Secrets of Hospitalist Practice Success: A Decade of Learning

David Bowman, MD, for HealthLeaders Media, November 20, 2008

The hospitalist specialty is just over a decade old. During that time, it has seen explosive growth and now includes 20,000 hospitalists nationwide. But for many physicians, the path has not always been easy.

While some practices have grown, others have diminished or fallen apart over the past 10 years as the specialty has evolved. One of the first multi-physician hospitalist practices in the country, the IPC Hospitalist Company group in Tucson, celebrated its 10 anniversary this year.

This story illustrates the opportunities and the challenges of building a practice dedicated to inpatient medicine, while providing valuable lessons for those entering the specialty today. In the last 10 years, we have learned the following keys to hospitalist success:

1. Aim for high quality care. It's crucial to be able to evaluate ourselves to figure out how we're doing with quality indicators, such as length of stay, readmission rates, and core measures. We rely on a web-based "clinical dashboard," that allows us to log on to a computer and track our performance and patients with real-time information. It answers questions such as: Did I document CMS clinical indicator medications, such as ACE inhibitors for heart patients? Did I send all my discharge notes to the patient's PCP? The bottom line is that it gives us quality of care tools customized for each patient so we can deliver proactive patient care.

One problem for hospitalists—and all doctors dealing with hospitalized patients—is the continuity of care and communication once the patient is discharged from the hospital. The patients go home and later visit their primary care physician, but all of the information about their hospitalization does not accompany them. This situation can result in complications, even readmission to the hospital. The IPC physicians refer to this as "voltage drop."

"At first we had to call the PCPs and interrupt them," says Douglas Kirkpatrick, MD, an IPC hospitalist with the Tucson group. "But if we didn't call, they were upset that we didn't keep them informed." The hospitalists used dictation for their notes, but it could take a week or two for the notes to be transcribed and get over to the primary care physician. "By then, the PCP had already seen the patient and didn't know what was going on. It was awkward, time-consuming and certainly not good for the patient."

2. Adopt the best technology and tools possible. IPC's size, depth of experience, and intellectual capital works to our advantage. In addition to the clinical and leadership training we receive, we are supported by the company's infrastructure, which supplies us with the systems needed to practice hospital medicine effectively and efficiently.

Having local management, decisions are not made from a distant corporate practice of medicine. Although we're backed by a large company, we function as an autonomous practice that determines our own scheduling, whether or not to add moonlighters, and so forth.

With a growing number of hospitalists around the country, IPC was in a position to address voltage drop. It created an electronic patient record system called IPC-Link® that significantly improved the efficiency of transitioning patients after discharge. Hospitalists typed their notes (first on a PDA, today over a secure Internet connection) and reports were automatically generated and faxed to the referring physicians.

Today, faxes sent to the patient's primary care physician, and any specialists involved, arrive within an average of 21 minutes, alerting the physician's to the patient's status, medications and other clinical data critical to the patient's recovery.

Patient data is also sent to IPC's Nurse Call Center, which contacts each discharged patient within 72 hours of leaving the hospital. IPC-Link codifies the hospitalist's notes in a searchable data repository so that IPC callers can create a "smart" survey customized to a particular patient's situation.

3. Promote effective communication with referring physicians. To increase referrals from community physicians, it's obligatory to communicate with them regularly, providing real-time notifications, about their patient's condition, tests, medications, etc., from the time of admission to patient discharge and hand-off to the PCP. This creates a sense of trust and assurance that their patients are in good hands.

4. Hire people with a strong work ethic, and develop ownership and buy-in. Today the Tucson group is an established and thriving practice. But challenges remain. One of them is the continued recruitment of new physicians to support the opportunities for growth.

We understand that we need to work as a team if we are to survive as a practice. And that takes cultivating friendship, loyalty, cooperation and enthusiasm. It's a plus that we're able to attract qualified and motivated hospitalists with above-industry compensation and performance bonuses.

As the hospitalist specialty grew, so did the Tucson practice. After initially projecting slow but steady growth, the group found it needed to hire four more physicians in just the first year. IPC took care of practice management and billing, along with negotiations with payers. The doctors recognized that at times IPC played "hardball" on their behalf. "If it had been just us docs, we never would have done it," says Kirkpatrick. "It really worked."

A key reason the relationship worked was that IPC did not dictate to the physicians how to run the practice.

5. Don't promise more than you can deliver. We've learned to be realistic about how many patient encounters we can each manage in one day. The consequences of overextending ourselves are burnout, disappointment, and compromised patient care.

Despite being one of the most established hospitalist groups in the country, the physicians claim that they are still in growth mode. "We are in this for the long haul," says Kirkpatrick. "People here are very dedicated."

Shelli Collingham, MD, the practice group leader, recalls that when she started out, "the term hospitalist was not even being used at the time." At that time, she worked with a multi-specialty group, and the medical director asked if she would take care of all the inpatients at Tucson Medical Center, the largest facility in the area.

"The first day I had 26 patients-–I will never forget that," she says. Collingham continued on her own for 10 months, until she was joined by two other "full-time inpatient physicians," William Odette, MD, and Douglas Kirkpatrick, MD.

In the beginning, the doctors were salaried hospital employees. Over time, the hospital asked them to become subcontractors as part of its effort to reduce the number of employees. "I had always been an employed physician and the thought of going out on my own was overwhelming," Collingham says.

David Bowman, MD, is Executive Director of IPC-Tucson, IPC The Hospitalist Company, Inc.
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