It is being acutely aware of all operations, including the smallest details: Does the patient have an armband on? Is the nurse washing their hands? Is the whiteboard information correct? Is the bed alarm enabled? It is the state of mind when everyone knows how things should work, look, feel, sound, and can recognize when something is out of bounds.
The next prerequisite is a preoccupation with failure. This refers to a system in which failure and near-misses are completely transparent, and openly and honestly discussed (without inciting individual blame or punitive action), and learned from communally. This “group thought” continually reaffirms the fact that systems, and everyone in them, are completely fallible to errors. It is the complete opposite of inattention and complacency. It is continuously asking “What can go wrong, how can it go wrong, when will it go wrong, and how can I stop it?”
The next prerequisite is reluctance to oversimplify. This does not imply that simplicity is bad, but that oversimplicity is lethal. It forces people and organizations to avoid shortcuts and to not rely on simplistic explanations for situations that need to be complicated. Think of this as making a complicated soufflé; if you leave out a step or an ingredient, the product will be far from a soufflé.
The next prerequisite is deference to expertise. This principle recognizes that authority and/or rank are not equivalent to expertise. This assumes that people and organizations are willing and able to defer decision-making to the person who will make the best decision, not to who ranks highest in the organizational chart. A junior hospitalist might be much more likely to make a good decision on building a new order set than the hospitalist director is.
The last prerequisite is resilience. Webster’s defines resilience as “the capability of a strained body to recover its size and shape after deformation caused especially by compressive stress … an ability to recover from or adjust easily to misfortune or change.” The “compressive stresses” and “misfortune or change” can present in a number of different ways, including bad patient outcomes, bad national press, or bad hospital rankings. A good HRO is not one that does not experience unexpected events, but is one that is not disabled by them. They routinely train and practice for worst-case scenarios. It is easy to “audit” resilience by looking at the organizational response to unexpected events. Are they handled with grace, ease, and speed, or with panic, anxiety, and ongoing uncertainty? Resilience involves adequately functioning despite adversity, recovering well, and learning from the experience.
Take-Home Message
The first three principles relate to how organizations can anticipate and reduce the risk of failure; the last two principles relate to how organizations mitigate the extent or severity of failure when it occurs. Together, they create the state of mindfulness, in which all senses are open and alert for signs of aberrations in the system, and where there is continuous learning of how to make the system function better.
What does this mean for a hospitalist to function in an HRO? Most hospitalists are on the front lines, where they routinely see where and how things can fail. They need to resist the urge to become complacent and remain continuously alert to signals that the system is not functioning for the safety of the patient. And when things do go awry, they need to be part of the resilience plan, to work with their teams to swiftly and effectively mitigate ongoing risks, and defer decision to expertise and not necessarily authority.
It also requires that each of us work within multidisciplinary teams in which all members add to the “state of mindfulness,” including the patient and their families (who very often note “aberrancies” before anyone else does). Think of your hospital as ascribed by Gordon Bethune, the former CEO of Continental Airlines. When asked why all employees received a bonus for on-time departure (instead of only employees on the front line), he held up his wristwatch and said, “What part of this watch don’t you think we need?”
Hospitalists can be powerful motivators for a culture change that empowers all hospital employees to be engaged in anticipating and managing failures—just by being mindful. This is a great place to start.
Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].
References
- Weick KE, Sutcliffe KM. Managing the unexpected: Resilient performance in an age of uncertainty, 2nd ed. 2007: Hoboken, NJ: John Wiley & Sons Inc.
- Agency for Healthcare Research and Quality. Becoming a high reliability organization: operational advice for hospital leaders. Agency for Healthcare Research and Quality website. Available at: http://www.ahrq.gov/qual/hroadvice/. Accessed Dec. 10, 2012.
Hospital Medicine Experts Outline Criteria To Consider Before Growing Your Group
—Brian Hazen, MD, medical director, Inova Fairfax Hospital Group, Fairfax, Va.
Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.
“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”
It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:
- Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
- Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
- Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
- Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
- Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
- Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
- Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.
“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”
Practice Analysis
Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.
“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”
In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.
“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.
“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”
Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.
“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”
The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”
The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.
“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”
Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.
“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”
—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver
The Long View
Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.
Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”
Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.
“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”
Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.
Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.
“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”
Richard Quinn is a freelance writer in New Jersey.
—Brian Hazen, MD, medical director, Inova Fairfax Hospital Group, Fairfax, Va.
Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.
“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”
It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:
- Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
- Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
- Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
- Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
- Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
- Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
- Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.
“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”
Practice Analysis
Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.
“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”
In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.
“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.
“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”
Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.
“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”
The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”
The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.
“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”
Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.
“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”
—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver
The Long View
Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.
Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”
Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.
“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”
Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.
Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.
“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”
Richard Quinn is a freelance writer in New Jersey.
—Brian Hazen, MD, medical director, Inova Fairfax Hospital Group, Fairfax, Va.
Ilan Alhadeff, MD, SFHM, program medical director for Cogent HMG at Hackensack University Medical Center in Hackensack, N.J., pays a lot of attention to the work relative-value units (wRVUs) his hospitalists are producing and the number of encounters they’re tallying. But he’s not particularly worried about what he sees on a daily, weekly, or even monthly basis; he takes a monthslong view of his data when he wants to forecast whether he is going to need to think about adding staff.
“When you look at months, you can start seeing trends,” Dr. Alhadeff says. “Let’s say there’s 16 to 18 average encounters. If your average is 16, you’re saying, ‘OK, you’re on the lower end of your normal.’ And if your average is 18, you’re on the higher end of normal. But if you start seeing 18 every month, odds are you’re going to start getting to 19. So at that point, that’s raising the thought that we need to start thinking about bringing someone else on.”
It’s a dance HM group leaders around the country have to do when confronted with the age-old question: Should we expand our service? The answer is more art than science, experts say, as there is no standardized formula for knowing when your HM group should request more support from administration to add an FTE—or two or three. And, in a nod to the HM adage that if you’ve seen one HM group (HMG), then you’ve seen one HMG, the roadmap to expansion varies from place to place. But in a series of interviews with The Hospitalist, physicians, consultants, and management experts suggest there are broad themes that guide the process, including:
- Data. Dashboard metrics, such as average daily census (ADC), wRVUs, patient encounters, and length of stay (LOS), must be quantified. No discussion on expansion can be intelligibly made without a firm understanding of where a practice currently stands.
- Benchmarking. Collating figures isn’t enough. Measure your group against other local HMGs, regional groups, and national standards. SHM’s 2012 State of Hospital Medicine report is a good place to start.
- Scope or schedule. Pushing into new business lines (e.g. orthopedic comanagement) often requires new staff, as does adding shifts to provide 24-hour on-site coverage. Those arguments are different from the case to be made for expanding based on increased patient encounters.
- Physician buy-in. Group leaders cannot unilaterally determine it’s time to add staff, particularly in small-group settings in which hiring a new physician means taking revenue away from the existing group, if only in the short term. Talk with group members before embarking on expansion. Keep track of physician turnover. If hospitalists are leaving often, it could be a sign the group is understaffed.
- Administrative buy-in. If a group leader’s request for a new hire comes without months of conversation ahead of it, it’s likely too late. Prepare C-suite executives in advance about potential growth needs so the discussion does not feel like a surprise.
- Know your market. Don’t wait until a new active-adult community floods the hospital with patients to begin analyzing the impact new residents might have. The same goes for companies that are bringing thousands of new workers to an area.
- Prepare to do nothing. Too often, group leaders think the easiest solution is hiring a physician to lessen workload. Instead, exhaust improved efficiency options and infrastructure improvements that could accomplish the same goal.
“There is no one specific measure,” says Burke Kealey, MD, SFHM, medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn., and an SHM board member. “You have to look at it from several different aspects, and all or most need to line up and say that, yes, you could use more help.”
Practice Analysis
Dr. Kealey, board liaison to SHM’s Practice Analysis Committee, says that benchmarking might be among the most important first steps in determining the right time to grow a practice. Group leaders should keep in mind, though, that comparative analysis to outside measures is only step one of gauging a group’s performance.
“The external benchmarking is easy,” he says. “You can look at SHM survey data. There are a lot of places that will do local market surveys; that’s easy stuff to look at. It’s the internal stuff that’s a bit harder to make the case for, ‘OK, yes, I am a little below the national benchmarks, but here’s why.’”
In those instances, group leaders need to “look at the value equation” and engage hospital administrators in a discussion on why such metrics as wRVUs and ADC might not match local, regional, or national standards. Perhaps a hospital has a lower payor mix than the sample pool, or comparable regional institutions have a better mix of medical and surgical comanagement populations. Regardless of the details of the tailored explanation, the conversation must be one that’s ongoing between a group leader and the C-suite or it is likely to fail, Dr. Kealey says.
“It really gets to the partnership between the hospital and the hospitalist group and working together throughout the whole year, and not just looking at staffing needs, but looking at the hospital’s quality,” he adds. “It’s looking at [the hospital’s] ability to retain the surgeons and the specialists. It’s the leadership that you’re providing. It’s showing that you’re a real partner, so that when it does come time to make that value argument, that we need to grow...there is buy-in.
“If you’re not a true partner and you just come in as an adversary, I think your odds of success are not very high.”
Steve Sloan, MD, a partner at AIM Hospitalist Group of Westmont, Ill., says that group leaders would be wise to obtain input from all of their physicians before adding a new doctor, as each new hire impacts compensation for existing staff members. In Dr. Sloan’s 16-member group, 11 physicians are partners who discuss growth plans. The other doctors are on partnership tracks. And while that makes discussions more difficult than when nine physicians formed the group in 2007, up-front dialogue is crucial, Dr. Sloan says.
“We try to get all the partners together to make major decisions, such as hiring,” he says. “We don’t need everyone involved in every decision, but it’s not just one or two people making the decision.”
The conversation about growth also differs if new hires are needed to move the group into a new business line or if the group is adding staff to deal with its current patient load. Both require a business case for expansion to be made, but either way, codifying expectations with hospital clients is another way to streamline the growth process, says Dr. Alhadeff. His group contracts with his hospital to provide services and has the ability to autonomously add or delete staff as needed. Although personnel moves don’t require prior approval from the hospital, there is “an expected fiscal responsibility on our end and predetermined agreement do so.”
The group also keeps administrative stakeholders updated to make sure everyone is on the same page. Other groups might delineate in a contract what thresholds need to be met for expansion to be viable.
“It needs to be agreed upon,” Dr. Alhadeff says. “I like the flexibility of being able to determine within our company what we’re doing. But in answer to that, there are unintentional consequences. If we determine that we’re going to bring on someone else, and then we see after a few months that there is not enough volume to support this new physician, we could run into a problem. We will then have to make a financial decision, and the worst thing is to have to fire someone.”
Dr. Alhadeff also worries about the flipside: failing to hire when staff is overworked.
“We run that risk also,” he says. “We are walking a tightrope all the time, and we need to balance that tightrope.”
—Kenneth Hertz, FACMPE, principal, Medical Group Management Association Health Care Consulting Group, Denver
The Long View
Another tightrope is timing. Kenneth Hertz, FACMPE, principal of the Medical Group Management Association’s Health Care Consulting Group, says that it can take six months or longer to hire a physician, which means group leaders need to have a continual focus on whether growth is needed or will soon be needed. He suggests forecasting at least 12 to 18 months in advance to stay ahead of staffing needs.
Unfortunately, he says, analysis often gets put on hold in the shuffle of dealing with daily duties. “This is kind of generic to practice administrators, who are putting out fires almost every day. And when you’re putting out fires every day, you don’t have the luxury and the time to look out there and see what’s happening and know everything that’s going on,” he says. “They need to understand the importance of it and how all the pieces tie in together.”
Brian Hazen, MD, medical director of Inova Fairfax Hospital Group in Fairfax, Va., says an important approach is to realize growth isn’t always a good thing. HM group leaders often want to grow before they have stabilized their existing business lines, he says, and that can be the worst tack to take. He also notes that a group leader should ingratiate their program into the fabric of their hospital and not just rely on data to make the argument of the group’s value. That means putting hospitalists on committees, spearheading safety programs, and being seen as a partner in the institution.
“Job One is always patient safety and physician sanity,” he says. “If you are careful about growth and buy-in, and you do the committee work and support everybody so that you’re firmly entrenched in the hospital as a value, it’s much safer to grow. Growing for the sake of growing, you risk overexpansion, and that’s dangerous.”
Many hospitalist groups looking to grow will use locum tenens to bridge the staffing gap while they hire new employees (see “No Strings Attached,” December 2012, p. 36), but Dr. Hazen says without a longer view, that only serves as a Band-Aid.
Hertz, the consultant, often uses an analogy to show how important it is to be constantly planning ahead of the growth curve.
“It is a little bit like building roads,” he says. “Once you decide you need to add two lanes, by the time those are finished, you realize we really need to add two more lanes.”
Richard Quinn is a freelance writer in New Jersey.