Hospital Medicine: The Hub of the Healthcare Continuum
Leigh Hamby, MD
Executive Vice President and CMO
Timothy D. Ranney, MD, MBA
Vice President of Medical Affairs
Good Samaritan Hospital
Executive Lead for Quality,
Arthur "Bud" McDowell, MD
Vice President for Clinical Affairs
President and CEO
Senior Leadership Editor
HealthLeaders: Hospitalists have been with us for more than a decade now. But their ranks are changing. What is the new breed of hospitalist physician, and what are some of the challenges of keeping hospitalist programs fully staffed?
Gene Fleming: When Cogent first got started in 1997, the typical hospitalist was an internist practicing in a community who decided that they wanted to have a hospital-based practice. So in the early days of hospital medicine, we were getting highly experienced physicians. Now, the typical physician coming into hospital medicine decides in medical school.
Arthur "Bud" McDowell: We started with hospitalists in 1996. Our emergency department was having trouble finding a physician to be the admitting doctor, so we hired two docs. One has since gone into private practice, but the other one stayed on and is the head of our hospitalist program. He's built and nurtured the program over time. As of today, 95% to nearly 100% of the medical admissions to our hospital, which amount to about 75% to 80% of the total admissions, are done by our 24 hospitalists. This is a mobile group, and there's a lot of opportunity out there because lots of hospitals and companies are offering them positions. So we've had to figure out ways of cultivating tracks of growth, so that they are not just grinding through patient care.
Timothy D. Ranney: Our geography covers an area the size of Indiana. We have about 350,000 people in that, compared to Indiana's 5.5 million. Many of our primary care physicians have wanted a hospitalist program since 1999. We're finally starting it July 1 this year. One thing we did differently in Kearney, because of the rural nature and the concern about potentially losing the physicians, is we actually targeted foreign visa candidates, so that they had to stay for three years, because we were concerned with turnover.
Leigh Hamby: Our hospitalist program in our flagship hospital started 15 years ago, from a visionary physician who built it as a service to the medical physicians. It was wildly successful, but we were a two-hospital system until about five years ago, so we had a hospitalist program at each of our facilities. In the last five years, we have acquired two other facilities that didn't have a hospitalist program, and putting one in was a major initiative that has helped turn the quality picture around at those hospitals. Starting hospitalist programs in the two recent acquisitions allowed us to jump-start a quality initiative—core measures, pathways—and reduce risk-adjusted mortality. It's a strategic tool.
HealthLeaders: On what goals should a hospitalist program focus, from staffing to patient care?
Fleming: A number of hospitals are struggling with their medical staff. Private physicians are leaving the hospital in droves, so there's a void. The C-suite looks to us to standardize care. They're looking for better response to the emergency room and referring physicians. They're looking for measurable, improved outcomes. Cogent's model brings order sets, best practice standards, and the measurement tools that allow us to demonstrate that we can improve quality and lower costs.
McDowell: We've evolved continuity across all shifts. I would liken it to the way an emergency department runs, where you try to hire a few people who like to work the night shift. The majority of them like to have regular hours. We have a nocturnist and a couple of physician assistants who work the third shift, and we have one physician who works 3 a.m. to 11 a.m. and does most of the admissions, and he's supplemented by a few others. Moonlighters mostly work weekends.
Fleming: Our physicians find the inpatient setting more exciting and rewarding. When I joined Cogent five years ago, the standard workload metric was 26 shifts per doctor per month, and now that's down to 15 to 17 shifts, depending on the market. So we've gone from the more mature, older physician who was accustomed to working more, to new graduates seeking a more balanced lifestyle.
Hamby: The hospitalist track is nice to have available to docs who are in private practice and want to do it for a while. We've also had some hospitalists that move to private practice and they've been very successful. So I see it as just another option for docs who are still trying to figure out what they want and what they like. Hospitalists don't mind working hard, as long as they're treated well and they have collaborative relationships with the native medical staff, because if you don't have that, they will not survive. Imagine picking a bunch of young folks only. The existing medical staff is going to treat them like residents. So one of the jobs that we have as leaders is to make sure we get the right mix of hospitalists into a new program, and also get the medical staff to understand that role of the hospitalist is a specialty. They are colleagues.
Fleming: What really helps to ameliorate burnout is a team approach to hospital medicine. We put a complete infrastructure around the physician, with nurses, managers, and other individuals. We typically start every day with a team meeting about handoffs and other case issues. There's billing support so the physicians spend time doing more of what they want to do and less time on dissatisfiers.
HealthLeaders: What incentives hold them accountable to quality metrics?
Ranney: We've made them part of the employment contract. We've got quality measures—you're going to improve your core measures, the ones you're specifically accountable for—but over time, that will migrate to not just your own set of patients, but also to influence over others' patients as well. We put 10% to 15% of their income at risk.
Hamby: We use a similar model, in that both process and outcome measures are built into the contract. We have a base salary and then a compensation bonus pool. Hospitalists are so important to the ongoing operations of the hospital, but we've historically had a difficult time getting them to attend meetings. So we've switched to a lead hospitalist or medical director model, where that person has a lot of the leadership responsibility for the performance appraisal of the hospitalists, but they have some protected time, so they are the ones who go to meetings and they're participating in pathway development, so that we have somebody we know we can count on.
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