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Larry Wellikson: Exceptional Hospitalists Bring Positive Change to Health Care Industry
Exceptional hospitalists
Even though hospital medicine and SHM are still relatively young, we can be very proud of what our specialty already has brought to changing our nation’s health care for the better. Many of these accomplishments, from winning the prestigious Eisenberg Award to our change leadership by SHM’s Center for Healthcare Innovation and Improvement at more 300 hospitals to the extraordinary growth of our specialty, have been well chronicled in The Hospitalist and elsewhere the last few years.
I wanted to use this month’s column to highlight the unique career directions of a few SHM members to shine a bright light on the influence hospitalists are making nationwide. Certainly, there are many more hospitalists beyond this group of five that I have selected, but this small cadre should serve as an example of the talent and reach of our specialty—with only more and greater things ahead to come in the future.
Chief Medical Officer of CMS
Pat Conway, MD, SFHM, is a pediatric hospitalist and the former chair of SHM’s Public Policy Committee. He left his pediatric academic practice to become a White House fellow, then returned to Cincinnati Children’s Hospital to serve as chief medical officer (CMO). When Don Berwick was in charge of the Centers for Medicare & Medicaid Services (CMS), he reached out to Pat and asked him to come to Washington to be part of Medicare’s senior team as the CMO for CMS. In this role, Pat has been a nationally recognized leader in performance improvement and patient safety, and he has been instrumental in bringing about evolutionary changes to the largest healthcare program in the world. Pat will be sharing his perspectives as a keynote speaker at HM13 (check out our 10-page HM13 preview starting on p. 45).
Resident Fellow at the American Enterprise Institute
Scott Gottlieb, MD, is a practicing hospitalist in New York City, but he is better known as a leading expert in healthcare policy, most recently acting as an advisor to presidential candidate Mitt Romney. From 2005 to 2007, Scott was a deputy commissioner at the FDA. He has worked as a senior advisor to the administrator at CMS, where he played an instrumental role in the implementation of the Medicare Drug Benefit in 2004.
Scott is best known for his frequent contributions to The Wall Street Journal, The New York Times, USA Today, and Forbes. He has held editorial positions at the British Medical Journal and the Journal of the American Medical Association, regularly appears as a guest commentator on CNBC, and is a frequent contributor to Politico.
At SHM, Scott has brought his national viewpoint to the Public Policy Committee. He proudly touts his experience as a practicing hospitalist as bringing a front-line reality to his national recognition and much-sought-after critical thinking about healthcare policy.
Chairman of the American Board of Internal Medicine
Bob Wachter, MD, MHM, was a thought leader in HM before our specialty even had a name, writing the initial peer-reviewed articles and coining the term “hospitalist.” Bob has built a pre-eminent hospitalist program at the University of California at San Francisco and helped influence and populate much of academic HM. His Wachter’s World blog (www.wachtersworld.com) is one of the most widely read medical blogs, reaching an audience well beyond our specialty.
Bob was one of the first presidents of SHM—back when we were known as NAIP, or the National Association of Inpatient Physicians—and set SHM on its strong growth and innovative direction that has made us the envy of other medical specialty societies. Last year, Modern Healthcare hailed Bob as the 14th most influential physician executive in the entire country.
On the ABIM board, Bob has represented the best of HM and brought our innovative spirit and our commitment to improvement, safety, and change leadership, culminating this year in the ABIM chairmanship. Bob will offer his unique insights into HM and the national healthcare agenda at HM13 (www.hospitalmedicine 2013.org).
CEO: Telemedicine for the ICU
Mary Jo Gorman, MD, MHM, is a hospitalist and intensivist who made her mark on HM as the chief medical officer (CMO) of IPC: The Hospitalist Company. As she offered her talents to SHM, she became chairman of SHM’s Public Policy Committee and eventually SHM president.
For the last few years, Mary Jo has been the CEO of ICUMedicine. In this role, she has been active around the country, bringing ICU competencies to many community hospitals by offering a telemedicine solution for critically ill patients. This unconventional approach to meeting a glaring need fits into Mary Jo’s career history of looking for new and different ways to bring better healthcare solutions to the front lines of patient care. Last year, Modern Healthcare recognized Mary Jo as one of the most influential female physician executives in the country.
CEO, Medical University of South Carolina (MUSC) Hospitals
After leaving Duke University, Pat Cawley, MD, MBA, MHM, started his career as a community-based hospitalist leader. After a number of leadership roles at SHM, Pat served as SHM president and was elected a Master in Hospital Medicine in 2012.
Pat initially was recruited to MUSC to build and manage their HM group. Soon he was tapped to be the CMO at MUSC. Earlier this year, Pat became the first hospitalist to be chosen to run a major academic medical center when he was promoted to CEO at MUSC.
In recent years, Pat has been a leading voice as the American Hospital Association looks to involve physician leaders. He is a rising star at AHA, helping to merge the cultures of hospital administrators and physicians to create the hospital of the future.
Hospitalists Contribute at the Highest Level
Obviously, I could go on and on, adding other hospitalists who are making unique and important contributions at the local and national level. It is interesting that at a time when many are still trying to get their heads around just what HM is, we already can recognize the immense talent that resides in hospitalist groups across the country. At a time when the U.S. healthcare system is being reshaped, hospitalists, such as those mentioned above and oh-so-many more, are already making large and small steps forward. We are helping to create a new healthcare enterprise, based on value, efficiency, effectiveness, and putting the patient first.
SHM wants to continue to be the place where the innovators and thought leaders of today and tomorrow can come together to multiply their efforts. The challenges are daunting, but the results can be rewarding, and the members of SHM are ready to bring our talents, energies, and commitments to do our part in this great American journey.
Exceptional hospitalists
Even though hospital medicine and SHM are still relatively young, we can be very proud of what our specialty already has brought to changing our nation’s health care for the better. Many of these accomplishments, from winning the prestigious Eisenberg Award to our change leadership by SHM’s Center for Healthcare Innovation and Improvement at more 300 hospitals to the extraordinary growth of our specialty, have been well chronicled in The Hospitalist and elsewhere the last few years.
I wanted to use this month’s column to highlight the unique career directions of a few SHM members to shine a bright light on the influence hospitalists are making nationwide. Certainly, there are many more hospitalists beyond this group of five that I have selected, but this small cadre should serve as an example of the talent and reach of our specialty—with only more and greater things ahead to come in the future.
Chief Medical Officer of CMS
Pat Conway, MD, SFHM, is a pediatric hospitalist and the former chair of SHM’s Public Policy Committee. He left his pediatric academic practice to become a White House fellow, then returned to Cincinnati Children’s Hospital to serve as chief medical officer (CMO). When Don Berwick was in charge of the Centers for Medicare & Medicaid Services (CMS), he reached out to Pat and asked him to come to Washington to be part of Medicare’s senior team as the CMO for CMS. In this role, Pat has been a nationally recognized leader in performance improvement and patient safety, and he has been instrumental in bringing about evolutionary changes to the largest healthcare program in the world. Pat will be sharing his perspectives as a keynote speaker at HM13 (check out our 10-page HM13 preview starting on p. 45).
Resident Fellow at the American Enterprise Institute
Scott Gottlieb, MD, is a practicing hospitalist in New York City, but he is better known as a leading expert in healthcare policy, most recently acting as an advisor to presidential candidate Mitt Romney. From 2005 to 2007, Scott was a deputy commissioner at the FDA. He has worked as a senior advisor to the administrator at CMS, where he played an instrumental role in the implementation of the Medicare Drug Benefit in 2004.
Scott is best known for his frequent contributions to The Wall Street Journal, The New York Times, USA Today, and Forbes. He has held editorial positions at the British Medical Journal and the Journal of the American Medical Association, regularly appears as a guest commentator on CNBC, and is a frequent contributor to Politico.
At SHM, Scott has brought his national viewpoint to the Public Policy Committee. He proudly touts his experience as a practicing hospitalist as bringing a front-line reality to his national recognition and much-sought-after critical thinking about healthcare policy.
Chairman of the American Board of Internal Medicine
Bob Wachter, MD, MHM, was a thought leader in HM before our specialty even had a name, writing the initial peer-reviewed articles and coining the term “hospitalist.” Bob has built a pre-eminent hospitalist program at the University of California at San Francisco and helped influence and populate much of academic HM. His Wachter’s World blog (www.wachtersworld.com) is one of the most widely read medical blogs, reaching an audience well beyond our specialty.
Bob was one of the first presidents of SHM—back when we were known as NAIP, or the National Association of Inpatient Physicians—and set SHM on its strong growth and innovative direction that has made us the envy of other medical specialty societies. Last year, Modern Healthcare hailed Bob as the 14th most influential physician executive in the entire country.
On the ABIM board, Bob has represented the best of HM and brought our innovative spirit and our commitment to improvement, safety, and change leadership, culminating this year in the ABIM chairmanship. Bob will offer his unique insights into HM and the national healthcare agenda at HM13 (www.hospitalmedicine 2013.org).
CEO: Telemedicine for the ICU
Mary Jo Gorman, MD, MHM, is a hospitalist and intensivist who made her mark on HM as the chief medical officer (CMO) of IPC: The Hospitalist Company. As she offered her talents to SHM, she became chairman of SHM’s Public Policy Committee and eventually SHM president.
For the last few years, Mary Jo has been the CEO of ICUMedicine. In this role, she has been active around the country, bringing ICU competencies to many community hospitals by offering a telemedicine solution for critically ill patients. This unconventional approach to meeting a glaring need fits into Mary Jo’s career history of looking for new and different ways to bring better healthcare solutions to the front lines of patient care. Last year, Modern Healthcare recognized Mary Jo as one of the most influential female physician executives in the country.
CEO, Medical University of South Carolina (MUSC) Hospitals
After leaving Duke University, Pat Cawley, MD, MBA, MHM, started his career as a community-based hospitalist leader. After a number of leadership roles at SHM, Pat served as SHM president and was elected a Master in Hospital Medicine in 2012.
Pat initially was recruited to MUSC to build and manage their HM group. Soon he was tapped to be the CMO at MUSC. Earlier this year, Pat became the first hospitalist to be chosen to run a major academic medical center when he was promoted to CEO at MUSC.
In recent years, Pat has been a leading voice as the American Hospital Association looks to involve physician leaders. He is a rising star at AHA, helping to merge the cultures of hospital administrators and physicians to create the hospital of the future.
Hospitalists Contribute at the Highest Level
Obviously, I could go on and on, adding other hospitalists who are making unique and important contributions at the local and national level. It is interesting that at a time when many are still trying to get their heads around just what HM is, we already can recognize the immense talent that resides in hospitalist groups across the country. At a time when the U.S. healthcare system is being reshaped, hospitalists, such as those mentioned above and oh-so-many more, are already making large and small steps forward. We are helping to create a new healthcare enterprise, based on value, efficiency, effectiveness, and putting the patient first.
SHM wants to continue to be the place where the innovators and thought leaders of today and tomorrow can come together to multiply their efforts. The challenges are daunting, but the results can be rewarding, and the members of SHM are ready to bring our talents, energies, and commitments to do our part in this great American journey.
Exceptional hospitalists
Even though hospital medicine and SHM are still relatively young, we can be very proud of what our specialty already has brought to changing our nation’s health care for the better. Many of these accomplishments, from winning the prestigious Eisenberg Award to our change leadership by SHM’s Center for Healthcare Innovation and Improvement at more 300 hospitals to the extraordinary growth of our specialty, have been well chronicled in The Hospitalist and elsewhere the last few years.
I wanted to use this month’s column to highlight the unique career directions of a few SHM members to shine a bright light on the influence hospitalists are making nationwide. Certainly, there are many more hospitalists beyond this group of five that I have selected, but this small cadre should serve as an example of the talent and reach of our specialty—with only more and greater things ahead to come in the future.
Chief Medical Officer of CMS
Pat Conway, MD, SFHM, is a pediatric hospitalist and the former chair of SHM’s Public Policy Committee. He left his pediatric academic practice to become a White House fellow, then returned to Cincinnati Children’s Hospital to serve as chief medical officer (CMO). When Don Berwick was in charge of the Centers for Medicare & Medicaid Services (CMS), he reached out to Pat and asked him to come to Washington to be part of Medicare’s senior team as the CMO for CMS. In this role, Pat has been a nationally recognized leader in performance improvement and patient safety, and he has been instrumental in bringing about evolutionary changes to the largest healthcare program in the world. Pat will be sharing his perspectives as a keynote speaker at HM13 (check out our 10-page HM13 preview starting on p. 45).
Resident Fellow at the American Enterprise Institute
Scott Gottlieb, MD, is a practicing hospitalist in New York City, but he is better known as a leading expert in healthcare policy, most recently acting as an advisor to presidential candidate Mitt Romney. From 2005 to 2007, Scott was a deputy commissioner at the FDA. He has worked as a senior advisor to the administrator at CMS, where he played an instrumental role in the implementation of the Medicare Drug Benefit in 2004.
Scott is best known for his frequent contributions to The Wall Street Journal, The New York Times, USA Today, and Forbes. He has held editorial positions at the British Medical Journal and the Journal of the American Medical Association, regularly appears as a guest commentator on CNBC, and is a frequent contributor to Politico.
At SHM, Scott has brought his national viewpoint to the Public Policy Committee. He proudly touts his experience as a practicing hospitalist as bringing a front-line reality to his national recognition and much-sought-after critical thinking about healthcare policy.
Chairman of the American Board of Internal Medicine
Bob Wachter, MD, MHM, was a thought leader in HM before our specialty even had a name, writing the initial peer-reviewed articles and coining the term “hospitalist.” Bob has built a pre-eminent hospitalist program at the University of California at San Francisco and helped influence and populate much of academic HM. His Wachter’s World blog (www.wachtersworld.com) is one of the most widely read medical blogs, reaching an audience well beyond our specialty.
Bob was one of the first presidents of SHM—back when we were known as NAIP, or the National Association of Inpatient Physicians—and set SHM on its strong growth and innovative direction that has made us the envy of other medical specialty societies. Last year, Modern Healthcare hailed Bob as the 14th most influential physician executive in the entire country.
On the ABIM board, Bob has represented the best of HM and brought our innovative spirit and our commitment to improvement, safety, and change leadership, culminating this year in the ABIM chairmanship. Bob will offer his unique insights into HM and the national healthcare agenda at HM13 (www.hospitalmedicine 2013.org).
CEO: Telemedicine for the ICU
Mary Jo Gorman, MD, MHM, is a hospitalist and intensivist who made her mark on HM as the chief medical officer (CMO) of IPC: The Hospitalist Company. As she offered her talents to SHM, she became chairman of SHM’s Public Policy Committee and eventually SHM president.
For the last few years, Mary Jo has been the CEO of ICUMedicine. In this role, she has been active around the country, bringing ICU competencies to many community hospitals by offering a telemedicine solution for critically ill patients. This unconventional approach to meeting a glaring need fits into Mary Jo’s career history of looking for new and different ways to bring better healthcare solutions to the front lines of patient care. Last year, Modern Healthcare recognized Mary Jo as one of the most influential female physician executives in the country.
CEO, Medical University of South Carolina (MUSC) Hospitals
After leaving Duke University, Pat Cawley, MD, MBA, MHM, started his career as a community-based hospitalist leader. After a number of leadership roles at SHM, Pat served as SHM president and was elected a Master in Hospital Medicine in 2012.
Pat initially was recruited to MUSC to build and manage their HM group. Soon he was tapped to be the CMO at MUSC. Earlier this year, Pat became the first hospitalist to be chosen to run a major academic medical center when he was promoted to CEO at MUSC.
In recent years, Pat has been a leading voice as the American Hospital Association looks to involve physician leaders. He is a rising star at AHA, helping to merge the cultures of hospital administrators and physicians to create the hospital of the future.
Hospitalists Contribute at the Highest Level
Obviously, I could go on and on, adding other hospitalists who are making unique and important contributions at the local and national level. It is interesting that at a time when many are still trying to get their heads around just what HM is, we already can recognize the immense talent that resides in hospitalist groups across the country. At a time when the U.S. healthcare system is being reshaped, hospitalists, such as those mentioned above and oh-so-many more, are already making large and small steps forward. We are helping to create a new healthcare enterprise, based on value, efficiency, effectiveness, and putting the patient first.
SHM wants to continue to be the place where the innovators and thought leaders of today and tomorrow can come together to multiply their efforts. The challenges are daunting, but the results can be rewarding, and the members of SHM are ready to bring our talents, energies, and commitments to do our part in this great American journey.
Medicare Funding May Become Enormous Burden for Generations of Future Taxpayers
February 2033
Dear sons:
Now that most of my baby boomer friends are 80 or 90 years old and are still hanging on, I wanted to apologize for leaving you in such a mess. Looking back, we all should have made some tough choices back in 2013, when some thoughtful belt-tightening would have created a fiscally sound ability for our country to provide healthcare and a safety net, not only to our senior citizens, but to all Americans. After today’s riots across the country, I felt I had to reach out to you and beg you to let rational minds prevail.
My fellow seniors, who paid into the Medicare and Social Security programs through our payroll taxes during the 30 to 40 years we worked in American industries, believe we are entitled to live forever with unlimited healthcare paid for by you. We are lined up almost every day at one doctor’s office or another to have our fourth joint replacement or our monthly MRI. Even though the actuaries tell us we all blew through our own contributions to Medicare sometime around our 75th birthdays, the general thinking of my friends on the golf course is that we paid for our parents’ healthcare and retirement, and you should just suck it up and stop whining.
Now I do admit that my friends tend to overlook the fact that when we were just in our 50s, like you are now, there were eight or nine workers (i.e. taxpayers) for every retiree. Now it seems it is one taxpayer working to support one retiree. The math just doesn’t work anymore. No wonder your tax burden is so suffocating that young workers can’t afford a home or a second car or even a vacation. I can see why there is talk by some of rationing care, but some of the rhetoric is kind of frightening.
Yes, there are more 90-year-olds with severe dementia on chronic dialysis than I would like to see. I don’t necessarily agree that everyone has a right to die with a normal BUN. Our generation did some great things with immunizations, cancer prevention, reducing the risks of coronary heart disease, and stroke prevention and treatment. The end result is that many of those who would have died earlier have lived beyond our country’s means to provide for them. For heaven’s sake, there are more than 1 million Americans over the age of 100 today. Once a woman gets past 65, it seems they are destined to live indefinitely.
Believe it or not, I was around in the 1960s when Medicare was first discussed and people were looking at life expectancies in the early 70s. No one saw the advent of so much expensive technology in diagnostic testing and surgical intervention. Despite more bipartisan national commissions and reports than I care to remember, no president or Congress has had the cojones to make the tough choices to provide the basic health needs for seniors in a fiscally sound system that doesn’t overwhelm the workforce.
I know the slogans urge a move from Medicare to “MediCan’t.” I know some want to bar seniors from getting flu shots and want to have pneumonia be the old man’s friend again. I sense a feeling that the elderly are becoming the enemy of the working class. I hear the rants that most of our nation’s wealth is held by those over 65, yet my generation wants more and more, feeling we paid for this and we deserve everything we have coming to us.
Once again, sorry this all had to fall on you, but I have got to run. I am going to see your grandmother. I can’t believe how well she is recovering from arthroscopic surgery. Pretty amazing for someone who is 105 years old.
Love,
Dad
Dr. Wellikson is CEO of SHM.
February 2033
Dear sons:
Now that most of my baby boomer friends are 80 or 90 years old and are still hanging on, I wanted to apologize for leaving you in such a mess. Looking back, we all should have made some tough choices back in 2013, when some thoughtful belt-tightening would have created a fiscally sound ability for our country to provide healthcare and a safety net, not only to our senior citizens, but to all Americans. After today’s riots across the country, I felt I had to reach out to you and beg you to let rational minds prevail.
My fellow seniors, who paid into the Medicare and Social Security programs through our payroll taxes during the 30 to 40 years we worked in American industries, believe we are entitled to live forever with unlimited healthcare paid for by you. We are lined up almost every day at one doctor’s office or another to have our fourth joint replacement or our monthly MRI. Even though the actuaries tell us we all blew through our own contributions to Medicare sometime around our 75th birthdays, the general thinking of my friends on the golf course is that we paid for our parents’ healthcare and retirement, and you should just suck it up and stop whining.
Now I do admit that my friends tend to overlook the fact that when we were just in our 50s, like you are now, there were eight or nine workers (i.e. taxpayers) for every retiree. Now it seems it is one taxpayer working to support one retiree. The math just doesn’t work anymore. No wonder your tax burden is so suffocating that young workers can’t afford a home or a second car or even a vacation. I can see why there is talk by some of rationing care, but some of the rhetoric is kind of frightening.
Yes, there are more 90-year-olds with severe dementia on chronic dialysis than I would like to see. I don’t necessarily agree that everyone has a right to die with a normal BUN. Our generation did some great things with immunizations, cancer prevention, reducing the risks of coronary heart disease, and stroke prevention and treatment. The end result is that many of those who would have died earlier have lived beyond our country’s means to provide for them. For heaven’s sake, there are more than 1 million Americans over the age of 100 today. Once a woman gets past 65, it seems they are destined to live indefinitely.
Believe it or not, I was around in the 1960s when Medicare was first discussed and people were looking at life expectancies in the early 70s. No one saw the advent of so much expensive technology in diagnostic testing and surgical intervention. Despite more bipartisan national commissions and reports than I care to remember, no president or Congress has had the cojones to make the tough choices to provide the basic health needs for seniors in a fiscally sound system that doesn’t overwhelm the workforce.
I know the slogans urge a move from Medicare to “MediCan’t.” I know some want to bar seniors from getting flu shots and want to have pneumonia be the old man’s friend again. I sense a feeling that the elderly are becoming the enemy of the working class. I hear the rants that most of our nation’s wealth is held by those over 65, yet my generation wants more and more, feeling we paid for this and we deserve everything we have coming to us.
Once again, sorry this all had to fall on you, but I have got to run. I am going to see your grandmother. I can’t believe how well she is recovering from arthroscopic surgery. Pretty amazing for someone who is 105 years old.
Love,
Dad
Dr. Wellikson is CEO of SHM.
February 2033
Dear sons:
Now that most of my baby boomer friends are 80 or 90 years old and are still hanging on, I wanted to apologize for leaving you in such a mess. Looking back, we all should have made some tough choices back in 2013, when some thoughtful belt-tightening would have created a fiscally sound ability for our country to provide healthcare and a safety net, not only to our senior citizens, but to all Americans. After today’s riots across the country, I felt I had to reach out to you and beg you to let rational minds prevail.
My fellow seniors, who paid into the Medicare and Social Security programs through our payroll taxes during the 30 to 40 years we worked in American industries, believe we are entitled to live forever with unlimited healthcare paid for by you. We are lined up almost every day at one doctor’s office or another to have our fourth joint replacement or our monthly MRI. Even though the actuaries tell us we all blew through our own contributions to Medicare sometime around our 75th birthdays, the general thinking of my friends on the golf course is that we paid for our parents’ healthcare and retirement, and you should just suck it up and stop whining.
Now I do admit that my friends tend to overlook the fact that when we were just in our 50s, like you are now, there were eight or nine workers (i.e. taxpayers) for every retiree. Now it seems it is one taxpayer working to support one retiree. The math just doesn’t work anymore. No wonder your tax burden is so suffocating that young workers can’t afford a home or a second car or even a vacation. I can see why there is talk by some of rationing care, but some of the rhetoric is kind of frightening.
Yes, there are more 90-year-olds with severe dementia on chronic dialysis than I would like to see. I don’t necessarily agree that everyone has a right to die with a normal BUN. Our generation did some great things with immunizations, cancer prevention, reducing the risks of coronary heart disease, and stroke prevention and treatment. The end result is that many of those who would have died earlier have lived beyond our country’s means to provide for them. For heaven’s sake, there are more than 1 million Americans over the age of 100 today. Once a woman gets past 65, it seems they are destined to live indefinitely.
Believe it or not, I was around in the 1960s when Medicare was first discussed and people were looking at life expectancies in the early 70s. No one saw the advent of so much expensive technology in diagnostic testing and surgical intervention. Despite more bipartisan national commissions and reports than I care to remember, no president or Congress has had the cojones to make the tough choices to provide the basic health needs for seniors in a fiscally sound system that doesn’t overwhelm the workforce.
I know the slogans urge a move from Medicare to “MediCan’t.” I know some want to bar seniors from getting flu shots and want to have pneumonia be the old man’s friend again. I sense a feeling that the elderly are becoming the enemy of the working class. I hear the rants that most of our nation’s wealth is held by those over 65, yet my generation wants more and more, feeling we paid for this and we deserve everything we have coming to us.
Once again, sorry this all had to fall on you, but I have got to run. I am going to see your grandmother. I can’t believe how well she is recovering from arthroscopic surgery. Pretty amazing for someone who is 105 years old.
Love,
Dad
Dr. Wellikson is CEO of SHM.
The Hospital Home Team: Physicians Increase Focus on Inpatient Care
For most of my medical career, the hospital functioned more as a swap meet, where every physician had his or her own booth, than as an integrated, community health resource with a focused mission. Although the innovation of HM might be counted as the beginning of a new, more aligned approach between physicians and the hospital as an institution, the rapidly evolving employment of physicians by hospitals and the focusing of physician practice primarily on inpatient care has taken this to another level.
The New Paradigm
A number of recent surveys by physician recruitment firms and physician management companies have found that less than 25% of physicians are self-employed. Planned changes to insurance and Medicare reimbursement for healthcare have driven cardiologists, orthopedists, surgeons, and many other physicians, who want to protect their flow of patients and dollars, to readily become hospital or large-group-practice employees. The entrance of accountable-care organizations (ACOs) to the landscape and the greater need for physician and hospital alignment have only accelerated this trend.
At the same time, the growth of all sorts of hospitalist specialties has further changed the medical staff of the hospital. Internal-medicine and family-practice hospitalists now number more than 35,000. There are probably more than 2,000 pediatric hospitalists. The newly formed Society of OB/GYN Hospitalists (SOGH) estimates there are more than 1,500 so-called laborists in the U.S., and there are several hundred neurohospitalists, orthopedic hospitalists, and acute-care surgeons.
It is clear to me that a “home team” for the hospital of the future is developing, and it includes hospitalists, ED physicians, critical-care physicians, and the growing panoply of hospital-employed cardiologists and surgeons. There is an opportunity for alignment and integration in what has been a fragmented delivery of healthcare.
On the commercial side of the equation, this new opportunity for physician-hospital alignment might allow for a new distribution of compensation. It already is common for hospitals to be transferring some of “their” Medicare Part A dollars to hospitalists. With penalties or additional payments in the ACO model (e.g. shared savings) or in value-based purchasing, there certainly are mechanisms to redistribute funding to new physician compensation models, based more on performance than on volume of services (i.e. the old productivity model).
On another level, where compensation and performance merge, the new medical staff has the ability to deliver a safer hospital experience to our patients and to improve performance. This could take the form of reduction in hospital-acquired infections (HAIs) or reducing unnecessary DVTs and PEs. It could take the form of a better discharge process that leads to fewer unnecessary readmissions or fewer preventable ED visits. On the OB side, 24-hour on-site availability of OB hospitalists has been shown to reduce adverse birth events and, therefore, reduce liability risk and malpractice premiums. On-site availability for patients with fractures and trauma cases by orthopedic hospitalists or hospital-employed orthopedists also can reduce expenses and adverse events for these acutely ill patients.
HM’s Role
With all these changes occurring so rapidly and with all these new players being thrown into the stew at the hospital, it may be worth a few minutes for the “traditional” hospitalist on the medical service to step back and see how our role may evolve. We already have an increasing role in comanagement of surgical and subspecialty patients, as well as a more integrated role at the ED-hospitalist interface. As hospitals look for hospital-focused physicians, there is a potential for scope creep that must be thoughtfully managed.
This may require “rules of engagement” with other key services. While it may be appropriate for a patient with an acute abdomen to be admitted to the hospitalist service, if the hospitalist determines that this patient needs surgery sooner rather than later, there needs to be a straightforward way to get the surgeon in house and on the case and the patient to the operating room. To this point, medical hospitalists can help manage the medical aspects of a neurosurgical case, but we don’t do burr holes. And if there is to be pushback from the surgeon, this can’t happen at 2 a.m. over the telephone; it must be handled by the service leaders at their weekly meeting.
On another level, hospitalists need to be careful that the hospital doesn’t just hand us the administrative functions of other physicians’ care. Hospitalists are not the default to do H&Ps on surgical cases or handle their discharges, even if this falls into the hospital strategy to be able to employ fewer high-priced surgeons and subspecialists by handing off some of their work to their hospitalists.
On the other hand, it is totally appropriate for many of the hospital-focused physicians to come together, possibly under the leadership of the hospital CMO, to look at the workflow and to set up a new way to deliver healthcare that not only redefines the workload, but also involves the rest of the team, including nursing, pharmacy, case management, and social services. Medical hospitalists will need to consider whether we should be the hub of the new physician enterprise and what that would mean for workload, FTEs, and scope of practice.
Such organizations as SHM and the American Hospital Association (AHA) are thinking how best to support and convene the hospital-based physician. AHA has developed a Physician Forum with more than 6,000 members who now have their practices aligned with their hospital. SHM has held meetings of the leaders of hospital-focused practice and is developing virtual forums on Hospital Medicine Exchange to keep the discussion going. Through the Hospital Care Collaborative (HCC), SHM is engaging the leadership of pharmacy, nursing, case management, social services, and respiratory therapy.
Although we are still early in creating the direction for the new medical staff, the water is rising and the current is moving rapidly. The strong forces that are driving new payment paradigms are leading to changes in compensation and an emphasis on definable, measureable outcomes of performance and safety. Hospitalists, who have been thinking in this way and who have some experience in the new ways, should be well positioned to lead and participate actively in the formation of the new hospital home team.
When opportunity knocks, you still have to get up and answer the door. It’s time to get ready to step up.
Dr. Wellikson is CEO of SHM.
For most of my medical career, the hospital functioned more as a swap meet, where every physician had his or her own booth, than as an integrated, community health resource with a focused mission. Although the innovation of HM might be counted as the beginning of a new, more aligned approach between physicians and the hospital as an institution, the rapidly evolving employment of physicians by hospitals and the focusing of physician practice primarily on inpatient care has taken this to another level.
The New Paradigm
A number of recent surveys by physician recruitment firms and physician management companies have found that less than 25% of physicians are self-employed. Planned changes to insurance and Medicare reimbursement for healthcare have driven cardiologists, orthopedists, surgeons, and many other physicians, who want to protect their flow of patients and dollars, to readily become hospital or large-group-practice employees. The entrance of accountable-care organizations (ACOs) to the landscape and the greater need for physician and hospital alignment have only accelerated this trend.
At the same time, the growth of all sorts of hospitalist specialties has further changed the medical staff of the hospital. Internal-medicine and family-practice hospitalists now number more than 35,000. There are probably more than 2,000 pediatric hospitalists. The newly formed Society of OB/GYN Hospitalists (SOGH) estimates there are more than 1,500 so-called laborists in the U.S., and there are several hundred neurohospitalists, orthopedic hospitalists, and acute-care surgeons.
It is clear to me that a “home team” for the hospital of the future is developing, and it includes hospitalists, ED physicians, critical-care physicians, and the growing panoply of hospital-employed cardiologists and surgeons. There is an opportunity for alignment and integration in what has been a fragmented delivery of healthcare.
On the commercial side of the equation, this new opportunity for physician-hospital alignment might allow for a new distribution of compensation. It already is common for hospitals to be transferring some of “their” Medicare Part A dollars to hospitalists. With penalties or additional payments in the ACO model (e.g. shared savings) or in value-based purchasing, there certainly are mechanisms to redistribute funding to new physician compensation models, based more on performance than on volume of services (i.e. the old productivity model).
On another level, where compensation and performance merge, the new medical staff has the ability to deliver a safer hospital experience to our patients and to improve performance. This could take the form of reduction in hospital-acquired infections (HAIs) or reducing unnecessary DVTs and PEs. It could take the form of a better discharge process that leads to fewer unnecessary readmissions or fewer preventable ED visits. On the OB side, 24-hour on-site availability of OB hospitalists has been shown to reduce adverse birth events and, therefore, reduce liability risk and malpractice premiums. On-site availability for patients with fractures and trauma cases by orthopedic hospitalists or hospital-employed orthopedists also can reduce expenses and adverse events for these acutely ill patients.
HM’s Role
With all these changes occurring so rapidly and with all these new players being thrown into the stew at the hospital, it may be worth a few minutes for the “traditional” hospitalist on the medical service to step back and see how our role may evolve. We already have an increasing role in comanagement of surgical and subspecialty patients, as well as a more integrated role at the ED-hospitalist interface. As hospitals look for hospital-focused physicians, there is a potential for scope creep that must be thoughtfully managed.
This may require “rules of engagement” with other key services. While it may be appropriate for a patient with an acute abdomen to be admitted to the hospitalist service, if the hospitalist determines that this patient needs surgery sooner rather than later, there needs to be a straightforward way to get the surgeon in house and on the case and the patient to the operating room. To this point, medical hospitalists can help manage the medical aspects of a neurosurgical case, but we don’t do burr holes. And if there is to be pushback from the surgeon, this can’t happen at 2 a.m. over the telephone; it must be handled by the service leaders at their weekly meeting.
On another level, hospitalists need to be careful that the hospital doesn’t just hand us the administrative functions of other physicians’ care. Hospitalists are not the default to do H&Ps on surgical cases or handle their discharges, even if this falls into the hospital strategy to be able to employ fewer high-priced surgeons and subspecialists by handing off some of their work to their hospitalists.
On the other hand, it is totally appropriate for many of the hospital-focused physicians to come together, possibly under the leadership of the hospital CMO, to look at the workflow and to set up a new way to deliver healthcare that not only redefines the workload, but also involves the rest of the team, including nursing, pharmacy, case management, and social services. Medical hospitalists will need to consider whether we should be the hub of the new physician enterprise and what that would mean for workload, FTEs, and scope of practice.
Such organizations as SHM and the American Hospital Association (AHA) are thinking how best to support and convene the hospital-based physician. AHA has developed a Physician Forum with more than 6,000 members who now have their practices aligned with their hospital. SHM has held meetings of the leaders of hospital-focused practice and is developing virtual forums on Hospital Medicine Exchange to keep the discussion going. Through the Hospital Care Collaborative (HCC), SHM is engaging the leadership of pharmacy, nursing, case management, social services, and respiratory therapy.
Although we are still early in creating the direction for the new medical staff, the water is rising and the current is moving rapidly. The strong forces that are driving new payment paradigms are leading to changes in compensation and an emphasis on definable, measureable outcomes of performance and safety. Hospitalists, who have been thinking in this way and who have some experience in the new ways, should be well positioned to lead and participate actively in the formation of the new hospital home team.
When opportunity knocks, you still have to get up and answer the door. It’s time to get ready to step up.
Dr. Wellikson is CEO of SHM.
For most of my medical career, the hospital functioned more as a swap meet, where every physician had his or her own booth, than as an integrated, community health resource with a focused mission. Although the innovation of HM might be counted as the beginning of a new, more aligned approach between physicians and the hospital as an institution, the rapidly evolving employment of physicians by hospitals and the focusing of physician practice primarily on inpatient care has taken this to another level.
The New Paradigm
A number of recent surveys by physician recruitment firms and physician management companies have found that less than 25% of physicians are self-employed. Planned changes to insurance and Medicare reimbursement for healthcare have driven cardiologists, orthopedists, surgeons, and many other physicians, who want to protect their flow of patients and dollars, to readily become hospital or large-group-practice employees. The entrance of accountable-care organizations (ACOs) to the landscape and the greater need for physician and hospital alignment have only accelerated this trend.
At the same time, the growth of all sorts of hospitalist specialties has further changed the medical staff of the hospital. Internal-medicine and family-practice hospitalists now number more than 35,000. There are probably more than 2,000 pediatric hospitalists. The newly formed Society of OB/GYN Hospitalists (SOGH) estimates there are more than 1,500 so-called laborists in the U.S., and there are several hundred neurohospitalists, orthopedic hospitalists, and acute-care surgeons.
It is clear to me that a “home team” for the hospital of the future is developing, and it includes hospitalists, ED physicians, critical-care physicians, and the growing panoply of hospital-employed cardiologists and surgeons. There is an opportunity for alignment and integration in what has been a fragmented delivery of healthcare.
On the commercial side of the equation, this new opportunity for physician-hospital alignment might allow for a new distribution of compensation. It already is common for hospitals to be transferring some of “their” Medicare Part A dollars to hospitalists. With penalties or additional payments in the ACO model (e.g. shared savings) or in value-based purchasing, there certainly are mechanisms to redistribute funding to new physician compensation models, based more on performance than on volume of services (i.e. the old productivity model).
On another level, where compensation and performance merge, the new medical staff has the ability to deliver a safer hospital experience to our patients and to improve performance. This could take the form of reduction in hospital-acquired infections (HAIs) or reducing unnecessary DVTs and PEs. It could take the form of a better discharge process that leads to fewer unnecessary readmissions or fewer preventable ED visits. On the OB side, 24-hour on-site availability of OB hospitalists has been shown to reduce adverse birth events and, therefore, reduce liability risk and malpractice premiums. On-site availability for patients with fractures and trauma cases by orthopedic hospitalists or hospital-employed orthopedists also can reduce expenses and adverse events for these acutely ill patients.
HM’s Role
With all these changes occurring so rapidly and with all these new players being thrown into the stew at the hospital, it may be worth a few minutes for the “traditional” hospitalist on the medical service to step back and see how our role may evolve. We already have an increasing role in comanagement of surgical and subspecialty patients, as well as a more integrated role at the ED-hospitalist interface. As hospitals look for hospital-focused physicians, there is a potential for scope creep that must be thoughtfully managed.
This may require “rules of engagement” with other key services. While it may be appropriate for a patient with an acute abdomen to be admitted to the hospitalist service, if the hospitalist determines that this patient needs surgery sooner rather than later, there needs to be a straightforward way to get the surgeon in house and on the case and the patient to the operating room. To this point, medical hospitalists can help manage the medical aspects of a neurosurgical case, but we don’t do burr holes. And if there is to be pushback from the surgeon, this can’t happen at 2 a.m. over the telephone; it must be handled by the service leaders at their weekly meeting.
On another level, hospitalists need to be careful that the hospital doesn’t just hand us the administrative functions of other physicians’ care. Hospitalists are not the default to do H&Ps on surgical cases or handle their discharges, even if this falls into the hospital strategy to be able to employ fewer high-priced surgeons and subspecialists by handing off some of their work to their hospitalists.
On the other hand, it is totally appropriate for many of the hospital-focused physicians to come together, possibly under the leadership of the hospital CMO, to look at the workflow and to set up a new way to deliver healthcare that not only redefines the workload, but also involves the rest of the team, including nursing, pharmacy, case management, and social services. Medical hospitalists will need to consider whether we should be the hub of the new physician enterprise and what that would mean for workload, FTEs, and scope of practice.
Such organizations as SHM and the American Hospital Association (AHA) are thinking how best to support and convene the hospital-based physician. AHA has developed a Physician Forum with more than 6,000 members who now have their practices aligned with their hospital. SHM has held meetings of the leaders of hospital-focused practice and is developing virtual forums on Hospital Medicine Exchange to keep the discussion going. Through the Hospital Care Collaborative (HCC), SHM is engaging the leadership of pharmacy, nursing, case management, social services, and respiratory therapy.
Although we are still early in creating the direction for the new medical staff, the water is rising and the current is moving rapidly. The strong forces that are driving new payment paradigms are leading to changes in compensation and an emphasis on definable, measureable outcomes of performance and safety. Hospitalists, who have been thinking in this way and who have some experience in the new ways, should be well positioned to lead and participate actively in the formation of the new hospital home team.
When opportunity knocks, you still have to get up and answer the door. It’s time to get ready to step up.
Dr. Wellikson is CEO of SHM.
Managing the Customer Care Experience in Hospital Care
I needed an oil change, so I took my car to Jiffy Lube. I had just pulled into the entrance to one of the service bays when a smiling man whose nametag read “Tony” approached me. “Welcome back, Mr. Wellikson. What can we help you with today?” Well, that was nice and so unexpected, as I had not remembered ever going to that Jiffy Lube. As it turns out, they have a video camera that shows incoming cars in their control room. They can read my license plate and call up my car on their computer system, access my record, and create a personal greeting. They also used my car’s past history as a starting point for this encounter. We were off to a good start.
Once I indicated I just wanted a routine oil change, Tony indicated he would be back in five to 10 minutes. He told me I should wait in the waiting room where they had wireless Internet, TV, magazines, and comfortable chairs.
In less than 10 minutes, Tony was back, clipboard in hand, with an assessment of my car’s status, including previous work and manufacturer’s recommendations, based on my car’s age and mileage. Once we negotiated not replacing all of the fluids and filters, Tony smiled and said the work should be completed in 10 minutes.
Soon, Tony came back to lead me out to my car, which had been wheeled out to the front of the garage bay with an open driver’s door waiting for me. After helping me into my seat, Tony came around and sat in the passenger seat and, once again with his ready clipboard, walked me through the 29 steps of inspections and fluid changes that had been made on my visit, reviewed the frequency of future needs for my vehicle, put a sticker on my inside windshield as a reminder, included $5 off for my next service, then patiently asked me if I had any questions.
Total time at Jiffy Lube: less than 30 minutes. Total cost: $29.99. Total customer experience: exceptional. Considering it was the third Jiffy Lube location I had used in the past three years, I can tell you the experience and system is the same throughout the company, whether the uniform name is Tony or Jose or Gladys.
Can such experiences offer hospitalists lessons about how we manage the customer experience in hospital care?
Scalable Innovation
In August 2012, Atul Gawande, MD, wrote a thought-provoking article in The New Yorker in which he coupled his detailed observation of how the restaurant chain The Cheesecake Factory manages to deliver 8 million meals annually nationwide with high quality at a reasonable cost and strong corporate profits with the emerging trend of healthcare delivery innovations being sought by large hospital chains and such innovations as ICU telemedicine.1
He noted that, according to the Bureau of Labor Statistics, less than 25% of physicians are currently self-employed, and the growing trend is hospitals being acquired or merged into larger and larger hospital chains. He observed that recent and future financial changes are moving toward payment for results and efficiencies and further away from just rewarding transactions and supplying services, whether of measureable value or with proven results. Cheesecake Factory has built its success on large-scale production-line processes that produce consistent results across hundreds of locations and millions of meals. It may now be time for healthcare, especially hospital care, to come into the 21st century, too.
How did Cheesecake Factory get to where they are? They studied what the best people were doing, figured out a way to standardize it, then looked for ways to bring it to everyone. Although we could look at research as medicine’s way of bringing new concepts forward, where we have fallen down as an industry and culture is our ability to deliver on this at the bedside. Why aren’t most myocardial infarction patients on beta-blockers? Why isn’t DVT prophylaxis universal? Why can’t we all wash our hands on a regular basis?
Medical care, especially the physician portion, has always placed an overwhelming bias on autonomy. We all know that even at the same hospital or within the same physician group of cardiologists or orthopedists (or even hospitalists) that there can be multiple ways to treat chest pain, replace a joint, or manage pneumonia. Dr. Gawande postulates that “customization should be 5%, not 95%, of what we do.” He is not suggesting cookbook medicine—rather, that we bring all of the current proven and consensus medical knowledge together and allow local professionals to agree to narrow their choices down to a consistent and reproducible process for managing care.
Hoag, a health network near my home in Orange County, Calif., has brought this approach to orthopedic care. Hoag purchased a smaller hospital near its main campus and is emphasizing state-of-the-art orthopedic care at the new facility. They aligned the incentives—clinically and financially—with a large but select group of orthopedists, and they have chosen just a few prosthetic choices for hip and knee replacements. They have narrowed their protocols for pre- and post-op care, and now do same-day joint replacements with lower complication rates and better return-to-activity results at lower costs. And trust me, the orthopedists at Hoag were as independent as any physicians you might run into. The demands of the new payor models and competition to provide consumers (i.e. patients) with a 21st-century experience pushed, pulled, and prodded these orthopedists, and an enlightened hospital leadership, to rise to the challenges.
HM Takeaway
So where do hospitalists fit into this emerging world of customer service, standardization, accountability for results, and payment change? As you might imagine, we are right in the middle of all of this. High-functioning HM groups have understood that we must help shape a better system for us to work in. We cannot perpetuate the old paradigm in which the hospital was simply a swap meet where each physician had a booth and performed a procedure with little regard to how efficient or effective the entire enterprise might be.
Hospitalists have always performed in a group setting and worked across the professional disciplines of medicine, surgery, and subspecialties, and with nurses, pharmacists, and therapists. In the best of breed, hospitalists are enculturated to think systemwide yet deliver to an individual patient.
As hospital chains look to standardize and deliver the best results and the most efficient use of resources, hospitalists can be positioned in a variety of ways. You can be an innovative partner, working with other professionals and the administration to seek new ways of doing things. You can be the manager or coordinator of other professionals and the rest of the team. But you also could evolve to be line workers and cogs in a larger machine, replaceable and commoditized. In the end, hospitalists will not only need to create value, but also position themselves to be professionally rewarded and respected for the value they create.
Dr. Gawande considers the perspectives of healthcare providers and patients as he looks to the future. “Patients won’t just look for the best specialist anymore; they’ll look for the best system,” he says. “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”
The changes ahead will be rapid and disruptive; some hospitals will be driven out of business, while some will be consolidated. Physicians will aggregate and become employees (although many will still think they are free agents). Standardization will be pushed, and customization and one-offs will be tolerated less and less.
In this new world, hospitalists have the opportunity to be at the leading edge, not just for other physicians but the entire healthcare team. We need to prepare for this challenge, not just with clinical skills, but with a culture and a mindset to adapt and evolve. We need to decide if we will be cogs in a machine or the innovators and managers of change. The time is now; the choice is ours.
Dr. Wellikson is CEO of SHM.
Reference
I needed an oil change, so I took my car to Jiffy Lube. I had just pulled into the entrance to one of the service bays when a smiling man whose nametag read “Tony” approached me. “Welcome back, Mr. Wellikson. What can we help you with today?” Well, that was nice and so unexpected, as I had not remembered ever going to that Jiffy Lube. As it turns out, they have a video camera that shows incoming cars in their control room. They can read my license plate and call up my car on their computer system, access my record, and create a personal greeting. They also used my car’s past history as a starting point for this encounter. We were off to a good start.
Once I indicated I just wanted a routine oil change, Tony indicated he would be back in five to 10 minutes. He told me I should wait in the waiting room where they had wireless Internet, TV, magazines, and comfortable chairs.
In less than 10 minutes, Tony was back, clipboard in hand, with an assessment of my car’s status, including previous work and manufacturer’s recommendations, based on my car’s age and mileage. Once we negotiated not replacing all of the fluids and filters, Tony smiled and said the work should be completed in 10 minutes.
Soon, Tony came back to lead me out to my car, which had been wheeled out to the front of the garage bay with an open driver’s door waiting for me. After helping me into my seat, Tony came around and sat in the passenger seat and, once again with his ready clipboard, walked me through the 29 steps of inspections and fluid changes that had been made on my visit, reviewed the frequency of future needs for my vehicle, put a sticker on my inside windshield as a reminder, included $5 off for my next service, then patiently asked me if I had any questions.
Total time at Jiffy Lube: less than 30 minutes. Total cost: $29.99. Total customer experience: exceptional. Considering it was the third Jiffy Lube location I had used in the past three years, I can tell you the experience and system is the same throughout the company, whether the uniform name is Tony or Jose or Gladys.
Can such experiences offer hospitalists lessons about how we manage the customer experience in hospital care?
Scalable Innovation
In August 2012, Atul Gawande, MD, wrote a thought-provoking article in The New Yorker in which he coupled his detailed observation of how the restaurant chain The Cheesecake Factory manages to deliver 8 million meals annually nationwide with high quality at a reasonable cost and strong corporate profits with the emerging trend of healthcare delivery innovations being sought by large hospital chains and such innovations as ICU telemedicine.1
He noted that, according to the Bureau of Labor Statistics, less than 25% of physicians are currently self-employed, and the growing trend is hospitals being acquired or merged into larger and larger hospital chains. He observed that recent and future financial changes are moving toward payment for results and efficiencies and further away from just rewarding transactions and supplying services, whether of measureable value or with proven results. Cheesecake Factory has built its success on large-scale production-line processes that produce consistent results across hundreds of locations and millions of meals. It may now be time for healthcare, especially hospital care, to come into the 21st century, too.
How did Cheesecake Factory get to where they are? They studied what the best people were doing, figured out a way to standardize it, then looked for ways to bring it to everyone. Although we could look at research as medicine’s way of bringing new concepts forward, where we have fallen down as an industry and culture is our ability to deliver on this at the bedside. Why aren’t most myocardial infarction patients on beta-blockers? Why isn’t DVT prophylaxis universal? Why can’t we all wash our hands on a regular basis?
Medical care, especially the physician portion, has always placed an overwhelming bias on autonomy. We all know that even at the same hospital or within the same physician group of cardiologists or orthopedists (or even hospitalists) that there can be multiple ways to treat chest pain, replace a joint, or manage pneumonia. Dr. Gawande postulates that “customization should be 5%, not 95%, of what we do.” He is not suggesting cookbook medicine—rather, that we bring all of the current proven and consensus medical knowledge together and allow local professionals to agree to narrow their choices down to a consistent and reproducible process for managing care.
Hoag, a health network near my home in Orange County, Calif., has brought this approach to orthopedic care. Hoag purchased a smaller hospital near its main campus and is emphasizing state-of-the-art orthopedic care at the new facility. They aligned the incentives—clinically and financially—with a large but select group of orthopedists, and they have chosen just a few prosthetic choices for hip and knee replacements. They have narrowed their protocols for pre- and post-op care, and now do same-day joint replacements with lower complication rates and better return-to-activity results at lower costs. And trust me, the orthopedists at Hoag were as independent as any physicians you might run into. The demands of the new payor models and competition to provide consumers (i.e. patients) with a 21st-century experience pushed, pulled, and prodded these orthopedists, and an enlightened hospital leadership, to rise to the challenges.
HM Takeaway
So where do hospitalists fit into this emerging world of customer service, standardization, accountability for results, and payment change? As you might imagine, we are right in the middle of all of this. High-functioning HM groups have understood that we must help shape a better system for us to work in. We cannot perpetuate the old paradigm in which the hospital was simply a swap meet where each physician had a booth and performed a procedure with little regard to how efficient or effective the entire enterprise might be.
Hospitalists have always performed in a group setting and worked across the professional disciplines of medicine, surgery, and subspecialties, and with nurses, pharmacists, and therapists. In the best of breed, hospitalists are enculturated to think systemwide yet deliver to an individual patient.
As hospital chains look to standardize and deliver the best results and the most efficient use of resources, hospitalists can be positioned in a variety of ways. You can be an innovative partner, working with other professionals and the administration to seek new ways of doing things. You can be the manager or coordinator of other professionals and the rest of the team. But you also could evolve to be line workers and cogs in a larger machine, replaceable and commoditized. In the end, hospitalists will not only need to create value, but also position themselves to be professionally rewarded and respected for the value they create.
Dr. Gawande considers the perspectives of healthcare providers and patients as he looks to the future. “Patients won’t just look for the best specialist anymore; they’ll look for the best system,” he says. “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”
The changes ahead will be rapid and disruptive; some hospitals will be driven out of business, while some will be consolidated. Physicians will aggregate and become employees (although many will still think they are free agents). Standardization will be pushed, and customization and one-offs will be tolerated less and less.
In this new world, hospitalists have the opportunity to be at the leading edge, not just for other physicians but the entire healthcare team. We need to prepare for this challenge, not just with clinical skills, but with a culture and a mindset to adapt and evolve. We need to decide if we will be cogs in a machine or the innovators and managers of change. The time is now; the choice is ours.
Dr. Wellikson is CEO of SHM.
Reference
I needed an oil change, so I took my car to Jiffy Lube. I had just pulled into the entrance to one of the service bays when a smiling man whose nametag read “Tony” approached me. “Welcome back, Mr. Wellikson. What can we help you with today?” Well, that was nice and so unexpected, as I had not remembered ever going to that Jiffy Lube. As it turns out, they have a video camera that shows incoming cars in their control room. They can read my license plate and call up my car on their computer system, access my record, and create a personal greeting. They also used my car’s past history as a starting point for this encounter. We were off to a good start.
Once I indicated I just wanted a routine oil change, Tony indicated he would be back in five to 10 minutes. He told me I should wait in the waiting room where they had wireless Internet, TV, magazines, and comfortable chairs.
In less than 10 minutes, Tony was back, clipboard in hand, with an assessment of my car’s status, including previous work and manufacturer’s recommendations, based on my car’s age and mileage. Once we negotiated not replacing all of the fluids and filters, Tony smiled and said the work should be completed in 10 minutes.
Soon, Tony came back to lead me out to my car, which had been wheeled out to the front of the garage bay with an open driver’s door waiting for me. After helping me into my seat, Tony came around and sat in the passenger seat and, once again with his ready clipboard, walked me through the 29 steps of inspections and fluid changes that had been made on my visit, reviewed the frequency of future needs for my vehicle, put a sticker on my inside windshield as a reminder, included $5 off for my next service, then patiently asked me if I had any questions.
Total time at Jiffy Lube: less than 30 minutes. Total cost: $29.99. Total customer experience: exceptional. Considering it was the third Jiffy Lube location I had used in the past three years, I can tell you the experience and system is the same throughout the company, whether the uniform name is Tony or Jose or Gladys.
Can such experiences offer hospitalists lessons about how we manage the customer experience in hospital care?
Scalable Innovation
In August 2012, Atul Gawande, MD, wrote a thought-provoking article in The New Yorker in which he coupled his detailed observation of how the restaurant chain The Cheesecake Factory manages to deliver 8 million meals annually nationwide with high quality at a reasonable cost and strong corporate profits with the emerging trend of healthcare delivery innovations being sought by large hospital chains and such innovations as ICU telemedicine.1
He noted that, according to the Bureau of Labor Statistics, less than 25% of physicians are currently self-employed, and the growing trend is hospitals being acquired or merged into larger and larger hospital chains. He observed that recent and future financial changes are moving toward payment for results and efficiencies and further away from just rewarding transactions and supplying services, whether of measureable value or with proven results. Cheesecake Factory has built its success on large-scale production-line processes that produce consistent results across hundreds of locations and millions of meals. It may now be time for healthcare, especially hospital care, to come into the 21st century, too.
How did Cheesecake Factory get to where they are? They studied what the best people were doing, figured out a way to standardize it, then looked for ways to bring it to everyone. Although we could look at research as medicine’s way of bringing new concepts forward, where we have fallen down as an industry and culture is our ability to deliver on this at the bedside. Why aren’t most myocardial infarction patients on beta-blockers? Why isn’t DVT prophylaxis universal? Why can’t we all wash our hands on a regular basis?
Medical care, especially the physician portion, has always placed an overwhelming bias on autonomy. We all know that even at the same hospital or within the same physician group of cardiologists or orthopedists (or even hospitalists) that there can be multiple ways to treat chest pain, replace a joint, or manage pneumonia. Dr. Gawande postulates that “customization should be 5%, not 95%, of what we do.” He is not suggesting cookbook medicine—rather, that we bring all of the current proven and consensus medical knowledge together and allow local professionals to agree to narrow their choices down to a consistent and reproducible process for managing care.
Hoag, a health network near my home in Orange County, Calif., has brought this approach to orthopedic care. Hoag purchased a smaller hospital near its main campus and is emphasizing state-of-the-art orthopedic care at the new facility. They aligned the incentives—clinically and financially—with a large but select group of orthopedists, and they have chosen just a few prosthetic choices for hip and knee replacements. They have narrowed their protocols for pre- and post-op care, and now do same-day joint replacements with lower complication rates and better return-to-activity results at lower costs. And trust me, the orthopedists at Hoag were as independent as any physicians you might run into. The demands of the new payor models and competition to provide consumers (i.e. patients) with a 21st-century experience pushed, pulled, and prodded these orthopedists, and an enlightened hospital leadership, to rise to the challenges.
HM Takeaway
So where do hospitalists fit into this emerging world of customer service, standardization, accountability for results, and payment change? As you might imagine, we are right in the middle of all of this. High-functioning HM groups have understood that we must help shape a better system for us to work in. We cannot perpetuate the old paradigm in which the hospital was simply a swap meet where each physician had a booth and performed a procedure with little regard to how efficient or effective the entire enterprise might be.
Hospitalists have always performed in a group setting and worked across the professional disciplines of medicine, surgery, and subspecialties, and with nurses, pharmacists, and therapists. In the best of breed, hospitalists are enculturated to think systemwide yet deliver to an individual patient.
As hospital chains look to standardize and deliver the best results and the most efficient use of resources, hospitalists can be positioned in a variety of ways. You can be an innovative partner, working with other professionals and the administration to seek new ways of doing things. You can be the manager or coordinator of other professionals and the rest of the team. But you also could evolve to be line workers and cogs in a larger machine, replaceable and commoditized. In the end, hospitalists will not only need to create value, but also position themselves to be professionally rewarded and respected for the value they create.
Dr. Gawande considers the perspectives of healthcare providers and patients as he looks to the future. “Patients won’t just look for the best specialist anymore; they’ll look for the best system,” he says. “Nurses and doctors will have to get used to delivering care in which our own convenience counts for less and the patients’ experience counts for more.”
The changes ahead will be rapid and disruptive; some hospitals will be driven out of business, while some will be consolidated. Physicians will aggregate and become employees (although many will still think they are free agents). Standardization will be pushed, and customization and one-offs will be tolerated less and less.
In this new world, hospitalists have the opportunity to be at the leading edge, not just for other physicians but the entire healthcare team. We need to prepare for this challenge, not just with clinical skills, but with a culture and a mindset to adapt and evolve. We need to decide if we will be cogs in a machine or the innovators and managers of change. The time is now; the choice is ours.
Dr. Wellikson is CEO of SHM.
Reference
The Future of the Society of Hospital Medicine
In the June edition of The Hospitalist, I wrote about the “Future of Hospital Medicine.” I wanted to concentrate this column on how SHM is evolving to support this vision of the future.
I previously referenced the variability of maturity and competence of the thousands of HM groups (HMGs) spread across the nation. SHM is considering creating standards that are validated by the stakeholders in hospital medicine. We hope that each HMG might use these standards to assess its own stage of development. For those HMGs that are already performing at a high level, SHM might recognize this status with an award. For those not quite at the highest level of function, SHM hopes to work with other organizations in HM to create programs and projects to raise your level of function. Our goal is for this process to be aspirational and, hopefully, support HMGs by having a platform to request more resources and to develop additional capabilities so that more and more HMGs over time can reach the highest level of function.
Attracting the Future of Hospital Medicine
SHM also recognizes that as we strive to have hospitalists continue to be key partners in creating the hospital of the future, we need to attract the best medical students and residents into hospital medicine. With this in mind, SHM is developing a detailed plan to communicate with medical students and residents about the best aspects of a career in HM. While this strategy has a long lead time, we do expect that over the next five to 10 years, more and more students will select HM as their career—and give us a deeper bench strength to meet the needs of future HMGs.
In order to keep hospitalists at the top of their game, SHM is looking for innovative ways to provide key educational content. Currently, the SHM annual meeting (www.hospitalmedicine2013.org) is the largest gathering of hospitalists, but even this huge meeting only attracts 25% of our members. Plans are under way to expand the reach of the annual meeting, allowing remote learning and participation through streaming and Web-based technology. For those 3,000 hospitalists who travel to the SHM annual meeting, SHM is looking to expand networking opportunities and create content for the bedside that is taught at the meeting, but that can be easily transported (e.g. via smartphone or tablet) with the attendee back to the bedside.
Certification, MOC, and Leadership
Hospitalists now and in the future will need to have tools that help them maintain their board certification and licensure. SHM has developed hospitalist-specific medical knowledge modules (MKMs) and self-assessment products, and has started to develop Performance Improvement Modules (PIMs) for hospitalists (www.hospitalmedicine.org/moc). SHM plans to partner with ACP, ABIM, and other organizations to allow our members access to additional important resources during the maintenance of certification (MOC) process. SHM’s commitment is to work with the boards to create the best interface and support for hospitalists during their lifelong learning and their certification efforts.
For those of you who already are HMG leaders, or are aspiring to become leaders, SHM has its nationally recognized Leadership Academies (www.hospitalmedicine.org/leadership), which have educated more than 2,000 hospitalist leaders. This year, we launch the Certification in Hospital Medicine Leadership program to provide recognition of those trained and committed to providing future leadership of the HMG and their hospitals. This unique certification will be an important credential for organizations and institutions recruiting new leaders, as well as for hospitalists looking for career advancement to become the leaders of the future.
Leadership in Performance Improvement
SHM continues to obtain funding from the government, foundations, and industry to provide tools and support to help hospitalists make real improvements at their hospitals. To date, SHM has been active in improving transitions of care in more than 500 hospitals with Project BOOST, preventing DVTs, and improving glycemic control (www.hospitalmedicine.org/thecenter). SHM now spends more than $3 million annually in these quality-improvement (QI) efforts, which are directed primarily at helping hospitalists improve their hospitals. Recently named the winner of the prestigious Eisenberg Award, given by the National Quality Forum and the Joint Commission, SHM expects that its QI efforts will expand to $5 million to $10 million annually in the coming years and provide opportunities for many of our members to be change agents. All of the changes on the horizon only increase the need for SHM to provide support to our hospitalists as they are called upon to lead and manage change.
SHM is no longer a small fringe medical society. With more than 11,000 members in all 50 states and Canada, SHM truly is a big tent. And the family keeps expanding as we now include internists, pediatricians, family physicians, medical students, residents, nurse practitioners, physician assistants, administrators, pharmacists, and nurses. In addition, HM now includes those practicing outside the hospital in extended-care facilities, long-term care and rehab facilities, LTACs, and other post-acute-care venues. And the ranks of hospitalists are increasing with the addition of hospitalists in such specialties as obstetrics, acute-care surgery, neurology, and orthopedics.
To continue to be the big tent for all hospitalists but still create a society with opportunities for networking and affinity groups, SHM has embarked on several strategies. SHM plans to create virtual communities (i.e. social networking) using Higher Logic. We plan to start with cohorts in Project BOOST and alumni from our Quality and Safety Educators Academy (QSEA) and our Leadership Academies, where contacts already have been made face to face over time. We see this as applicable for any subset of SHM that has the need and desire to create virtual communities and connections.
SHM also has created sections for our members trained in med-peds and international members from around the globe. In the future, SHM could expand to have 10 to 20 sections, including those for family physicians or pediatricians or nurse practitioners or administrators. We hope these organizations within an organization will give our members a platform to be in contact with other hospitalists just like themselves and create an opportunity for SHM to continually understand our members’ needs, and to design those projects and programs to meet those needs.
Just as our nation’s hospitalists are challenged to be innovative and creative as they play an active role in developing the hospital of the future, it is important for SHM to continue to evolve and develop new technologies and approaches to ensure our members have the support they need for the difficult tasks ahead.
Dr. Wellikson is CEO of SHM.
In the June edition of The Hospitalist, I wrote about the “Future of Hospital Medicine.” I wanted to concentrate this column on how SHM is evolving to support this vision of the future.
I previously referenced the variability of maturity and competence of the thousands of HM groups (HMGs) spread across the nation. SHM is considering creating standards that are validated by the stakeholders in hospital medicine. We hope that each HMG might use these standards to assess its own stage of development. For those HMGs that are already performing at a high level, SHM might recognize this status with an award. For those not quite at the highest level of function, SHM hopes to work with other organizations in HM to create programs and projects to raise your level of function. Our goal is for this process to be aspirational and, hopefully, support HMGs by having a platform to request more resources and to develop additional capabilities so that more and more HMGs over time can reach the highest level of function.
Attracting the Future of Hospital Medicine
SHM also recognizes that as we strive to have hospitalists continue to be key partners in creating the hospital of the future, we need to attract the best medical students and residents into hospital medicine. With this in mind, SHM is developing a detailed plan to communicate with medical students and residents about the best aspects of a career in HM. While this strategy has a long lead time, we do expect that over the next five to 10 years, more and more students will select HM as their career—and give us a deeper bench strength to meet the needs of future HMGs.
In order to keep hospitalists at the top of their game, SHM is looking for innovative ways to provide key educational content. Currently, the SHM annual meeting (www.hospitalmedicine2013.org) is the largest gathering of hospitalists, but even this huge meeting only attracts 25% of our members. Plans are under way to expand the reach of the annual meeting, allowing remote learning and participation through streaming and Web-based technology. For those 3,000 hospitalists who travel to the SHM annual meeting, SHM is looking to expand networking opportunities and create content for the bedside that is taught at the meeting, but that can be easily transported (e.g. via smartphone or tablet) with the attendee back to the bedside.
Certification, MOC, and Leadership
Hospitalists now and in the future will need to have tools that help them maintain their board certification and licensure. SHM has developed hospitalist-specific medical knowledge modules (MKMs) and self-assessment products, and has started to develop Performance Improvement Modules (PIMs) for hospitalists (www.hospitalmedicine.org/moc). SHM plans to partner with ACP, ABIM, and other organizations to allow our members access to additional important resources during the maintenance of certification (MOC) process. SHM’s commitment is to work with the boards to create the best interface and support for hospitalists during their lifelong learning and their certification efforts.
For those of you who already are HMG leaders, or are aspiring to become leaders, SHM has its nationally recognized Leadership Academies (www.hospitalmedicine.org/leadership), which have educated more than 2,000 hospitalist leaders. This year, we launch the Certification in Hospital Medicine Leadership program to provide recognition of those trained and committed to providing future leadership of the HMG and their hospitals. This unique certification will be an important credential for organizations and institutions recruiting new leaders, as well as for hospitalists looking for career advancement to become the leaders of the future.
Leadership in Performance Improvement
SHM continues to obtain funding from the government, foundations, and industry to provide tools and support to help hospitalists make real improvements at their hospitals. To date, SHM has been active in improving transitions of care in more than 500 hospitals with Project BOOST, preventing DVTs, and improving glycemic control (www.hospitalmedicine.org/thecenter). SHM now spends more than $3 million annually in these quality-improvement (QI) efforts, which are directed primarily at helping hospitalists improve their hospitals. Recently named the winner of the prestigious Eisenberg Award, given by the National Quality Forum and the Joint Commission, SHM expects that its QI efforts will expand to $5 million to $10 million annually in the coming years and provide opportunities for many of our members to be change agents. All of the changes on the horizon only increase the need for SHM to provide support to our hospitalists as they are called upon to lead and manage change.
SHM is no longer a small fringe medical society. With more than 11,000 members in all 50 states and Canada, SHM truly is a big tent. And the family keeps expanding as we now include internists, pediatricians, family physicians, medical students, residents, nurse practitioners, physician assistants, administrators, pharmacists, and nurses. In addition, HM now includes those practicing outside the hospital in extended-care facilities, long-term care and rehab facilities, LTACs, and other post-acute-care venues. And the ranks of hospitalists are increasing with the addition of hospitalists in such specialties as obstetrics, acute-care surgery, neurology, and orthopedics.
To continue to be the big tent for all hospitalists but still create a society with opportunities for networking and affinity groups, SHM has embarked on several strategies. SHM plans to create virtual communities (i.e. social networking) using Higher Logic. We plan to start with cohorts in Project BOOST and alumni from our Quality and Safety Educators Academy (QSEA) and our Leadership Academies, where contacts already have been made face to face over time. We see this as applicable for any subset of SHM that has the need and desire to create virtual communities and connections.
SHM also has created sections for our members trained in med-peds and international members from around the globe. In the future, SHM could expand to have 10 to 20 sections, including those for family physicians or pediatricians or nurse practitioners or administrators. We hope these organizations within an organization will give our members a platform to be in contact with other hospitalists just like themselves and create an opportunity for SHM to continually understand our members’ needs, and to design those projects and programs to meet those needs.
Just as our nation’s hospitalists are challenged to be innovative and creative as they play an active role in developing the hospital of the future, it is important for SHM to continue to evolve and develop new technologies and approaches to ensure our members have the support they need for the difficult tasks ahead.
Dr. Wellikson is CEO of SHM.
In the June edition of The Hospitalist, I wrote about the “Future of Hospital Medicine.” I wanted to concentrate this column on how SHM is evolving to support this vision of the future.
I previously referenced the variability of maturity and competence of the thousands of HM groups (HMGs) spread across the nation. SHM is considering creating standards that are validated by the stakeholders in hospital medicine. We hope that each HMG might use these standards to assess its own stage of development. For those HMGs that are already performing at a high level, SHM might recognize this status with an award. For those not quite at the highest level of function, SHM hopes to work with other organizations in HM to create programs and projects to raise your level of function. Our goal is for this process to be aspirational and, hopefully, support HMGs by having a platform to request more resources and to develop additional capabilities so that more and more HMGs over time can reach the highest level of function.
Attracting the Future of Hospital Medicine
SHM also recognizes that as we strive to have hospitalists continue to be key partners in creating the hospital of the future, we need to attract the best medical students and residents into hospital medicine. With this in mind, SHM is developing a detailed plan to communicate with medical students and residents about the best aspects of a career in HM. While this strategy has a long lead time, we do expect that over the next five to 10 years, more and more students will select HM as their career—and give us a deeper bench strength to meet the needs of future HMGs.
In order to keep hospitalists at the top of their game, SHM is looking for innovative ways to provide key educational content. Currently, the SHM annual meeting (www.hospitalmedicine2013.org) is the largest gathering of hospitalists, but even this huge meeting only attracts 25% of our members. Plans are under way to expand the reach of the annual meeting, allowing remote learning and participation through streaming and Web-based technology. For those 3,000 hospitalists who travel to the SHM annual meeting, SHM is looking to expand networking opportunities and create content for the bedside that is taught at the meeting, but that can be easily transported (e.g. via smartphone or tablet) with the attendee back to the bedside.
Certification, MOC, and Leadership
Hospitalists now and in the future will need to have tools that help them maintain their board certification and licensure. SHM has developed hospitalist-specific medical knowledge modules (MKMs) and self-assessment products, and has started to develop Performance Improvement Modules (PIMs) for hospitalists (www.hospitalmedicine.org/moc). SHM plans to partner with ACP, ABIM, and other organizations to allow our members access to additional important resources during the maintenance of certification (MOC) process. SHM’s commitment is to work with the boards to create the best interface and support for hospitalists during their lifelong learning and their certification efforts.
For those of you who already are HMG leaders, or are aspiring to become leaders, SHM has its nationally recognized Leadership Academies (www.hospitalmedicine.org/leadership), which have educated more than 2,000 hospitalist leaders. This year, we launch the Certification in Hospital Medicine Leadership program to provide recognition of those trained and committed to providing future leadership of the HMG and their hospitals. This unique certification will be an important credential for organizations and institutions recruiting new leaders, as well as for hospitalists looking for career advancement to become the leaders of the future.
Leadership in Performance Improvement
SHM continues to obtain funding from the government, foundations, and industry to provide tools and support to help hospitalists make real improvements at their hospitals. To date, SHM has been active in improving transitions of care in more than 500 hospitals with Project BOOST, preventing DVTs, and improving glycemic control (www.hospitalmedicine.org/thecenter). SHM now spends more than $3 million annually in these quality-improvement (QI) efforts, which are directed primarily at helping hospitalists improve their hospitals. Recently named the winner of the prestigious Eisenberg Award, given by the National Quality Forum and the Joint Commission, SHM expects that its QI efforts will expand to $5 million to $10 million annually in the coming years and provide opportunities for many of our members to be change agents. All of the changes on the horizon only increase the need for SHM to provide support to our hospitalists as they are called upon to lead and manage change.
SHM is no longer a small fringe medical society. With more than 11,000 members in all 50 states and Canada, SHM truly is a big tent. And the family keeps expanding as we now include internists, pediatricians, family physicians, medical students, residents, nurse practitioners, physician assistants, administrators, pharmacists, and nurses. In addition, HM now includes those practicing outside the hospital in extended-care facilities, long-term care and rehab facilities, LTACs, and other post-acute-care venues. And the ranks of hospitalists are increasing with the addition of hospitalists in such specialties as obstetrics, acute-care surgery, neurology, and orthopedics.
To continue to be the big tent for all hospitalists but still create a society with opportunities for networking and affinity groups, SHM has embarked on several strategies. SHM plans to create virtual communities (i.e. social networking) using Higher Logic. We plan to start with cohorts in Project BOOST and alumni from our Quality and Safety Educators Academy (QSEA) and our Leadership Academies, where contacts already have been made face to face over time. We see this as applicable for any subset of SHM that has the need and desire to create virtual communities and connections.
SHM also has created sections for our members trained in med-peds and international members from around the globe. In the future, SHM could expand to have 10 to 20 sections, including those for family physicians or pediatricians or nurse practitioners or administrators. We hope these organizations within an organization will give our members a platform to be in contact with other hospitalists just like themselves and create an opportunity for SHM to continually understand our members’ needs, and to design those projects and programs to meet those needs.
Just as our nation’s hospitalists are challenged to be innovative and creative as they play an active role in developing the hospital of the future, it is important for SHM to continue to evolve and develop new technologies and approaches to ensure our members have the support they need for the difficult tasks ahead.
Dr. Wellikson is CEO of SHM.
The Future of Hospital Medicine
Hospital medicine is 15 years old now and, as the fastest-growing medical specialty, has created innovation and excitement in healthcare. With more than 34,000 hospitalists at more than 4,000 hospitals, hospitalists are now an accepted part of the medical community. But clearly HM is still a work in progress, with our best days still ahead of us.
So what’s in store for us as we look to the next five to 10 years?
First, it is important to note that the very institution of the hospital is evolving. Hospitals no longer are defined by the walls of their buildings; hospitals view themselves as significant community resources along a continuum of care that includes care when the patient is horizontally confined during an acute illness. Just as hospitals need to be involved in the care of the community (e.g. to reduce preventable readmissions or ED visits), so too hospitalists’ scope of practice is expanding.
Expanding HM Scope
At one time, long, long ago, the scope of hospitalists’ work could be narrowly defined as the care of the acutely ill patient with such a medical illness as heart failure or pneumonia. Today, hospitalists routinely comanage surgical problems and serve as the prime admitter for medical cases (acute chest pain, sepsis, and the like) previously sent directly to specialists.
As surgeons and specialists have narrowed their practices, hospitalists have been called on to be proceduralists, inserting central lines and even doing bedside ultrasound. With a decreasing workforce of critical-care-trained physicians, hospitalists are being challenged to provide an ever-increasing amount of critical care, a phenomenon that will increase in the future and further stretch the competencies and training of most hospitalists.
At the edges of acute care, hospitalists are being called upon to augment the “neighborhood” around the patient-centered medical home. In some settings, hospitalists now provide the initial post-discharge, follow-up outpatient visits to “complete” the hospitalization, stabilize the patient, and transition them back to their community provider. CareMore Health Plan in California is setting the standard for this transitionalist role, also known as an “extensivist.” As the demand from hospitals and payors to reduce post-discharge bounce-back to the ED or to be readmitted increases, hospitalists and the medical home will need to carefully coordinate their roles if HM is to provide our patients (and their families) with what they need and expect—a smooth, coordinated transition from the hospital to home with clear communication and accountability
Fulfill the Promise
To do this, and do this well, hospitalists will need to fulfill our promise. We have spent the last decade positioning hospitalists as having two patients: the clinical care of the patient in front of us and the improvement of the system we work in. We have acknowledged that most hospitalists don’t come out of residency, or even years in practice, with all the skills needed for this unique and important role.
In many ways, SHM has become the society of “everything you didn’t learn in training that you found out you need to know in practice.” SHM has trained more than 2,000 hospitalists in our Leadership Academies. We have expanded our annual-meeting course offerings to include perioperative care, neurology, critical care, and procedures.
Through the Center for Hospital Improvement and Innovation, SHM has developed courses in quality-improvement (QI) skills and processes, as well as support and tactics for helping hospitalists make real change at their institutions through SHM’s mentored implementation in transitions of care (Project BOOST), preventing DVT, and improving glycemic control.
But even with SHM and many other organizations touching thousands of hospitalists, the HM landscape is varied. Some hospitalist groups are well-formed, well-staffed and supported, and they are delivering on the full promise of HM today. Yet many HM groups are very much a work in progress.
This is not surprising when you realize that the role of hospitalists has been evolving in real time while the hospitals we all work in are changing as well. Throw into the mix the addition of more than 30,000 hospitalists over the last decade with various training, skills, and experience, and it is not unexpected that the results have been a mixed bag.
In the next decade, however, HM groups will need to step up their game to fulfill the promise of HM more broadly in our nation’s hospitals. SHM hopes to provide a guidepost in this process and is considering developing standards for HM groups (HMGs) and possibly creating an aspirational award along the lines of the Baldrige Award. At the beginning, maybe only a few hundred HMGs will qualify for such an award, but the hope is that other HMGs will use this opportunity to obtain the resources and make the improvements to also achieve the highest standard for hospitalists.
A Perfect Partner
At the same time, it is clear that both the government and private insurers are heading toward a new way to pay for healthcare, moving away from the current transactional manner in which the procedure and the visit is the currency, to something where value and performance become crucial.
This is a system in which preventing the DVT is more valued than waiting for the complication and treating it, where doing the first hospitalization right and working with the family and the patient to make the best transition out of the hospital is rewarded more than billing the insurer for the readmission.
The efficient and competent HM group is an ideal partner for the hospital in this future world.
In addition, the hospital community is being reshaped. More and more physicians are gravitating to the hospital as an employee or essential partner. More than 70% of cardiologists are now hospital-employed. Specialty hospitalists, most notably in the fields of OBGYN, neurology, orthopedics, surgery, and psychiatry, are growing.
Accountable-care organizations (ACOs) are being supported by Medicare and should continue to grow as another hospital-physician risk-sharing entity. In many places, hospitalists have been in place for more than 10 years as the original physician partners with their hospitals. It is very likely that hospitalists will be right in the middle of the new medical staff and in driving the expected efficiencies and improvements as the hospital of the future and payment system changes continue to evolve.
In all of this, it is important for HM to continue to be creative and innovative, and not hamstrung by the conventional and the status quo. This calls for more than just fresh ideas and the courage to be bold. It requires new skills and competencies. We must continue to knock down the barriers of autonomy and exchange that for active participation in, and leadership of, the team. We must continue to move away from the mystique of the physician and embrace the need to set a course for change, be willing to be measured and be less than perfect, and seize the opportunity to improve and innovate.
Although the last decade of HM has been no piece of cake, the next 10 years will be even more challenging. The good news is that our skills and competencies can make us a central player, a key partner. But we will need to rise to meet this challenge.
Dr. Wellikson is CEO of SHM.
Hospital medicine is 15 years old now and, as the fastest-growing medical specialty, has created innovation and excitement in healthcare. With more than 34,000 hospitalists at more than 4,000 hospitals, hospitalists are now an accepted part of the medical community. But clearly HM is still a work in progress, with our best days still ahead of us.
So what’s in store for us as we look to the next five to 10 years?
First, it is important to note that the very institution of the hospital is evolving. Hospitals no longer are defined by the walls of their buildings; hospitals view themselves as significant community resources along a continuum of care that includes care when the patient is horizontally confined during an acute illness. Just as hospitals need to be involved in the care of the community (e.g. to reduce preventable readmissions or ED visits), so too hospitalists’ scope of practice is expanding.
Expanding HM Scope
At one time, long, long ago, the scope of hospitalists’ work could be narrowly defined as the care of the acutely ill patient with such a medical illness as heart failure or pneumonia. Today, hospitalists routinely comanage surgical problems and serve as the prime admitter for medical cases (acute chest pain, sepsis, and the like) previously sent directly to specialists.
As surgeons and specialists have narrowed their practices, hospitalists have been called on to be proceduralists, inserting central lines and even doing bedside ultrasound. With a decreasing workforce of critical-care-trained physicians, hospitalists are being challenged to provide an ever-increasing amount of critical care, a phenomenon that will increase in the future and further stretch the competencies and training of most hospitalists.
At the edges of acute care, hospitalists are being called upon to augment the “neighborhood” around the patient-centered medical home. In some settings, hospitalists now provide the initial post-discharge, follow-up outpatient visits to “complete” the hospitalization, stabilize the patient, and transition them back to their community provider. CareMore Health Plan in California is setting the standard for this transitionalist role, also known as an “extensivist.” As the demand from hospitals and payors to reduce post-discharge bounce-back to the ED or to be readmitted increases, hospitalists and the medical home will need to carefully coordinate their roles if HM is to provide our patients (and their families) with what they need and expect—a smooth, coordinated transition from the hospital to home with clear communication and accountability
Fulfill the Promise
To do this, and do this well, hospitalists will need to fulfill our promise. We have spent the last decade positioning hospitalists as having two patients: the clinical care of the patient in front of us and the improvement of the system we work in. We have acknowledged that most hospitalists don’t come out of residency, or even years in practice, with all the skills needed for this unique and important role.
In many ways, SHM has become the society of “everything you didn’t learn in training that you found out you need to know in practice.” SHM has trained more than 2,000 hospitalists in our Leadership Academies. We have expanded our annual-meeting course offerings to include perioperative care, neurology, critical care, and procedures.
Through the Center for Hospital Improvement and Innovation, SHM has developed courses in quality-improvement (QI) skills and processes, as well as support and tactics for helping hospitalists make real change at their institutions through SHM’s mentored implementation in transitions of care (Project BOOST), preventing DVT, and improving glycemic control.
But even with SHM and many other organizations touching thousands of hospitalists, the HM landscape is varied. Some hospitalist groups are well-formed, well-staffed and supported, and they are delivering on the full promise of HM today. Yet many HM groups are very much a work in progress.
This is not surprising when you realize that the role of hospitalists has been evolving in real time while the hospitals we all work in are changing as well. Throw into the mix the addition of more than 30,000 hospitalists over the last decade with various training, skills, and experience, and it is not unexpected that the results have been a mixed bag.
In the next decade, however, HM groups will need to step up their game to fulfill the promise of HM more broadly in our nation’s hospitals. SHM hopes to provide a guidepost in this process and is considering developing standards for HM groups (HMGs) and possibly creating an aspirational award along the lines of the Baldrige Award. At the beginning, maybe only a few hundred HMGs will qualify for such an award, but the hope is that other HMGs will use this opportunity to obtain the resources and make the improvements to also achieve the highest standard for hospitalists.
A Perfect Partner
At the same time, it is clear that both the government and private insurers are heading toward a new way to pay for healthcare, moving away from the current transactional manner in which the procedure and the visit is the currency, to something where value and performance become crucial.
This is a system in which preventing the DVT is more valued than waiting for the complication and treating it, where doing the first hospitalization right and working with the family and the patient to make the best transition out of the hospital is rewarded more than billing the insurer for the readmission.
The efficient and competent HM group is an ideal partner for the hospital in this future world.
In addition, the hospital community is being reshaped. More and more physicians are gravitating to the hospital as an employee or essential partner. More than 70% of cardiologists are now hospital-employed. Specialty hospitalists, most notably in the fields of OBGYN, neurology, orthopedics, surgery, and psychiatry, are growing.
Accountable-care organizations (ACOs) are being supported by Medicare and should continue to grow as another hospital-physician risk-sharing entity. In many places, hospitalists have been in place for more than 10 years as the original physician partners with their hospitals. It is very likely that hospitalists will be right in the middle of the new medical staff and in driving the expected efficiencies and improvements as the hospital of the future and payment system changes continue to evolve.
In all of this, it is important for HM to continue to be creative and innovative, and not hamstrung by the conventional and the status quo. This calls for more than just fresh ideas and the courage to be bold. It requires new skills and competencies. We must continue to knock down the barriers of autonomy and exchange that for active participation in, and leadership of, the team. We must continue to move away from the mystique of the physician and embrace the need to set a course for change, be willing to be measured and be less than perfect, and seize the opportunity to improve and innovate.
Although the last decade of HM has been no piece of cake, the next 10 years will be even more challenging. The good news is that our skills and competencies can make us a central player, a key partner. But we will need to rise to meet this challenge.
Dr. Wellikson is CEO of SHM.
Hospital medicine is 15 years old now and, as the fastest-growing medical specialty, has created innovation and excitement in healthcare. With more than 34,000 hospitalists at more than 4,000 hospitals, hospitalists are now an accepted part of the medical community. But clearly HM is still a work in progress, with our best days still ahead of us.
So what’s in store for us as we look to the next five to 10 years?
First, it is important to note that the very institution of the hospital is evolving. Hospitals no longer are defined by the walls of their buildings; hospitals view themselves as significant community resources along a continuum of care that includes care when the patient is horizontally confined during an acute illness. Just as hospitals need to be involved in the care of the community (e.g. to reduce preventable readmissions or ED visits), so too hospitalists’ scope of practice is expanding.
Expanding HM Scope
At one time, long, long ago, the scope of hospitalists’ work could be narrowly defined as the care of the acutely ill patient with such a medical illness as heart failure or pneumonia. Today, hospitalists routinely comanage surgical problems and serve as the prime admitter for medical cases (acute chest pain, sepsis, and the like) previously sent directly to specialists.
As surgeons and specialists have narrowed their practices, hospitalists have been called on to be proceduralists, inserting central lines and even doing bedside ultrasound. With a decreasing workforce of critical-care-trained physicians, hospitalists are being challenged to provide an ever-increasing amount of critical care, a phenomenon that will increase in the future and further stretch the competencies and training of most hospitalists.
At the edges of acute care, hospitalists are being called upon to augment the “neighborhood” around the patient-centered medical home. In some settings, hospitalists now provide the initial post-discharge, follow-up outpatient visits to “complete” the hospitalization, stabilize the patient, and transition them back to their community provider. CareMore Health Plan in California is setting the standard for this transitionalist role, also known as an “extensivist.” As the demand from hospitals and payors to reduce post-discharge bounce-back to the ED or to be readmitted increases, hospitalists and the medical home will need to carefully coordinate their roles if HM is to provide our patients (and their families) with what they need and expect—a smooth, coordinated transition from the hospital to home with clear communication and accountability
Fulfill the Promise
To do this, and do this well, hospitalists will need to fulfill our promise. We have spent the last decade positioning hospitalists as having two patients: the clinical care of the patient in front of us and the improvement of the system we work in. We have acknowledged that most hospitalists don’t come out of residency, or even years in practice, with all the skills needed for this unique and important role.
In many ways, SHM has become the society of “everything you didn’t learn in training that you found out you need to know in practice.” SHM has trained more than 2,000 hospitalists in our Leadership Academies. We have expanded our annual-meeting course offerings to include perioperative care, neurology, critical care, and procedures.
Through the Center for Hospital Improvement and Innovation, SHM has developed courses in quality-improvement (QI) skills and processes, as well as support and tactics for helping hospitalists make real change at their institutions through SHM’s mentored implementation in transitions of care (Project BOOST), preventing DVT, and improving glycemic control.
But even with SHM and many other organizations touching thousands of hospitalists, the HM landscape is varied. Some hospitalist groups are well-formed, well-staffed and supported, and they are delivering on the full promise of HM today. Yet many HM groups are very much a work in progress.
This is not surprising when you realize that the role of hospitalists has been evolving in real time while the hospitals we all work in are changing as well. Throw into the mix the addition of more than 30,000 hospitalists over the last decade with various training, skills, and experience, and it is not unexpected that the results have been a mixed bag.
In the next decade, however, HM groups will need to step up their game to fulfill the promise of HM more broadly in our nation’s hospitals. SHM hopes to provide a guidepost in this process and is considering developing standards for HM groups (HMGs) and possibly creating an aspirational award along the lines of the Baldrige Award. At the beginning, maybe only a few hundred HMGs will qualify for such an award, but the hope is that other HMGs will use this opportunity to obtain the resources and make the improvements to also achieve the highest standard for hospitalists.
A Perfect Partner
At the same time, it is clear that both the government and private insurers are heading toward a new way to pay for healthcare, moving away from the current transactional manner in which the procedure and the visit is the currency, to something where value and performance become crucial.
This is a system in which preventing the DVT is more valued than waiting for the complication and treating it, where doing the first hospitalization right and working with the family and the patient to make the best transition out of the hospital is rewarded more than billing the insurer for the readmission.
The efficient and competent HM group is an ideal partner for the hospital in this future world.
In addition, the hospital community is being reshaped. More and more physicians are gravitating to the hospital as an employee or essential partner. More than 70% of cardiologists are now hospital-employed. Specialty hospitalists, most notably in the fields of OBGYN, neurology, orthopedics, surgery, and psychiatry, are growing.
Accountable-care organizations (ACOs) are being supported by Medicare and should continue to grow as another hospital-physician risk-sharing entity. In many places, hospitalists have been in place for more than 10 years as the original physician partners with their hospitals. It is very likely that hospitalists will be right in the middle of the new medical staff and in driving the expected efficiencies and improvements as the hospital of the future and payment system changes continue to evolve.
In all of this, it is important for HM to continue to be creative and innovative, and not hamstrung by the conventional and the status quo. This calls for more than just fresh ideas and the courage to be bold. It requires new skills and competencies. We must continue to knock down the barriers of autonomy and exchange that for active participation in, and leadership of, the team. We must continue to move away from the mystique of the physician and embrace the need to set a course for change, be willing to be measured and be less than perfect, and seize the opportunity to improve and innovate.
Although the last decade of HM has been no piece of cake, the next 10 years will be even more challenging. The good news is that our skills and competencies can make us a central player, a key partner. But we will need to rise to meet this challenge.
Dr. Wellikson is CEO of SHM.
Hospitalists Are the Answer
Earlier this year, the Journal of the American Medical Association (JAMA) published the article “A Physician Management Infrastructure,” by Peter Pronovost and Jill Marsteller.1 Pronovost and Marsteller’s commentary gets to the very heart of the need for change in healthcare delivery and the major barriers to that change.
As they note, quality improvement (QI) continues to receive attention from every sector of the healthcare market, but systematic and widespread benefits—actual improvement in quality of care—are years away from reaching the patient. The major impediments to delivering performance changes at the front lines of healthcare are both attitudinal and structural.
However, such obstacles can be overcome, starting today.
The authors rightly cite the development of physician leadership as a significant factor in the long-term success of QI. For too long, healthcare leaders have taken a “learn as you go” approach to leadership development. This antiquated philosophy that the best physician leaders ascend naturally to leadership falsely assumes that today’s leaders are perfectly suited for their jobs.
Training Tomorrow’s Leaders Today
In order for meaningful QI to succeed, systematic leadership development in healthcare must be a priority. Those hospitals and healthcare systems that acknowledge this reality already are reaping the benefits. Across the country, more than 1,200 hospitalists have participated in SHM’s Leadership Academy, a rigorous multicourse program that trains physicians in the fundamentals of hospital-based leadership. Leadership Academy participants then go on to lead new programs, many of which are QI-related, in their hospitals. This year, SHM will announce a Certification for Leaders in Hospital Medicine, which will further raise the bar, and mentor, enable, and define the future leaders for our hospitals.
The collective experience of HM also indicates that formal mentorship programs are a critical element to systematic leadership development. The exponential growth of SHM’s mentor-based QI programs to reduce readmissions, prevent VTEs, and improve glycemic control in hospitals—now implemented in more than 300 hospital sites across the country—is a testament to the need for one-on-one mentorship and leadership development and the impact it can have on patient care.
SHM continues to provide broad training in performance improvement and patient safety in its one-day “Quality Improvement Skills” pre-course at the annual meeting (HM11, May 10-13, Grapevine, Texas, www. hospitalmedicine2011.org). In the coming months, SHM will debut a nine-part series of Web-based modules that are essential to any hospitalist now charged with taking an active role in improving performance at their hospital.
Teamwork Is Key
Looking at the evolved present-day hospital, but more to the future, SHM and hospitalists recognize that empowered and coordinated teams of health professionals will deliver the best care. SHM is working to promote the development of high-performing teams (HPTs) with the rest of the Hospital Care Collaborative (HCC), which includes national organizations for nurses, pharmacists, case managers, medical social workers, and respiratory therapists. SHM also has convened a senior group from C-suites, nursing executives, and the American Hospital Association; the plan is to publish a roadmap to promoting the growth and success of HPTs.
All the good intentions and teams and physician champions will still be hamstrung to affect real change in the current payment system, which still rewards healthcare in a transactional fashion, where we pay by the unit of the visit or the procedure. That is why SHM has taken our message to Washington and why we are supporting innovations that reward performance.
The value-based purchasing initiatives that will move substantial dollars to those hospitals that show they can deliver better performance (we’re talking millions of dollars, even at the start) is a beginning of hopefully a sea change in how we think about paying for healthcare (see “Value-Based Purchasing Raises the Stakes,” p. 1). And SHM continues to actively promote having national hospitalist thought leaders be right in the middle of setting the new standards of healthcare at the National Quality Forum, the Joint Commission, and AMA’s Physician Consortium on Performance Improvement, along with other national organizations.
Dr. Pronovost sees the gaps and barriers in having a management structure at our nation’s hospitals that is staffed, financed, and trained to deliver high performance. He does specifically call out hospitalists as a new specialty that is better organized to potentially be part of the solution. SHM and our hospitalists want to move this from a possibility and a potential to affect real change, consistently, day after day, at as many hospitals as we can reach. That is the promise of hospital medicine, and that is the vision of SHM. TH
Dr. Wellikson is CEO of SHM.
Reference
- Pronovost PJ, Marstellar JA. A physician management infrastructure. JAMA. 2011;305(5):500-501.
Earlier this year, the Journal of the American Medical Association (JAMA) published the article “A Physician Management Infrastructure,” by Peter Pronovost and Jill Marsteller.1 Pronovost and Marsteller’s commentary gets to the very heart of the need for change in healthcare delivery and the major barriers to that change.
As they note, quality improvement (QI) continues to receive attention from every sector of the healthcare market, but systematic and widespread benefits—actual improvement in quality of care—are years away from reaching the patient. The major impediments to delivering performance changes at the front lines of healthcare are both attitudinal and structural.
However, such obstacles can be overcome, starting today.
The authors rightly cite the development of physician leadership as a significant factor in the long-term success of QI. For too long, healthcare leaders have taken a “learn as you go” approach to leadership development. This antiquated philosophy that the best physician leaders ascend naturally to leadership falsely assumes that today’s leaders are perfectly suited for their jobs.
Training Tomorrow’s Leaders Today
In order for meaningful QI to succeed, systematic leadership development in healthcare must be a priority. Those hospitals and healthcare systems that acknowledge this reality already are reaping the benefits. Across the country, more than 1,200 hospitalists have participated in SHM’s Leadership Academy, a rigorous multicourse program that trains physicians in the fundamentals of hospital-based leadership. Leadership Academy participants then go on to lead new programs, many of which are QI-related, in their hospitals. This year, SHM will announce a Certification for Leaders in Hospital Medicine, which will further raise the bar, and mentor, enable, and define the future leaders for our hospitals.
The collective experience of HM also indicates that formal mentorship programs are a critical element to systematic leadership development. The exponential growth of SHM’s mentor-based QI programs to reduce readmissions, prevent VTEs, and improve glycemic control in hospitals—now implemented in more than 300 hospital sites across the country—is a testament to the need for one-on-one mentorship and leadership development and the impact it can have on patient care.
SHM continues to provide broad training in performance improvement and patient safety in its one-day “Quality Improvement Skills” pre-course at the annual meeting (HM11, May 10-13, Grapevine, Texas, www. hospitalmedicine2011.org). In the coming months, SHM will debut a nine-part series of Web-based modules that are essential to any hospitalist now charged with taking an active role in improving performance at their hospital.
Teamwork Is Key
Looking at the evolved present-day hospital, but more to the future, SHM and hospitalists recognize that empowered and coordinated teams of health professionals will deliver the best care. SHM is working to promote the development of high-performing teams (HPTs) with the rest of the Hospital Care Collaborative (HCC), which includes national organizations for nurses, pharmacists, case managers, medical social workers, and respiratory therapists. SHM also has convened a senior group from C-suites, nursing executives, and the American Hospital Association; the plan is to publish a roadmap to promoting the growth and success of HPTs.
All the good intentions and teams and physician champions will still be hamstrung to affect real change in the current payment system, which still rewards healthcare in a transactional fashion, where we pay by the unit of the visit or the procedure. That is why SHM has taken our message to Washington and why we are supporting innovations that reward performance.
The value-based purchasing initiatives that will move substantial dollars to those hospitals that show they can deliver better performance (we’re talking millions of dollars, even at the start) is a beginning of hopefully a sea change in how we think about paying for healthcare (see “Value-Based Purchasing Raises the Stakes,” p. 1). And SHM continues to actively promote having national hospitalist thought leaders be right in the middle of setting the new standards of healthcare at the National Quality Forum, the Joint Commission, and AMA’s Physician Consortium on Performance Improvement, along with other national organizations.
Dr. Pronovost sees the gaps and barriers in having a management structure at our nation’s hospitals that is staffed, financed, and trained to deliver high performance. He does specifically call out hospitalists as a new specialty that is better organized to potentially be part of the solution. SHM and our hospitalists want to move this from a possibility and a potential to affect real change, consistently, day after day, at as many hospitals as we can reach. That is the promise of hospital medicine, and that is the vision of SHM. TH
Dr. Wellikson is CEO of SHM.
Reference
- Pronovost PJ, Marstellar JA. A physician management infrastructure. JAMA. 2011;305(5):500-501.
Earlier this year, the Journal of the American Medical Association (JAMA) published the article “A Physician Management Infrastructure,” by Peter Pronovost and Jill Marsteller.1 Pronovost and Marsteller’s commentary gets to the very heart of the need for change in healthcare delivery and the major barriers to that change.
As they note, quality improvement (QI) continues to receive attention from every sector of the healthcare market, but systematic and widespread benefits—actual improvement in quality of care—are years away from reaching the patient. The major impediments to delivering performance changes at the front lines of healthcare are both attitudinal and structural.
However, such obstacles can be overcome, starting today.
The authors rightly cite the development of physician leadership as a significant factor in the long-term success of QI. For too long, healthcare leaders have taken a “learn as you go” approach to leadership development. This antiquated philosophy that the best physician leaders ascend naturally to leadership falsely assumes that today’s leaders are perfectly suited for their jobs.
Training Tomorrow’s Leaders Today
In order for meaningful QI to succeed, systematic leadership development in healthcare must be a priority. Those hospitals and healthcare systems that acknowledge this reality already are reaping the benefits. Across the country, more than 1,200 hospitalists have participated in SHM’s Leadership Academy, a rigorous multicourse program that trains physicians in the fundamentals of hospital-based leadership. Leadership Academy participants then go on to lead new programs, many of which are QI-related, in their hospitals. This year, SHM will announce a Certification for Leaders in Hospital Medicine, which will further raise the bar, and mentor, enable, and define the future leaders for our hospitals.
The collective experience of HM also indicates that formal mentorship programs are a critical element to systematic leadership development. The exponential growth of SHM’s mentor-based QI programs to reduce readmissions, prevent VTEs, and improve glycemic control in hospitals—now implemented in more than 300 hospital sites across the country—is a testament to the need for one-on-one mentorship and leadership development and the impact it can have on patient care.
SHM continues to provide broad training in performance improvement and patient safety in its one-day “Quality Improvement Skills” pre-course at the annual meeting (HM11, May 10-13, Grapevine, Texas, www. hospitalmedicine2011.org). In the coming months, SHM will debut a nine-part series of Web-based modules that are essential to any hospitalist now charged with taking an active role in improving performance at their hospital.
Teamwork Is Key
Looking at the evolved present-day hospital, but more to the future, SHM and hospitalists recognize that empowered and coordinated teams of health professionals will deliver the best care. SHM is working to promote the development of high-performing teams (HPTs) with the rest of the Hospital Care Collaborative (HCC), which includes national organizations for nurses, pharmacists, case managers, medical social workers, and respiratory therapists. SHM also has convened a senior group from C-suites, nursing executives, and the American Hospital Association; the plan is to publish a roadmap to promoting the growth and success of HPTs.
All the good intentions and teams and physician champions will still be hamstrung to affect real change in the current payment system, which still rewards healthcare in a transactional fashion, where we pay by the unit of the visit or the procedure. That is why SHM has taken our message to Washington and why we are supporting innovations that reward performance.
The value-based purchasing initiatives that will move substantial dollars to those hospitals that show they can deliver better performance (we’re talking millions of dollars, even at the start) is a beginning of hopefully a sea change in how we think about paying for healthcare (see “Value-Based Purchasing Raises the Stakes,” p. 1). And SHM continues to actively promote having national hospitalist thought leaders be right in the middle of setting the new standards of healthcare at the National Quality Forum, the Joint Commission, and AMA’s Physician Consortium on Performance Improvement, along with other national organizations.
Dr. Pronovost sees the gaps and barriers in having a management structure at our nation’s hospitals that is staffed, financed, and trained to deliver high performance. He does specifically call out hospitalists as a new specialty that is better organized to potentially be part of the solution. SHM and our hospitalists want to move this from a possibility and a potential to affect real change, consistently, day after day, at as many hospitals as we can reach. That is the promise of hospital medicine, and that is the vision of SHM. TH
Dr. Wellikson is CEO of SHM.
Reference
- Pronovost PJ, Marstellar JA. A physician management infrastructure. JAMA. 2011;305(5):500-501.
How You Can Save Your Hospital a Million Bucks
What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.
SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.
In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.
This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.
The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.
VBP Metrics
So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.
The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.
HM to the Rescue
No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.
SHM’s board of directors recently passed the following position statement on value-based purchasing:
“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”
As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.
In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.
Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.
Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH
Dr. Wellikson is CEO of SHM.
What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.
SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.
In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.
This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.
The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.
VBP Metrics
So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.
The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.
HM to the Rescue
No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.
SHM’s board of directors recently passed the following position statement on value-based purchasing:
“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”
As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.
In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.
Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.
Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH
Dr. Wellikson is CEO of SHM.
What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.
SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.
In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.
This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.
The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.
VBP Metrics
So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.
The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.
HM to the Rescue
No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.
SHM’s board of directors recently passed the following position statement on value-based purchasing:
“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”
As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.
In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.
Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.
Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH
Dr. Wellikson is CEO of SHM.
The Laborist Movement
It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.
OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.
New “Partners” Drive Down Costs
HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.
In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.
Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.
Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.
Solution to the Insane Schedule?
The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.
This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.
This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.
The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.
Change Is All Around
In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.
As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.
As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.
Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.
The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH
Dr. Wellikson is CEO of SHM.
It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.
OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.
New “Partners” Drive Down Costs
HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.
In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.
Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.
Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.
Solution to the Insane Schedule?
The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.
This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.
This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.
The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.
Change Is All Around
In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.
As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.
As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.
Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.
The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH
Dr. Wellikson is CEO of SHM.
It is hard to think of medical hospitalists as the establishment, but with more than 30,000 hospitalists nationwide working at most U.S. hospitals, HM is a firm part of today’s medical practice. While, dare I say, “traditional” HM is still very much in its evolution, other specialties of HM have not only cropped up on the scene, but some also have developed enough of a presence to be worthy of drawing some early conclusions.
OB-GYN hospitalists, also known as laborists, now practice at more than 100 hospitals in more than 35 states, according to http://obgynhospitalist.com. In many ways, the OB hospitalist movement is tracking the HM movement of 10 years ago. Although there are several similarities, there are more differences than just what the doctors do in their medical practices.
New “Partners” Drive Down Costs
HM has been driven as much by hospital payment by DRGs as anything else. As hospitals realized that hospitalists could better utilize resources and still maintain quality, the ability to reduce length of stay allowed hospitals to have the capital to support the early development of HM groups.
In obstetrics, the ability of laborists to reduce liability risks, and therefore malpractice premiums, for the hospital is a major driver of the recent growth in OB-GYN hospitalist groups. Some hospitals have been able to reduce the amount they must hold in reserve for future OB-related malpractice claims by more than $1 million after the first year of starting a laborist program. Additionally, hospitals’ annual malpractice premiums have dropped significantly.
Availability of on-site hospitalists has played a crucial role in this new delivery model for most of the hospitalist specialties. For hospitals with laborists, this has meant a significant decrease (for some, a total relief) in unattended deliveries, which in some hospitals was as high as 10% before the new breed of hospitalist arrived on the scene. This 24/7 obstetrician presence has reduced complications from many labor and delivery emergencies, and has led to improved patient safety and improved overall performance at the crucial moment of delivery. This is especially true for high-risk and emergency situations.
Just as in the rest of HM, the 24/7 availability has been complementary, not competitive, to community-based obstetricians: Unassigned patients now have someone to deliver their baby; community obstetricians have a hospital-based “partner” who is ready to fill any gaps in the community obstetricians’ presence in the hospital; and there is a ready assistant surgeon to those patients who require a C-section delivery.
Solution to the Insane Schedule?
The advent of laborists also has created some key professional options for established OB-GYN physicians, as well as for those just coming out of training. Some older obstetricians would stop delivering babies altogether, even though they enjoyed that part of their practice, because of the time demands on having to simultaneously deliver babies randomly in the middle of the night, then show up the next day for a full gynecology surgery schedule or office practice. Their only option seemed to be to concentrate on gynecology and shelve the obstetrics. Now, community obstetricians can partner with the laborists and still provide prenatal care and perform some deliveries, or they can leave their private OB-GYN practice altogether and become full-time OB hospitalists.
This point was driven home recently when a hospital in Oregon started an OB hospitalist group and needed only four hospitalists. The hospital received more than 40 applications, most from practicing obstetricians.
This points to another difference with laborists. You can start a fully staffed group with just four OB hospitalists, each working a 24-hour shift every third day. Medical HM groups might start out with four hospitalists, but they quickly need to grow to 10, 15, or more as responsibilities for more unassigned patients, surgical comanagement, etc., require more hands on deck.
The similarities between OB hospitalists and the rest of HM include the increased demand for accountability for patient safety and for meeting measureable performance standards, which are difficult to achieve while practicing both in the acute setting of the hospital and the more chronic setting of an office-based practice. In addition, there is a clear movement afoot for significant evolution in medical practice more broadly, where younger, and even established, physicians are looking for a more predictable lifestyle and compensation in a medical world that is clearly shifting to a new model.
Change Is All Around
In some specialties, predictability has led to the narrowing of practice by setting or subspecialty. For example, OB-GYNs are selecting to focus solely on gynecology, OB hospital medicine, or prenatal care. In general internal medicine, there are those who only do office-based medicine and those who are hospitalists. Some surgeons are now doing shifts as acute-care surgeons and limiting their practice to just inpatient care.
As much as a change in practice style, there is a resurgence of employment of physicians, either by medical groups, independent physician organizations, or hospitals. Even the strong, revenue-producing specialties like cardiology are seeing a new paradigm. Today, almost 60% of cardiologists are employed by some entity, and 38% of cardiologists are employed by the hospital.
As healthcare reform, payment reform, and new entities like accountable care organizations (ACOs) take shape, physician-provided medical care is moving from a cottage industry of individual and small group private practice to employment and amalgamation.
Change is inevitable, and it is coming from a variety of viewpoints. Patients want better access to the best and safest care available. America’s businesses and the government, which fund healthcare, want predictable costs and measurable quality for the care they buy. Physicians want help in meeting new standards, predictable compensation for their work, and a lifestyle that meets their professional and personal aspirations.
The movement to the hospitalist model, first in the care of medical patients, and more recently for obstetrical, surgical, and other patients, is just one piece of a medical system in evolution. Stay tuned. We are still very much at the early stages of this course change. We all still have much work to do to create a future that works for our patients, our funders, and our providers of healthcare. TH
Dr. Wellikson is CEO of SHM.
You Can See 40 a Day
Now that I have your attention, I hope no one thinks the “40 patients per day” suggestion is in any way SHM current policy. But it is becoming increasingly clear that demands for the hospitalist workforce and demands on ongoing accountability for performance will require a redefinition of the role the hospitalist should have in patient care.
This isn’t unique to HM. In many ways, the patient-centered medical home (PCMH) and accountable-care organizations (ACOs) will in their own ways redefine the physician’s role at many steps along the healthcare continuum. But, as usual, HM might very well be at the leading edge.
Scope of Practice
There just aren’t enough qualified hospitalists to do the work, let alone all of the things coming our way with an ever-expanding scope of practice. Sure, hospitalists will always have a central role in managing the acute care of most medical illnesses. We already manage more inpatient heart-failure patients and more chest pain than cardiologists; more seizures, strokes, and dementia than neurologists; and more diabetes than endocrinologists. In many hospitals, we have replaced PCPs in managing acutely ill patients on medical floors.
But in recent years, hospitalists have played an increasing role in comanaging orthopedic and other surgical patients, and are playing a larger role in the care of patients formerly managed solely by subspecialists. As neurologists have left the building, hospitalists have had to expand our management of patients with acute neurologic problems. And as the critical-care shortage expands, hospitalists are playing a greater role in our nation’s ICUs.
Forward-thinking hospitals are redefining the roles of ED physicians in an era of hospitalists. Patients who present with a temperature of 104, a BP of 90/60, and a pulmonary infiltrate get a 60-second evaluation in the ED and are quickly admitted upstairs to the hospitalists. No need for two to three hours of an ED workup for a patient everyone knows is coming into the house. More and more EDs are routinely using hospitalists as in-house consultants on difficult patient decisions.
As ACOs become commonplace and as hospitals become responsible for the gaps post-discharge, look for some HM groups to be asked to manage the subacute patient experience, those critical first post-hospital visits in the 30 days after hospitalization. PCPs and medical homes will have their own capacity issues and difficulties in managing these fragile patients just out of the hospital.
Add to this all the time hospitalists need to spend each day in developing and implementing performance improvement, and in creating and participating in the new hospital team, it is no wonder that a limited HM workforce is being stretched beyond its capacity.
Workforce Issues
In many ways, this is a blessing for an individual hospitalist, especially one with a track record of competency and skill. This is at least part of the reason that HM was one of only five medical specialties in which incomes increased in 2009, and why hospitals everywhere are looking for strategies to attract and retain the best talent.
While this trend might bode well for the individual hospitalist looking for career flexibility, the ever-enlarging specialty of HM cannot easily fill all the needs described above, even with a large influx of medical students or residents in internal medicine, family medicine, and pediatrics, or even with recruitment of additional nonphysician providers. The work is growing too fast and the people just aren’t available.
Job Description
It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?
If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.
Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.
The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?
What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?
The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.
But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.
Some EDs right now have a new person, the scribe, who sees the patient side by side with the physician, transcribing the orders, writing the notes, and interfacing with the hospital’s electronic health record (EHR). Does this free up the ED physician to see more patients? Does this lead to better care? Does this lead to better payment collection or fewer liability suits?
And this is just replacing one element of the doctors’ job. Think how existing healthcare professionals and new ones on the horizon can change the workforce.
The point is, the role and the need for the unique skill set of the well-tuned hospitalist have grown too broad for us to continue with business as usual. It is time to systematically look at the tasks that need to be accomplished for each acutely ill patient and to evaluate the entire healthcare team available, their competencies and their skill sets, and to set a “new paradigm” for their deployment.
This will require some documentation of each professional’s competence and a trust that they can deliver on a daily basis. In this new world, the hospitalist moves from playing lead trumpet to being the conductor of the orchestra, to being the coxswain for a crew team, or the quarterback of a multiskilled team.
In this world, the hospitalist could oversee 40 patients a day in a very different role than occurs today. The team would be empowered by viewing the “hospitalist’s patients” as all of our patients, and the patients would benefit from an accountable team focused directly on them.
This is a world not taught in residency, but one that the future clamors for. There is not an easy path from today to the future, but as in many things in the last decade or so, I trust that the best of HM is up to the task of playing a leading role in designing and implementing the future of healthcare.
SHM will continue to do its part to help you at every step along the way. TH
Dr. Wellikson is CEO of SHM.
Now that I have your attention, I hope no one thinks the “40 patients per day” suggestion is in any way SHM current policy. But it is becoming increasingly clear that demands for the hospitalist workforce and demands on ongoing accountability for performance will require a redefinition of the role the hospitalist should have in patient care.
This isn’t unique to HM. In many ways, the patient-centered medical home (PCMH) and accountable-care organizations (ACOs) will in their own ways redefine the physician’s role at many steps along the healthcare continuum. But, as usual, HM might very well be at the leading edge.
Scope of Practice
There just aren’t enough qualified hospitalists to do the work, let alone all of the things coming our way with an ever-expanding scope of practice. Sure, hospitalists will always have a central role in managing the acute care of most medical illnesses. We already manage more inpatient heart-failure patients and more chest pain than cardiologists; more seizures, strokes, and dementia than neurologists; and more diabetes than endocrinologists. In many hospitals, we have replaced PCPs in managing acutely ill patients on medical floors.
But in recent years, hospitalists have played an increasing role in comanaging orthopedic and other surgical patients, and are playing a larger role in the care of patients formerly managed solely by subspecialists. As neurologists have left the building, hospitalists have had to expand our management of patients with acute neurologic problems. And as the critical-care shortage expands, hospitalists are playing a greater role in our nation’s ICUs.
Forward-thinking hospitals are redefining the roles of ED physicians in an era of hospitalists. Patients who present with a temperature of 104, a BP of 90/60, and a pulmonary infiltrate get a 60-second evaluation in the ED and are quickly admitted upstairs to the hospitalists. No need for two to three hours of an ED workup for a patient everyone knows is coming into the house. More and more EDs are routinely using hospitalists as in-house consultants on difficult patient decisions.
As ACOs become commonplace and as hospitals become responsible for the gaps post-discharge, look for some HM groups to be asked to manage the subacute patient experience, those critical first post-hospital visits in the 30 days after hospitalization. PCPs and medical homes will have their own capacity issues and difficulties in managing these fragile patients just out of the hospital.
Add to this all the time hospitalists need to spend each day in developing and implementing performance improvement, and in creating and participating in the new hospital team, it is no wonder that a limited HM workforce is being stretched beyond its capacity.
Workforce Issues
In many ways, this is a blessing for an individual hospitalist, especially one with a track record of competency and skill. This is at least part of the reason that HM was one of only five medical specialties in which incomes increased in 2009, and why hospitals everywhere are looking for strategies to attract and retain the best talent.
While this trend might bode well for the individual hospitalist looking for career flexibility, the ever-enlarging specialty of HM cannot easily fill all the needs described above, even with a large influx of medical students or residents in internal medicine, family medicine, and pediatrics, or even with recruitment of additional nonphysician providers. The work is growing too fast and the people just aren’t available.
Job Description
It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?
If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.
Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.
The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?
What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?
The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.
But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.
Some EDs right now have a new person, the scribe, who sees the patient side by side with the physician, transcribing the orders, writing the notes, and interfacing with the hospital’s electronic health record (EHR). Does this free up the ED physician to see more patients? Does this lead to better care? Does this lead to better payment collection or fewer liability suits?
And this is just replacing one element of the doctors’ job. Think how existing healthcare professionals and new ones on the horizon can change the workforce.
The point is, the role and the need for the unique skill set of the well-tuned hospitalist have grown too broad for us to continue with business as usual. It is time to systematically look at the tasks that need to be accomplished for each acutely ill patient and to evaluate the entire healthcare team available, their competencies and their skill sets, and to set a “new paradigm” for their deployment.
This will require some documentation of each professional’s competence and a trust that they can deliver on a daily basis. In this new world, the hospitalist moves from playing lead trumpet to being the conductor of the orchestra, to being the coxswain for a crew team, or the quarterback of a multiskilled team.
In this world, the hospitalist could oversee 40 patients a day in a very different role than occurs today. The team would be empowered by viewing the “hospitalist’s patients” as all of our patients, and the patients would benefit from an accountable team focused directly on them.
This is a world not taught in residency, but one that the future clamors for. There is not an easy path from today to the future, but as in many things in the last decade or so, I trust that the best of HM is up to the task of playing a leading role in designing and implementing the future of healthcare.
SHM will continue to do its part to help you at every step along the way. TH
Dr. Wellikson is CEO of SHM.
Now that I have your attention, I hope no one thinks the “40 patients per day” suggestion is in any way SHM current policy. But it is becoming increasingly clear that demands for the hospitalist workforce and demands on ongoing accountability for performance will require a redefinition of the role the hospitalist should have in patient care.
This isn’t unique to HM. In many ways, the patient-centered medical home (PCMH) and accountable-care organizations (ACOs) will in their own ways redefine the physician’s role at many steps along the healthcare continuum. But, as usual, HM might very well be at the leading edge.
Scope of Practice
There just aren’t enough qualified hospitalists to do the work, let alone all of the things coming our way with an ever-expanding scope of practice. Sure, hospitalists will always have a central role in managing the acute care of most medical illnesses. We already manage more inpatient heart-failure patients and more chest pain than cardiologists; more seizures, strokes, and dementia than neurologists; and more diabetes than endocrinologists. In many hospitals, we have replaced PCPs in managing acutely ill patients on medical floors.
But in recent years, hospitalists have played an increasing role in comanaging orthopedic and other surgical patients, and are playing a larger role in the care of patients formerly managed solely by subspecialists. As neurologists have left the building, hospitalists have had to expand our management of patients with acute neurologic problems. And as the critical-care shortage expands, hospitalists are playing a greater role in our nation’s ICUs.
Forward-thinking hospitals are redefining the roles of ED physicians in an era of hospitalists. Patients who present with a temperature of 104, a BP of 90/60, and a pulmonary infiltrate get a 60-second evaluation in the ED and are quickly admitted upstairs to the hospitalists. No need for two to three hours of an ED workup for a patient everyone knows is coming into the house. More and more EDs are routinely using hospitalists as in-house consultants on difficult patient decisions.
As ACOs become commonplace and as hospitals become responsible for the gaps post-discharge, look for some HM groups to be asked to manage the subacute patient experience, those critical first post-hospital visits in the 30 days after hospitalization. PCPs and medical homes will have their own capacity issues and difficulties in managing these fragile patients just out of the hospital.
Add to this all the time hospitalists need to spend each day in developing and implementing performance improvement, and in creating and participating in the new hospital team, it is no wonder that a limited HM workforce is being stretched beyond its capacity.
Workforce Issues
In many ways, this is a blessing for an individual hospitalist, especially one with a track record of competency and skill. This is at least part of the reason that HM was one of only five medical specialties in which incomes increased in 2009, and why hospitals everywhere are looking for strategies to attract and retain the best talent.
While this trend might bode well for the individual hospitalist looking for career flexibility, the ever-enlarging specialty of HM cannot easily fill all the needs described above, even with a large influx of medical students or residents in internal medicine, family medicine, and pediatrics, or even with recruitment of additional nonphysician providers. The work is growing too fast and the people just aren’t available.
Job Description
It is time to rethink the job description for the physician hospitalists. How do we want to deploy the $100-plus-per-hour hospitalist, who is in short supply, to get the most out of this limited resource?
If we step back a minute and start to list all the roles hospitalists have played in patient care, we might see ways to involve existing health professionals, and we might also see a need to add some new players, to alter the current hierarchy and authority. If we keep the focus on always providing the best care for the patient and to only ask each member of the team to play roles consistent with their training and competencies, then we can come out the other side of all this in better shape than we are in now.
Hospitalists today are asked to take a detailed history, do a complete physical examination, review any old records, speak to the referring physicians, talk to the doctor and possibly the nurse in the ED, meet with the nurse on the floor, make an initial diagnosis, order initial and subsequent tests to confirm or deny each specific diagnosis, order initial therapies (pharmaceutical and other), adjust therapy as the tests clarify or muddy the diagnostic approach, order additional tests to make sure the therapies are helpful and not toxic, record all of these ideas, directions, assumptions, and guesses in the medical record, generate a bill to collect payment for care rendered, meet with the patient and possibly the family to educate them about the potential disease states and each therapy ordered, assess the home (or nonhospital) situation, and make plans and arrangements for discharge, round on the patient at least once daily to redo and revise many of these steps as the course of the disease and new information warrants, produce instructions at discharge to include a summary of the hospital course, new therapies, future testing at a level for the patient and their family, and also for the future physicians in compliance with the requirements for billing and in compliance with hospital regulations and the community standards, make sure your care elements are being documented for performance evaluations and to satisfy whatever alphabet soup is looking at measurement and accountability, and along the way figure out what information any consultants, comanagers, other hospitalists, nurses, etc. might need to know, and create a venue or process to communicate the information. And I am sure there are more roles I have left out.
The point is, do we really need an MD to do all of these things? Is it time to create a process, a trusted team, and a new way to deliver the best care and deploy our limited resources more economically and effectively?
What are the unique roles and skill sets that physician hospitalists can bring to their patients’ care? And, more important, what are the current roles that would be better handed off to another member of the team?
The hospitalist should be the integrator of information, who then works with the entire team to set a direction and plan for diagnosis and therapy. Most everything else could be delegated to someone else.
But that presupposes a trust in the competencies of the rest of the team. Do I believe the history and physical already performed in the ED, by the nurse, by the NPP, or by another physician, or do I need to repeat this again? Do I trust the pharmacist to select the correct agent and know how to monitor its effectiveness and potential toxicity, and to be prepared to transition to outpatient therapy? Do I trust that the nurse (and every nurse on every shift) will be able educate the patient about their disease and hospital course and to provide accurate and timely information about the patient? And on and on.
Some EDs right now have a new person, the scribe, who sees the patient side by side with the physician, transcribing the orders, writing the notes, and interfacing with the hospital’s electronic health record (EHR). Does this free up the ED physician to see more patients? Does this lead to better care? Does this lead to better payment collection or fewer liability suits?
And this is just replacing one element of the doctors’ job. Think how existing healthcare professionals and new ones on the horizon can change the workforce.
The point is, the role and the need for the unique skill set of the well-tuned hospitalist have grown too broad for us to continue with business as usual. It is time to systematically look at the tasks that need to be accomplished for each acutely ill patient and to evaluate the entire healthcare team available, their competencies and their skill sets, and to set a “new paradigm” for their deployment.
This will require some documentation of each professional’s competence and a trust that they can deliver on a daily basis. In this new world, the hospitalist moves from playing lead trumpet to being the conductor of the orchestra, to being the coxswain for a crew team, or the quarterback of a multiskilled team.
In this world, the hospitalist could oversee 40 patients a day in a very different role than occurs today. The team would be empowered by viewing the “hospitalist’s patients” as all of our patients, and the patients would benefit from an accountable team focused directly on them.
This is a world not taught in residency, but one that the future clamors for. There is not an easy path from today to the future, but as in many things in the last decade or so, I trust that the best of HM is up to the task of playing a leading role in designing and implementing the future of healthcare.
SHM will continue to do its part to help you at every step along the way. TH
Dr. Wellikson is CEO of SHM.