Liz Tascio

When a Catholic group moved to buy Lutheran Medical Center in Wheat Ridge, Colo., just outside of Denver, hospitalist Steven Krebs, MD, had strong objections. Sisters of Charity of Leavenworth Health System already was part-owner of the 400-bed medical center. As the sole owner, it would require the hospital to follow Catholic rules regarding end-of-life care and reproductive health, meaning some medical services would be prohibited.

“It’s really the last hospital before you go into the mountains. There’s no real hospital facility until Vail, almost 100 miles up the road,” Dr. Krebs says. Patients who wanted a tubal ligation, an emergency contraceptive, or other medical services typically not offered in a Catholic hospital would have to travel to receive them—or not receive them at all.

After negotiations failed to produce a satisfactory outcome, Dr. Krebs took the drastic step of becoming part of a lawsuit to stop the sale. In May 2008, Colorado’s governor signed into law a bill that allows the state attorney general to review how the sale of a nonprofit hospital affects patient care. If he believes care will be affected, the attorney general may ask for more information from the sponsors of the transaction or require a public hearing be held before determining whether to approve the transaction.

The sale is pending.

In an ideal world, patients would get the same excellent care, no matter who owns or runs a hospital. A sale or a change in executive leadership wouldn’t alter the tone of a hospital. As the Colorado case shows, ownership and leadership matter.

Hospitalists who have been through a hospital sale or a change of leadership say it’s possible to influence the process from within, to benefit the hospital, the patients, and the hospitalists themselves, often through simple negotiation and clear communication.

Become a Resource, Partner for Leadership

Established hospitalist programs are in an especially strong bargaining position. “We have a track record we can point to,” says Brian Bossard, MD, director of Inpatient Physician Associates, whose medical center, BryanLGH in Lincoln, Neb., went through a search for a new CEO in early 2008. That track record includes a strong relationship between the hospitalist program and hospital administrators.

When the medical center considered formalizing its hospitalist program in 2002, for example, Dr. Bossard went with administrators to regional and national meetings. “Instead of having competing perspectives on what the costs of the program should be and what the value equation is, we came from a similar perspective,” he explains. “Since that time, that trust has been maintained by coming through on promises, whether it’s being able to manage the volumes or get good results.”

A strong foundation can lead to a well-integrated hospitalist program and positive relationships with the CEO and COO, Dr. Bossard adds. Though he considers the change in CEOs at BryanLGH “a little unsettling,” he says he’s confident his hospitalist program has the support of the hospital community. Perhaps as evidence of that, the hospital hiring committee considered input from hospitalists before making a final selection.

Dr. Bossard plans to present to the new CEO the hospitalist program’s accomplishments, goals, and potential challenges early on, so the CEO can get to know the program. “The [hospitalists] really should try to position themselves, in my view anyway, as sort of an insider with useful information, a leader they can go to to ask what’s really going on in the hospital,” Dr. Bossard says. “Hospitalist programs will grow so rapidly within hospital systems, taking care of 50% to 75%, to sometimes close to 100% of patients. They’re really great sources of information.”

Keep Lines of Communication Open

Strong relationships with hospital leadership creates a stable environment where hospitalists feel valued. It also helps ensure a program can weather almost any storm, says Julia Wright, MD, University of Wisconsin Hospital and Clinics hospitalist director and the director of hospital medicine at UW School of Medicine and Public Health in Madison, Wis. “Once you get to the point where you have value, a mission, a system of operations, and a delivery-of-care plan, then that might translate into some personal ownership in the program that could withstand a change in administration,” she says.

Dr. Wright, who took a five-person hospitalist program and has enlarged it to 13, says she understands the value of communication with hospital executives. She also has a game plan, should executive leadership at her hospital change. “The first thing I would do is sit down and discuss what my mission is,” she says. “Continued dialogue after that is really important.” The dialogue would include meeting with hospital administration regularly, as well as talking about objectives and ways to meet them. “I just know what’s worked to keep our program on track,” she says, “and it’s been very successful.”

Leverage a Change in Administration

At Meriter Hospital in Madison, Wis., Cate Ranheim, MD, director of the hospitalist program, found a change in administration actually benefitted her hospitalists. “Our previous administration was essentially a chief operating officer (COO) who approved—or more often—refused, every request for even the simplest things, from sinks to filing cabinets to call rooms,” she explains. “The former CEO was here for 30-plus years, as was the COO, and was virtually invisible within the institution.”

The COO was a strong advocate for the hospitalist group, but Dr. Ranheim says she still had to go through tough negotiations to get what the group needed. When a new CEO came in and announced an open-door policy, Dr. Ranheim jumped at the opportunity to be heard. “Whenever I need something for the group, I go directly to him, and I have never been refused anything because he knows I am not game-playing or negotiating,” she says. “If I say the group needs something, it really does.”

Dr. Ranheim’s experience actually is fairly common. Executive leadership or ownership changes often create “a window of opportunity to further some agendas,” Dr. Wright points out. “If there’s a group that’s been saying, ‘We really want to start this new initiative and just haven’t been able to get there yet,’ this might be the time to do that.”

Whether the transition is a good time can depend on how comfortable a hospitalist group feels with the new executive. “In my own experience, it’s all about personality,” Dr. Ranheim says. “As hospitalist director, I instantly trusted my new CEO, and that trust has never been violated in either direction.” She adds, “Of course, I still do get everything in writing.”

Pay Attention to National Standards

Whether hospitalists can bring about improvements during a hospital change of ownership or leadership isn’t just based on how much the program improves care or reduces costs at the facility. National standards also should come into play, Dr. Bossard says. “The hospitalist negotiator and the administration need to be comfortable with their command of what the data shows and what their standards are,” he cautions.

At Lutheran Medical Center in Colorado, Dr. Krebs felt strongly the change in ownership would cause patients hardship and go against national standards. Though both sides attempted to collect feedback and reach a compromise, neither came up with a solution that satisfied Dr. Krebs. He felt he had no choice but to seek legal action. (Exempla Healthcare, which manages the medical center, also sued to stop the sale).

“If the parent organization of Jehovah’s Witnesses took over a hospital and declared that no one could have a transfusion, no one would allow that,” Dr. Krebs argues. “If I have a patient that’s a Jehovah’s Witness, and they say, ‘I won’t have a transfusion,’ that’s very important. However, that person doesn’t have the right to impose their belief system on someone else.”

Dr. Krebs says he has the support of his medical community and his hospital, largely because, as a hospitalist, he’s been involved with the community all along. He says any hospitalist who hopes to influence standards of care should get involved, too, by sitting on or chairing a hospital committee, becoming an integral part of the medical community early on, and, above all, providing great care.

“If you leverage the facility you’re in to the Nth degree for income, you’re not going to be viewed as a partner, but as a vendor commodity, and you’ll have very little influence,” Dr. Krebs says. “There’s a benefit to being a hospitalist. You are in a unique position to exert influence on the hospital, because in some ways, both parties need the other to do well.” TH

When a Catholic group moved to buy Lutheran Medical Center in Wheat Ridge, Colo., just outside of Denver, hospitalist Steven Krebs, MD, had strong objections. Sisters of Charity of Leavenworth Health System already was part-owner of the 400-bed medical center. As the sole owner, it would require the hospital to follow Catholic rules regarding end-of-life care and reproductive health, meaning some medical services would be prohibited.

“It’s really the last hospital before you go into the mountains. There’s no real hospital facility until Vail, almost 100 miles up the road,” Dr. Krebs says. Patients who wanted a tubal ligation, an emergency contraceptive, or other medical services typically not offered in a Catholic hospital would have to travel to receive them—or not receive them at all.

After negotiations failed to produce a satisfactory outcome, Dr. Krebs took the drastic step of becoming part of a lawsuit to stop the sale. In May 2008, Colorado’s governor signed into law a bill that allows the state attorney general to review how the sale of a nonprofit hospital affects patient care. If he believes care will be affected, the attorney general may ask for more information from the sponsors of the transaction or require a public hearing be held before determining whether to approve the transaction.

The sale is pending.

In an ideal world, patients would get the same excellent care, no matter who owns or runs a hospital. A sale or a change in executive leadership wouldn’t alter the tone of a hospital. As the Colorado case shows, ownership and leadership matter.

Hospitalists who have been through a hospital sale or a change of leadership say it’s possible to influence the process from within, to benefit the hospital, the patients, and the hospitalists themselves, often through simple negotiation and clear communication.

Become a Resource, Partner for Leadership

Established hospitalist programs are in an especially strong bargaining position. “We have a track record we can point to,” says Brian Bossard, MD, director of Inpatient Physician Associates, whose medical center, BryanLGH in Lincoln, Neb., went through a search for a new CEO in early 2008. That track record includes a strong relationship between the hospitalist program and hospital administrators.

When the medical center considered formalizing its hospitalist program in 2002, for example, Dr. Bossard went with administrators to regional and national meetings. “Instead of having competing perspectives on what the costs of the program should be and what the value equation is, we came from a similar perspective,” he explains. “Since that time, that trust has been maintained by coming through on promises, whether it’s being able to manage the volumes or get good results.”

A strong foundation can lead to a well-integrated hospitalist program and positive relationships with the CEO and COO, Dr. Bossard adds. Though he considers the change in CEOs at BryanLGH “a little unsettling,” he says he’s confident his hospitalist program has the support of the hospital community. Perhaps as evidence of that, the hospital hiring committee considered input from hospitalists before making a final selection.

Dr. Bossard plans to present to the new CEO the hospitalist program’s accomplishments, goals, and potential challenges early on, so the CEO can get to know the program. “The [hospitalists] really should try to position themselves, in my view anyway, as sort of an insider with useful information, a leader they can go to to ask what’s really going on in the hospital,” Dr. Bossard says. “Hospitalist programs will grow so rapidly within hospital systems, taking care of 50% to 75%, to sometimes close to 100% of patients. They’re really great sources of information.”

Keep Lines of Communication Open

Strong relationships with hospital leadership creates a stable environment where hospitalists feel valued. It also helps ensure a program can weather almost any storm, says Julia Wright, MD, University of Wisconsin Hospital and Clinics hospitalist director and the director of hospital medicine at UW School of Medicine and Public Health in Madison, Wis. “Once you get to the point where you have value, a mission, a system of operations, and a delivery-of-care plan, then that might translate into some personal ownership in the program that could withstand a change in administration,” she says.

Dr. Wright, who took a five-person hospitalist program and has enlarged it to 13, says she understands the value of communication with hospital executives. She also has a game plan, should executive leadership at her hospital change. “The first thing I would do is sit down and discuss what my mission is,” she says. “Continued dialogue after that is really important.” The dialogue would include meeting with hospital administration regularly, as well as talking about objectives and ways to meet them. “I just know what’s worked to keep our program on track,” she says, “and it’s been very successful.”

Leverage a Change in Administration

At Meriter Hospital in Madison, Wis., Cate Ranheim, MD, director of the hospitalist program, found a change in administration actually benefitted her hospitalists. “Our previous administration was essentially a chief operating officer (COO) who approved—or more often—refused, every request for even the simplest things, from sinks to filing cabinets to call rooms,” she explains. “The former CEO was here for 30-plus years, as was the COO, and was virtually invisible within the institution.”

The COO was a strong advocate for the hospitalist group, but Dr. Ranheim says she still had to go through tough negotiations to get what the group needed. When a new CEO came in and announced an open-door policy, Dr. Ranheim jumped at the opportunity to be heard. “Whenever I need something for the group, I go directly to him, and I have never been refused anything because he knows I am not game-playing or negotiating,” she says. “If I say the group needs something, it really does.”

Dr. Ranheim’s experience actually is fairly common. Executive leadership or ownership changes often create “a window of opportunity to further some agendas,” Dr. Wright points out. “If there’s a group that’s been saying, ‘We really want to start this new initiative and just haven’t been able to get there yet,’ this might be the time to do that.”

Whether the transition is a good time can depend on how comfortable a hospitalist group feels with the new executive. “In my own experience, it’s all about personality,” Dr. Ranheim says. “As hospitalist director, I instantly trusted my new CEO, and that trust has never been violated in either direction.” She adds, “Of course, I still do get everything in writing.”

Pay Attention to National Standards

Whether hospitalists can bring about improvements during a hospital change of ownership or leadership isn’t just based on how much the program improves care or reduces costs at the facility. National standards also should come into play, Dr. Bossard says. “The hospitalist negotiator and the administration need to be comfortable with their command of what the data shows and what their standards are,” he cautions.

At Lutheran Medical Center in Colorado, Dr. Krebs felt strongly the change in ownership would cause patients hardship and go against national standards. Though both sides attempted to collect feedback and reach a compromise, neither came up with a solution that satisfied Dr. Krebs. He felt he had no choice but to seek legal action. (Exempla Healthcare, which manages the medical center, also sued to stop the sale).

“If the parent organization of Jehovah’s Witnesses took over a hospital and declared that no one could have a transfusion, no one would allow that,” Dr. Krebs argues. “If I have a patient that’s a Jehovah’s Witness, and they say, ‘I won’t have a transfusion,’ that’s very important. However, that person doesn’t have the right to impose their belief system on someone else.”

Dr. Krebs says he has the support of his medical community and his hospital, largely because, as a hospitalist, he’s been involved with the community all along. He says any hospitalist who hopes to influence standards of care should get involved, too, by sitting on or chairing a hospital committee, becoming an integral part of the medical community early on, and, above all, providing great care.

“If you leverage the facility you’re in to the Nth degree for income, you’re not going to be viewed as a partner, but as a vendor commodity, and you’ll have very little influence,” Dr. Krebs says. “There’s a benefit to being a hospitalist. You are in a unique position to exert influence on the hospital, because in some ways, both parties need the other to do well.” TH

When a Catholic group moved to buy Lutheran Medical Center in Wheat Ridge, Colo., just outside of Denver, hospitalist Steven Krebs, MD, had strong objections. Sisters of Charity of Leavenworth Health System already was part-owner of the 400-bed medical center. As the sole owner, it would require the hospital to follow Catholic rules regarding end-of-life care and reproductive health, meaning some medical services would be prohibited.

“It’s really the last hospital before you go into the mountains. There’s no real hospital facility until Vail, almost 100 miles up the road,” Dr. Krebs says. Patients who wanted a tubal ligation, an emergency contraceptive, or other medical services typically not offered in a Catholic hospital would have to travel to receive them—or not receive them at all.

After negotiations failed to produce a satisfactory outcome, Dr. Krebs took the drastic step of becoming part of a lawsuit to stop the sale. In May 2008, Colorado’s governor signed into law a bill that allows the state attorney general to review how the sale of a nonprofit hospital affects patient care. If he believes care will be affected, the attorney general may ask for more information from the sponsors of the transaction or require a public hearing be held before determining whether to approve the transaction.

The sale is pending.

In an ideal world, patients would get the same excellent care, no matter who owns or runs a hospital. A sale or a change in executive leadership wouldn’t alter the tone of a hospital. As the Colorado case shows, ownership and leadership matter.

Hospitalists who have been through a hospital sale or a change of leadership say it’s possible to influence the process from within, to benefit the hospital, the patients, and the hospitalists themselves, often through simple negotiation and clear communication.

Become a Resource, Partner for Leadership

Established hospitalist programs are in an especially strong bargaining position. “We have a track record we can point to,” says Brian Bossard, MD, director of Inpatient Physician Associates, whose medical center, BryanLGH in Lincoln, Neb., went through a search for a new CEO in early 2008. That track record includes a strong relationship between the hospitalist program and hospital administrators.

When the medical center considered formalizing its hospitalist program in 2002, for example, Dr. Bossard went with administrators to regional and national meetings. “Instead of having competing perspectives on what the costs of the program should be and what the value equation is, we came from a similar perspective,” he explains. “Since that time, that trust has been maintained by coming through on promises, whether it’s being able to manage the volumes or get good results.”

A strong foundation can lead to a well-integrated hospitalist program and positive relationships with the CEO and COO, Dr. Bossard adds. Though he considers the change in CEOs at BryanLGH “a little unsettling,” he says he’s confident his hospitalist program has the support of the hospital community. Perhaps as evidence of that, the hospital hiring committee considered input from hospitalists before making a final selection.

Dr. Bossard plans to present to the new CEO the hospitalist program’s accomplishments, goals, and potential challenges early on, so the CEO can get to know the program. “The [hospitalists] really should try to position themselves, in my view anyway, as sort of an insider with useful information, a leader they can go to to ask what’s really going on in the hospital,” Dr. Bossard says. “Hospitalist programs will grow so rapidly within hospital systems, taking care of 50% to 75%, to sometimes close to 100% of patients. They’re really great sources of information.”

Keep Lines of Communication Open

Strong relationships with hospital leadership creates a stable environment where hospitalists feel valued. It also helps ensure a program can weather almost any storm, says Julia Wright, MD, University of Wisconsin Hospital and Clinics hospitalist director and the director of hospital medicine at UW School of Medicine and Public Health in Madison, Wis. “Once you get to the point where you have value, a mission, a system of operations, and a delivery-of-care plan, then that might translate into some personal ownership in the program that could withstand a change in administration,” she says.

Dr. Wright, who took a five-person hospitalist program and has enlarged it to 13, says she understands the value of communication with hospital executives. She also has a game plan, should executive leadership at her hospital change. “The first thing I would do is sit down and discuss what my mission is,” she says. “Continued dialogue after that is really important.” The dialogue would include meeting with hospital administration regularly, as well as talking about objectives and ways to meet them. “I just know what’s worked to keep our program on track,” she says, “and it’s been very successful.”

Leverage a Change in Administration

At Meriter Hospital in Madison, Wis., Cate Ranheim, MD, director of the hospitalist program, found a change in administration actually benefitted her hospitalists. “Our previous administration was essentially a chief operating officer (COO) who approved—or more often—refused, every request for even the simplest things, from sinks to filing cabinets to call rooms,” she explains. “The former CEO was here for 30-plus years, as was the COO, and was virtually invisible within the institution.”

The COO was a strong advocate for the hospitalist group, but Dr. Ranheim says she still had to go through tough negotiations to get what the group needed. When a new CEO came in and announced an open-door policy, Dr. Ranheim jumped at the opportunity to be heard. “Whenever I need something for the group, I go directly to him, and I have never been refused anything because he knows I am not game-playing or negotiating,” she says. “If I say the group needs something, it really does.”

Dr. Ranheim’s experience actually is fairly common. Executive leadership or ownership changes often create “a window of opportunity to further some agendas,” Dr. Wright points out. “If there’s a group that’s been saying, ‘We really want to start this new initiative and just haven’t been able to get there yet,’ this might be the time to do that.”

Whether the transition is a good time can depend on how comfortable a hospitalist group feels with the new executive. “In my own experience, it’s all about personality,” Dr. Ranheim says. “As hospitalist director, I instantly trusted my new CEO, and that trust has never been violated in either direction.” She adds, “Of course, I still do get everything in writing.”

Pay Attention to National Standards

Whether hospitalists can bring about improvements during a hospital change of ownership or leadership isn’t just based on how much the program improves care or reduces costs at the facility. National standards also should come into play, Dr. Bossard says. “The hospitalist negotiator and the administration need to be comfortable with their command of what the data shows and what their standards are,” he cautions.

At Lutheran Medical Center in Colorado, Dr. Krebs felt strongly the change in ownership would cause patients hardship and go against national standards. Though both sides attempted to collect feedback and reach a compromise, neither came up with a solution that satisfied Dr. Krebs. He felt he had no choice but to seek legal action. (Exempla Healthcare, which manages the medical center, also sued to stop the sale).

“If the parent organization of Jehovah’s Witnesses took over a hospital and declared that no one could have a transfusion, no one would allow that,” Dr. Krebs argues. “If I have a patient that’s a Jehovah’s Witness, and they say, ‘I won’t have a transfusion,’ that’s very important. However, that person doesn’t have the right to impose their belief system on someone else.”

Dr. Krebs says he has the support of his medical community and his hospital, largely because, as a hospitalist, he’s been involved with the community all along. He says any hospitalist who hopes to influence standards of care should get involved, too, by sitting on or chairing a hospital committee, becoming an integral part of the medical community early on, and, above all, providing great care.

“If you leverage the facility you’re in to the Nth degree for income, you’re not going to be viewed as a partner, but as a vendor commodity, and you’ll have very little influence,” Dr. Krebs says. “There’s a benefit to being a hospitalist. You are in a unique position to exert influence on the hospital, because in some ways, both parties need the other to do well.” TH

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.

Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.

The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.

The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.

What They’re Doing

“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.

Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.

He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.

“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.

It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.

“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.

How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.

“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”

For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.

“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”

The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”

The group just revised its history-and-physical template to include more prompts, reminding the admitting physician to check for these POAIs.

Reminders like that coupled with the right technology can make it easier for hospitalists to capture all this information, says Brian Harte, MD, acting chairman of the Department of Hospital Medicine at the Cleveland Clinic, and a member of SHM’s Hospital Quality and Patient Safety Committee.

“What we will be doing is looking at ways to include this primarily into our electronic documentation,” Dr. Harte says. “[We’re] finding a way to cue people so that the default is to think about them, to answer ‘yes’ or ‘no’ to these conditions.”

He recommends giving physicians and nurses plenty of opportunities to note conditions—and not just by adding “pop-up” reminders in electronic records, which, he points out, can start looking like a Web site without ad blockers.

About two years ago, Beth Israel Deaconess Medical Center in Boston was trying to determine how central lines were becoming infected. It was discovered the facility didn’t have a system to record who had placed the lines.

“We wanted a smaller group of providers doing a higher volume of lines, with the belief that if we trained these people and helped them understand, we could minimize the variation of putting in the lines, and we could change the outcome,” says Joseph Li, MD, director of the hospital medicine program at Beth Israel Deaconess.

The hospital now has a nurse dedicated to checking the lines every day. It also designates skin-care nurses who regularly check for pressure ulcers.

Understanding the motivations behind the changes in IPPS will go a long way toward helping hospitalists adapt to them and provide better care, asserts Dr. Li, a member of the SHM Board of Directors.

“Of course we never want to leave something by accident inside a patient,” Dr. Li says. But less dramatic complications, like bedsores, can start to seem routine. “I think what happens over time is people get dulled to it,” he says. “They begin to believe it’s OK to have pressure ulcers, and it’s never OK.”

Difficulties

For all the good intentions behind CMS’s changes, it might be problematic for hospitalists to screen for the conditions CMS selected, says Heidi Wald, MD, MSPH, assistant professor of medicine at the University of Colorado, Denver, School of Medicine. Dr. Wald co-wrote a commentary called “Nonpayment for Harms Resulting from Medical Care” in the December 2007 Journal of the American Medical Association (JAMA).

A diagnosis can be coded as present on admission, not present on admission, unable to determine because the documentation was lacking, or unable to clinically say, Dr. Wald notes. She wants more information from CMS’s pilot studies, and says it remains to be seen how efficient the changes will be in practice.

For an example of how things can get complicated, Dr. Wald suggests a hypothetical situation: A patient comes to the emergency department with chest pain, is admitted to the hospital, receives a catheter, develops a fever, and is found in a subsequent urinalysis to have a urinary tract infection (UTI).

“Did the ED doc screen for a UTI on admission?” Dr. Wald asks. “Probably not. It would be ‘clinically unable to determine,’ from the way I’m reading it, because they didn’t have testing on admission. So in this case, it would behoove you not to screen.”

Dr. Wald praises CMS for giving hospitals a financial reason to focus on complications. She’s happy to see an increase in awareness of nosocomial infections.

“This is the right thing for hospitals to be doing, to find out ways to improve practice and to decrease infectious complications,” she notes. “I think the financial incentive is a way to push the cultural change along.”

Temple University in Philadelphia, which has about 25 hospitalists in its group, hopes to roll out formal changes in its policies in late spring or early summer, says William Ford, MD, program medical director of Cogent Healthcare and chief of the section of hospital medicine at Temple.

His hospitalists’ monthly meeting will include a regular, five-minute presentation on a topic in emergency medicine that pertains to the CMS changes, Dr. Ford says. It also will be part of their monthly journal meetings.

The goal is to make three of the conditions—UTIs, blood infections, and ulcers—part of physicians’ daily assessment, keeping it uppermost in their minds to continually evaluate the need for treatments such as Foley catheters or central lines.

Sometimes “three days go by and the doctor doesn’t think, because he or she is treating other parts of their illness, ‘Do they still need that Foley catheter, do they still need that IV?’ ” Dr. Ford notes. “If the patient does not need those two modalities, discontinue them … because those are two big causes for infection.”

Early Reaction

While the changes are incentive to be more attentive to detail, Dr. Ferrance wonders whether there could be a down side.

“I’ll be honest and admit I didn’t catch every single Stage 1 decubitus ulcer on every patient I admitted,” he says. “Now I’m much more vigilant.” Still, he adds: “It increases the paperwork burden, and it adds to the nonpatient part of our day. I have to wonder if the increased burden of paperwork pays off in that much benefit to the patient.”

And pressure is building. Insurers Aetna Inc. and WellPoint Inc. are following Medicare’s example, moving to end payment for some of the most serious hospital errors. Other major insurers are investigating changing their policies.

The public also cares quite a bit about the issue, Dr. Wald notes. When a New York Times blog mentioned Dr. Wald’s JAMA article, readers left scores of comments. Some were stunned to hear hospitals can be paid extra when complications occur.

Professional societies and organizations can help medical centers adjust to these changes by providing guidance and leadership, suggests Dr. Li. Hospitals will benefit by educating all providers about the system changes and the reasons behind them, he says.

“This is about a lot more than the doctor and the patient,” he argues. “This is about changing the culture and institution.” TH

Liz Tascio is a medical journalist based in New York.

Pediatric hospitalist Patrick Conway, MD, MSc, has become the first hospitalist accepted into The White House Fellows Program, a spokeswoman for the program says.

Dr. Conway had just reported to a new job at Cincinnati Children’s Hospital Medical Center when he found out he’d been accepted into the White House program. He’s serving with 14 other fellows, including one other medical professional, until August. He’ll return to Cincinnati with a deeper understanding of how physicians can affect federal health policy.

“It’s a once-in-a-lifetime learning experience, to see policy setting at the highest level of government,” Dr. Conway says.

Throughout the year, Dr. Conway, 33, will work in the office of Michael Leavitt, secretary of Health and Human Services (HHS), and with Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ).

“He’s an amazingly sharp physician who brings a great wealth of expertise, both because of the research he’s done but also in a clinical sense,” says Dr. Clancy, one of Dr. Conway’s mentors in the program. “He has a great grasp of policy.”

Dr. Conway has had to hit the ground running in his new role.

“We’re involving him directly in a number of very high-priority areas” including the improvement of healthcare quality and value, Dr. Clancy says. “He’ll be doing some research and a lot of trying to distill what we know from research to try and influence policy.”

The year will also bring another achievement: Dr. Conway will become a dad for the first time; his wife, Heather, is due March 30.

“I’m sort of peripherally involved,” he says ruefully. “I haven’t made it to any OB appointments.”

Dr. Conway, originally from College Station, Texas, received a master’s in health services research from the University of Pennsylvania. He earned his MD from Baylor College of Medicine and did his pediatrics residency at Children’s Hospital Boston, the primary pediatric teaching hospital for Harvard Medical School. He worked with healthcare clients as a management consultant at McKinsey & Company in Chicago, and he was a Robert Wood Johnson Clinical Scholar from 2005 to 2007. He’s done volunteer work in Nicaragua, the Dominican Republic, Bolivia, and Ghana. When he returns to Cincinnati Children’s, he’ll resume work as assistant professor in the Center for Health Care Quality and the Division of General Pediatrics.

On the Radar

While a Robert Wood Johnson scholar, Dr. Conway’s primary mentor was Ron Keren, MD, MPH, attending physician and director of the General Pediatrics Fellowship Program at the Children’s Hospital of Philadelphia. They worked together on a study of the use of prophylactic antibiotics in recurrent urinary tract infections in children, published last summer in the Journal of the American Medical Association (JAMA). The study found that, contrary to expectations, prophylactic antibiotics are not associated with a lower risk of recurrent infections and are associated with a higher risk of resistant infections.1

Dr. Keren was one of the people who recommended Dr. Conway on his application for the White House fellowship.

“Patrick … is intense,” says Dr. Keren, laughing. “But not in an obvious way. He’s very mild-mannered and polite and easy going on the outside. But when he starts a project, he is pretty aggressive as far as setting a very ambitious timeline, pushing things forward, and working as hard as possible. I just had to point him in the right direction every now and then, and he got the job done.”

Dr. Conway, lead author of the JAMA study, also contributed to a video news release and podcasts about its results. He impressed some of Dr. Clancy’s colleagues at the AHRQ with his ability to make the information easy to understand for people without a clinical medical background, Dr. Clancy says. That skill made him a good candidate for the fellowship.

“My goal is that he would get a lot of exposure to how healthcare policy is made, and that he would go back to Cincinnati Children’s understanding how physicians can play a more vital role in making sure that we get health policy right,” Dr. Clancy says. “To do that, you’ve got to be bilingual both in policy and in medicine—and there aren’t enough people who have that skill.”

And there’s something else to look forward to. “Supposedly we get the opportunity to ride mountain bikes with the president if we’re good enough,” Dr. Conway says. “I bike, but not extensively, so I’m working up to that. I need to make sure I don’t embarrass myself.”

Hospitalist Goals

Dr. Conway says one of his focuses is on the implementation of health information technology that better serves physicians and patients.

“We are interested in the alignment of incentive payments to physicians who use information technology to improve the care delivered to patients,” including electronic medical records and interoperability of data, he says. “In the last five years or so, there’s been increased interest in pay for performance, and now we’re moving toward thinking about how to structure these programs to pay for and enable quality improvement and the effective utilization of information technology.

“From a hospitalist perspective, I think one of the important issues is that many of these quality measures are directly related to the care delivered in hospitals by, primarily, hospitalists, so therefore it’s important for hospitalists to be involved in these processes.”

He’s also working with HHS on a value-driven healthcare initiative, intended “to bring transparency around quality and cost in healthcare and to enable quality improvement,” Dr. Conway says. “In this case, transparency for all stakeholders, so for consumers, for providers, for payers. We can criticize the process from the outside or we can get involved. We need to get involved.”

He has had a clearer idea than most about his career plan from the start, said Chris Landrigan, MD, MPH, research and fellowship director, inpatient pediatrics service, and assistant professor of pediatrics at Children’s Hospital Boston, where Dr. Conway interned. The two found they had a lot in common: Both were interested in the operations of the health system and in finding ways to improve it through clinical work, research, and policy, Dr. Landrigan says.

“Most of our work together has revolved around looking at the variations in care in hospital systems,” Dr. Landrigan says. “Some of my work has been in trying to set up a research network for pediatric hospitalists, and to try and improve the care of hospitalized children.”

Dr. Landrigan was surveying pediatric hospitalists about how they treat several common conditions, looking for variations, when Dr. Conway arrived at Children’s.

“He immediately said, ‘How do we know how this compares to what pediatricians do?’ ” Dr. Landrigan says. “I said, ‘Well, we don’t,’ So he set out on a project and asked a random sample of pediatricians around the country.”

Dr. Conway’s work revealed greater variations of care among pediatricians than among pediatric hospitalists—a finding Dr. Conway brought all the way to publication.2

HHS and AHRQ “have been very focused on issues that are near and dear to Patrick’s heart,” Dr. Landrigan says. “I think he’s got the experience and the intelligence to really make substantial contributions there. There’s no question in my mind that he’ll end up a leader in healthcare.”

One of those contributions has been to educate high-level decision-makers on a vital question.

“I have to explain every time I meet somebody what a hospitalist is,” Dr. Conway says. “We meet with everybody, from President Bush to Cabinet secretaries, and at all those meetings I say, ‘I practice generally as a pediatric hospitalist,’ at which point they say, ‘What’s a hospitalist?’ ”

That’s not likely to remain a problem as more hospitalists get involved at high levels.

“I would fully expect that we’re going to see hospitalists play a major role in assessing patient care and quality, and I hope that Patrick’s being named a White House fellow is a harbinger of that,” Dr. Clancy says. “We’re thrilled to have him here, and I hope to see more physicians taking a very serious interest in healthcare policy.” TH

Liz Tascio is a journalist based in New York.

References

1. Conway PH, Cnann A, Zaoutis T, et al. Recurrent Urinary Tract Infections in Children: Risk Factors and Association With Prophylactic Antimicrobials. JAMA. 2007 July 11;298(2):179-186.
2. Conway PH, Edwards S, Stucky ER, et al. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics. 2006 Aug;118(2):441-447.

Pediatric hospitalist Patrick Conway, MD, MSc, has become the first hospitalist accepted into The White House Fellows Program, a spokeswoman for the program says.

Dr. Conway had just reported to a new job at Cincinnati Children’s Hospital Medical Center when he found out he’d been accepted into the White House program. He’s serving with 14 other fellows, including one other medical professional, until August. He’ll return to Cincinnati with a deeper understanding of how physicians can affect federal health policy.

“It’s a once-in-a-lifetime learning experience, to see policy setting at the highest level of government,” Dr. Conway says.

Throughout the year, Dr. Conway, 33, will work in the office of Michael Leavitt, secretary of Health and Human Services (HHS), and with Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ).

“He’s an amazingly sharp physician who brings a great wealth of expertise, both because of the research he’s done but also in a clinical sense,” says Dr. Clancy, one of Dr. Conway’s mentors in the program. “He has a great grasp of policy.”

Dr. Conway has had to hit the ground running in his new role.

“We’re involving him directly in a number of very high-priority areas” including the improvement of healthcare quality and value, Dr. Clancy says. “He’ll be doing some research and a lot of trying to distill what we know from research to try and influence policy.”

The year will also bring another achievement: Dr. Conway will become a dad for the first time; his wife, Heather, is due March 30.

“I’m sort of peripherally involved,” he says ruefully. “I haven’t made it to any OB appointments.”

Dr. Conway, originally from College Station, Texas, received a master’s in health services research from the University of Pennsylvania. He earned his MD from Baylor College of Medicine and did his pediatrics residency at Children’s Hospital Boston, the primary pediatric teaching hospital for Harvard Medical School. He worked with healthcare clients as a management consultant at McKinsey & Company in Chicago, and he was a Robert Wood Johnson Clinical Scholar from 2005 to 2007. He’s done volunteer work in Nicaragua, the Dominican Republic, Bolivia, and Ghana. When he returns to Cincinnati Children’s, he’ll resume work as assistant professor in the Center for Health Care Quality and the Division of General Pediatrics.

On the Radar

While a Robert Wood Johnson scholar, Dr. Conway’s primary mentor was Ron Keren, MD, MPH, attending physician and director of the General Pediatrics Fellowship Program at the Children’s Hospital of Philadelphia. They worked together on a study of the use of prophylactic antibiotics in recurrent urinary tract infections in children, published last summer in the Journal of the American Medical Association (JAMA). The study found that, contrary to expectations, prophylactic antibiotics are not associated with a lower risk of recurrent infections and are associated with a higher risk of resistant infections.1

Dr. Keren was one of the people who recommended Dr. Conway on his application for the White House fellowship.

“Patrick … is intense,” says Dr. Keren, laughing. “But not in an obvious way. He’s very mild-mannered and polite and easy going on the outside. But when he starts a project, he is pretty aggressive as far as setting a very ambitious timeline, pushing things forward, and working as hard as possible. I just had to point him in the right direction every now and then, and he got the job done.”

Dr. Conway, lead author of the JAMA study, also contributed to a video news release and podcasts about its results. He impressed some of Dr. Clancy’s colleagues at the AHRQ with his ability to make the information easy to understand for people without a clinical medical background, Dr. Clancy says. That skill made him a good candidate for the fellowship.

“My goal is that he would get a lot of exposure to how healthcare policy is made, and that he would go back to Cincinnati Children’s understanding how physicians can play a more vital role in making sure that we get health policy right,” Dr. Clancy says. “To do that, you’ve got to be bilingual both in policy and in medicine—and there aren’t enough people who have that skill.”

And there’s something else to look forward to. “Supposedly we get the opportunity to ride mountain bikes with the president if we’re good enough,” Dr. Conway says. “I bike, but not extensively, so I’m working up to that. I need to make sure I don’t embarrass myself.”

Hospitalist Goals

Dr. Conway says one of his focuses is on the implementation of health information technology that better serves physicians and patients.

“We are interested in the alignment of incentive payments to physicians who use information technology to improve the care delivered to patients,” including electronic medical records and interoperability of data, he says. “In the last five years or so, there’s been increased interest in pay for performance, and now we’re moving toward thinking about how to structure these programs to pay for and enable quality improvement and the effective utilization of information technology.

“From a hospitalist perspective, I think one of the important issues is that many of these quality measures are directly related to the care delivered in hospitals by, primarily, hospitalists, so therefore it’s important for hospitalists to be involved in these processes.”

He’s also working with HHS on a value-driven healthcare initiative, intended “to bring transparency around quality and cost in healthcare and to enable quality improvement,” Dr. Conway says. “In this case, transparency for all stakeholders, so for consumers, for providers, for payers. We can criticize the process from the outside or we can get involved. We need to get involved.”

He has had a clearer idea than most about his career plan from the start, said Chris Landrigan, MD, MPH, research and fellowship director, inpatient pediatrics service, and assistant professor of pediatrics at Children’s Hospital Boston, where Dr. Conway interned. The two found they had a lot in common: Both were interested in the operations of the health system and in finding ways to improve it through clinical work, research, and policy, Dr. Landrigan says.

“Most of our work together has revolved around looking at the variations in care in hospital systems,” Dr. Landrigan says. “Some of my work has been in trying to set up a research network for pediatric hospitalists, and to try and improve the care of hospitalized children.”

Dr. Landrigan was surveying pediatric hospitalists about how they treat several common conditions, looking for variations, when Dr. Conway arrived at Children’s.

“He immediately said, ‘How do we know how this compares to what pediatricians do?’ ” Dr. Landrigan says. “I said, ‘Well, we don’t,’ So he set out on a project and asked a random sample of pediatricians around the country.”

Dr. Conway’s work revealed greater variations of care among pediatricians than among pediatric hospitalists—a finding Dr. Conway brought all the way to publication.2

HHS and AHRQ “have been very focused on issues that are near and dear to Patrick’s heart,” Dr. Landrigan says. “I think he’s got the experience and the intelligence to really make substantial contributions there. There’s no question in my mind that he’ll end up a leader in healthcare.”

One of those contributions has been to educate high-level decision-makers on a vital question.

“I have to explain every time I meet somebody what a hospitalist is,” Dr. Conway says. “We meet with everybody, from President Bush to Cabinet secretaries, and at all those meetings I say, ‘I practice generally as a pediatric hospitalist,’ at which point they say, ‘What’s a hospitalist?’ ”

That’s not likely to remain a problem as more hospitalists get involved at high levels.

“I would fully expect that we’re going to see hospitalists play a major role in assessing patient care and quality, and I hope that Patrick’s being named a White House fellow is a harbinger of that,” Dr. Clancy says. “We’re thrilled to have him here, and I hope to see more physicians taking a very serious interest in healthcare policy.” TH

Liz Tascio is a journalist based in New York.

References

1. Conway PH, Cnann A, Zaoutis T, et al. Recurrent Urinary Tract Infections in Children: Risk Factors and Association With Prophylactic Antimicrobials. JAMA. 2007 July 11;298(2):179-186.
2. Conway PH, Edwards S, Stucky ER, et al. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics. 2006 Aug;118(2):441-447.

Pediatric hospitalist Patrick Conway, MD, MSc, has become the first hospitalist accepted into The White House Fellows Program, a spokeswoman for the program says.

Dr. Conway had just reported to a new job at Cincinnati Children’s Hospital Medical Center when he found out he’d been accepted into the White House program. He’s serving with 14 other fellows, including one other medical professional, until August. He’ll return to Cincinnati with a deeper understanding of how physicians can affect federal health policy.

“It’s a once-in-a-lifetime learning experience, to see policy setting at the highest level of government,” Dr. Conway says.

Throughout the year, Dr. Conway, 33, will work in the office of Michael Leavitt, secretary of Health and Human Services (HHS), and with Carolyn Clancy, MD, director of the Agency for Healthcare Research and Quality (AHRQ).

“He’s an amazingly sharp physician who brings a great wealth of expertise, both because of the research he’s done but also in a clinical sense,” says Dr. Clancy, one of Dr. Conway’s mentors in the program. “He has a great grasp of policy.”

Dr. Conway has had to hit the ground running in his new role.

“We’re involving him directly in a number of very high-priority areas” including the improvement of healthcare quality and value, Dr. Clancy says. “He’ll be doing some research and a lot of trying to distill what we know from research to try and influence policy.”

The year will also bring another achievement: Dr. Conway will become a dad for the first time; his wife, Heather, is due March 30.

“I’m sort of peripherally involved,” he says ruefully. “I haven’t made it to any OB appointments.”

Dr. Conway, originally from College Station, Texas, received a master’s in health services research from the University of Pennsylvania. He earned his MD from Baylor College of Medicine and did his pediatrics residency at Children’s Hospital Boston, the primary pediatric teaching hospital for Harvard Medical School. He worked with healthcare clients as a management consultant at McKinsey & Company in Chicago, and he was a Robert Wood Johnson Clinical Scholar from 2005 to 2007. He’s done volunteer work in Nicaragua, the Dominican Republic, Bolivia, and Ghana. When he returns to Cincinnati Children’s, he’ll resume work as assistant professor in the Center for Health Care Quality and the Division of General Pediatrics.

On the Radar

While a Robert Wood Johnson scholar, Dr. Conway’s primary mentor was Ron Keren, MD, MPH, attending physician and director of the General Pediatrics Fellowship Program at the Children’s Hospital of Philadelphia. They worked together on a study of the use of prophylactic antibiotics in recurrent urinary tract infections in children, published last summer in the Journal of the American Medical Association (JAMA). The study found that, contrary to expectations, prophylactic antibiotics are not associated with a lower risk of recurrent infections and are associated with a higher risk of resistant infections.1

Dr. Keren was one of the people who recommended Dr. Conway on his application for the White House fellowship.

“Patrick … is intense,” says Dr. Keren, laughing. “But not in an obvious way. He’s very mild-mannered and polite and easy going on the outside. But when he starts a project, he is pretty aggressive as far as setting a very ambitious timeline, pushing things forward, and working as hard as possible. I just had to point him in the right direction every now and then, and he got the job done.”

Dr. Conway, lead author of the JAMA study, also contributed to a video news release and podcasts about its results. He impressed some of Dr. Clancy’s colleagues at the AHRQ with his ability to make the information easy to understand for people without a clinical medical background, Dr. Clancy says. That skill made him a good candidate for the fellowship.

“My goal is that he would get a lot of exposure to how healthcare policy is made, and that he would go back to Cincinnati Children’s understanding how physicians can play a more vital role in making sure that we get health policy right,” Dr. Clancy says. “To do that, you’ve got to be bilingual both in policy and in medicine—and there aren’t enough people who have that skill.”

And there’s something else to look forward to. “Supposedly we get the opportunity to ride mountain bikes with the president if we’re good enough,” Dr. Conway says. “I bike, but not extensively, so I’m working up to that. I need to make sure I don’t embarrass myself.”

Hospitalist Goals

Dr. Conway says one of his focuses is on the implementation of health information technology that better serves physicians and patients.

“We are interested in the alignment of incentive payments to physicians who use information technology to improve the care delivered to patients,” including electronic medical records and interoperability of data, he says. “In the last five years or so, there’s been increased interest in pay for performance, and now we’re moving toward thinking about how to structure these programs to pay for and enable quality improvement and the effective utilization of information technology.

“From a hospitalist perspective, I think one of the important issues is that many of these quality measures are directly related to the care delivered in hospitals by, primarily, hospitalists, so therefore it’s important for hospitalists to be involved in these processes.”

He’s also working with HHS on a value-driven healthcare initiative, intended “to bring transparency around quality and cost in healthcare and to enable quality improvement,” Dr. Conway says. “In this case, transparency for all stakeholders, so for consumers, for providers, for payers. We can criticize the process from the outside or we can get involved. We need to get involved.”

He has had a clearer idea than most about his career plan from the start, said Chris Landrigan, MD, MPH, research and fellowship director, inpatient pediatrics service, and assistant professor of pediatrics at Children’s Hospital Boston, where Dr. Conway interned. The two found they had a lot in common: Both were interested in the operations of the health system and in finding ways to improve it through clinical work, research, and policy, Dr. Landrigan says.

“Most of our work together has revolved around looking at the variations in care in hospital systems,” Dr. Landrigan says. “Some of my work has been in trying to set up a research network for pediatric hospitalists, and to try and improve the care of hospitalized children.”

Dr. Landrigan was surveying pediatric hospitalists about how they treat several common conditions, looking for variations, when Dr. Conway arrived at Children’s.

“He immediately said, ‘How do we know how this compares to what pediatricians do?’ ” Dr. Landrigan says. “I said, ‘Well, we don’t,’ So he set out on a project and asked a random sample of pediatricians around the country.”

Dr. Conway’s work revealed greater variations of care among pediatricians than among pediatric hospitalists—a finding Dr. Conway brought all the way to publication.2

HHS and AHRQ “have been very focused on issues that are near and dear to Patrick’s heart,” Dr. Landrigan says. “I think he’s got the experience and the intelligence to really make substantial contributions there. There’s no question in my mind that he’ll end up a leader in healthcare.”

One of those contributions has been to educate high-level decision-makers on a vital question.

“I have to explain every time I meet somebody what a hospitalist is,” Dr. Conway says. “We meet with everybody, from President Bush to Cabinet secretaries, and at all those meetings I say, ‘I practice generally as a pediatric hospitalist,’ at which point they say, ‘What’s a hospitalist?’ ”

That’s not likely to remain a problem as more hospitalists get involved at high levels.

“I would fully expect that we’re going to see hospitalists play a major role in assessing patient care and quality, and I hope that Patrick’s being named a White House fellow is a harbinger of that,” Dr. Clancy says. “We’re thrilled to have him here, and I hope to see more physicians taking a very serious interest in healthcare policy.” TH

Liz Tascio is a journalist based in New York.

References

1. Conway PH, Cnann A, Zaoutis T, et al. Recurrent Urinary Tract Infections in Children: Risk Factors and Association With Prophylactic Antimicrobials. JAMA. 2007 July 11;298(2):179-186.
2. Conway PH, Edwards S, Stucky ER, et al. Variations in management of common inpatient pediatric illnesses: hospitalists and community pediatricians. Pediatrics. 2006 Aug;118(2):441-447.

What’s on your wish list for 2008? For many hospitalists, the list is full of cultural changes they’d like to see sweep through their institutions, prying loose old, entrenched habits and replacing them with new, efficient methods and practices. They’re changes that would improve patient safety and care and create better working conditions for physicians.

Those ideas don’t have to remain wishes. We’ve compiled a list of some of the top changes hospitalists say they’d like to see in the coming year, including ideas for how to implement them and some success stories to prove change is possible. Of course, it’s not easy.

“We had to work, and we had to work hard,” says Dr. William Ford, MD, director of the hospitalist program at Temple University in Philadelphia. It took major collaboration and a lot of face-to-face talks to create the cultural shifts he wanted to see at Temple, which partnered with Cogent Healthcare in 2006. But the work paid off, winning support for an observation unit from key stakeholders, such as residency program leaders and nurses.

Dr. Ford’s experience might inspire hospitalists who wish to improve the following critical facets of how hospital medicine is done:

1) Integrate hospitalists into policy-making bodies of institutions. Hospitalists work right in the thick of things, yet don’t often have a voice in their institution’s strategic planning, says Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California, Irvine. Bringing hospitalists onto major committees would benefit everyone, he says.

Hospitalists have a vested interest in their institutions and a deep knowledge of it. They should be involved in operations, business development, and growth, Dr. Amin notes. That can mean growing the surgical business, increasing referrals, or meeting joint commission goals and requirements of the Accreditation Council for Graduate Medical Education (ACGME).

“Many of the bylaws of an institution have been created 10, 20 years ago, when there wasn’t such a thing as hospitalists,” so they don’t automatically get a seat at the table, Dr. Amin says.

But that should change, he argues, because today hospitalists affect every part of an institution. Hospitalists should sit on medical executive committees and contribute to discussions about bylaws, planning, business strategy, and more.

“The hospitalist is integral to helping a hospital improve operations and patient safety,” Dr. Amin says. “Having a permanent seat on the medical executive committee seems like a natural role for the hospitalist director to have.”

2) Reduce paperwork. Mark Thoelke, MD, clinical director of the hospitalist program and associate professor of medicine at Washington University School of Medicine in St. Louis, would love to put down his pen.

“I’ve been doing this job for 15 years now,” he says. “When I started, there was one piece of paper I’d fill out for admissions. [Now] we have to fill out 15 separate pieces of paper when we admit a patient to the hospital.”

Worthwhile and well-meaning patient process improvement groups tend to generate more paperwork for physicians, he points out.

“Nobody seems to want to complain about this because you’re going to be perceived as someone who’s against patient safety,” Dr. Thoelke says. “I feel very strongly about providing excellent patient care. But it makes it harder for me to take care of patients if I’m concerned about filling out multiple pieces of paper.”

To combat the paper flood, his institution has been using Lean Six Sigma, a business improvement strategy that addresses speed and quality. Admission forms are now in a single large packet available in one spot. Dr. Thoelke would like to see even more improvements.

“The end result of any committee is a new piece of paper that the physician has to fill out,” Dr. Thoelke says. “The perception is, it’s just one piece of paper. But it adds up to an incredible amount of time.”

3) Eliminate 24-hour shifts. Chris Landrigan, MD, MPH, studies the relationship between workplace safety and patient care, particularly the long hours residents tend to work.

In general, residents’ shifts are restricted to no more than 24 consecutive hours, plus up to six hours for paperwork and arranging patient care, according to the ACGME. Residents are to have 10-hour rest periods between duty shifts, and can work no more than 80 hours a week, averaged over four weeks.

“There’s no question that traditional shifts of 24 or more hours endanger residents and their patients,” says Dr. Landrigan director of the Sleep and Patient Safety Program, Brigham and Women’s Hospital, and research and fellowship director, Inpatient Pediatrics Service, Children’s Hospital Boston. “Twenty-four hour shifts are associated with an increased rate of serious medical errors, and residents frequently crash their cars on the way home from working these marathon shifts. In the last few years, I know of eight residents at Children’s alone who have had post-call crashes on the way home from work.”

In accordance with ACGME standards limiting residents’ work hours, hospitalists can encourage a cultural shift that would improve workplace safety and patient care, he says. “Hospitalists in some cases are the residency directors, or some of the key teachers, and have a lot of influence there,” he says. “They’re in a position to begin to challenge the traditional model, just as they have in other ways.”

Dr. Landrigan acknowledges this massive change will be slow to catch on, but it’s already started. At Brigham and Women’s Hospital, 24-hour shifts for surgical residents have been eliminated on most rotations, he says, and a few programs in New York, Ohio, and elsewhere have done the same. “The department of surgery at Brigham and Women’s viewed the data themselves, and they felt that this was an important issue,” Dr. Landrigan says. He plans to study the impact of eliminating 24-hour shifts in the surgical intensive care units at Brigham and Women’s.

4) Include leadership training in medical school curriculum. “When you go to medical school, you [learn] to make a diagnosis and interact with a patient essentially on a one-on-one level,” says Eric Howell, MD, assistant professor of medicine, faculty leader, Helen B. Taussig College, Johns Hopkins University School of Medicine in Baltimore, and the chairman of SHM’s leadership committee.

“But in the hospital, that teaching is almost counterproductive,” he explains. There, the physician-patient relationship expands into one with multiple players. The physician leads a team with the patient at its center that can include case managers, nurses, administrative staff, ancillary staff, social workers, and others.

Physicians get no training in school about how to manage multidisciplinary teams, or how to create change where change is needed; instead, they learn on the job, Dr. Howell says. At a summit in Chicago this fall, the Leadership Committee discussed the possibility of providing scholarships for residents to attend SHM’s leadership academies.

“That got a lot of positive reviews, even unofficially,” Dr. Howell says. “The other thing we’re doing is we’re trying to get the word out that many hospitalists have the tools to lead teams, and to manage teams, to non-hospitalist groups,” such as hospital administrators and the American College of Healthcare Executives. “We’re trying to get the word out that there are physicians in hospitals available to lead.”

5) Make “hospitalist” a specialty. Dr. Ford would like to see “hospitalist” recognized as a medical sub-specialty in 2008. As specialists, hospitalists would have specific training requirements and other benefits, he says.

“Right now, we’re a big black box,” Dr. Ford says. “There are no clearly defined guidelines for what we can and can’t do.”

A formal credential for hospitalists is closer to reality. The American Board of Internal Medicine (ABIM) has officially approved the creation of a Focused Recognition for Hospital Medicine through its Maintenance of Certification (MOC) system. The ABIM’s formal proposal to the American Board of Medical Specialties (ABMS) is expected to be approved by September 2008. SHM began pursuing certification three years ago and intends to reach out to the pediatric and family medicine boards so certification can be available to all hospitalists.

The move would help make “hospitalist” a more recognizable term in the medical community and in the public arena, says Dr. Ford. “We’re not just your stereotypical general practice doctor. I think we’re more than that. I’d like to promote more of a global perspective of what hospitals are: We make the best use of resources as well as provide the most up-to-date care.”

6) Break down silos and collaborate more. “Medicine in general really is traditionally a siloed field, and at our institution there has been a lot of effort to break down those silos and work collaboratively,” Dr. Howell says.

In 1999 and 2000, the Johns Hopkins Bayview Medical Center, where Dr. Howell works, addressed a major patient throughput issue by bringing together two large groups for negotiation: the emergency department (ED) and the department of medicine. Together they reduced ED waiting time by 90 minutes, Dr. Howell says. The collaborative process received national recognition and resulted in joint publications. They did it again seven years later, this time bringing five large groups to the negotiating table and reducing the wait time even more.

“Each of those groups had to give up something,” such as control over the process, and they had to agree to greater transparency, Dr. Howell concedes. “But in return, they got a lot more.”

Bayview used collaboration again to tackle the issue of ambulance diversion, known as Red Alert, to dramatic effect. In fiscal year 2006, the campus had 2,025 Red Alert hours. The following year, it was 503. Fiscal year 2008 had, as of October, zero Red Alert hours.

“For years, we had been trying to solve the problems individually,” Dr. Howell says. “Imagine if everybody were approaching problems from the teamwork perspective right away. This is a cultural shift that’s going to have to change, and I think it’s going to take a long time. But for hospitalist medicine, these things are already happening.”

7) Improve staffing and retention rates. It almost doesn’t matter how sophisticated hospital culture is overall if the institution still battles one crucial weakness: burnout.

“There is a true burnout factor to hospitalists,” Dr. Amin says. “A lot of institutions are challenged with having the appropriate staffing of hospitalists. Part of that boils down to economics.”

Dr. Amin understands that bumping up staffing is tough to promote when the additions don’t correspond with increased revenue. An appropriate staffing model takes into account a number of variables, including patient load, vacation schedules, and non-clinical duties such as teaching, academics, research, administration, and quality-improvement efforts, he says.

Hiring hospitalists is not like hiring a new primary care doctor or another specialist who might attract new patients to the institution, he says. “A hospitalist program will have the same volume of patients that need to be covered regardless. If a hospitalist goes on vacation, one can’t close the hospital.”

Yet stop-gap measures, such as double shifts when someone’s on vacation, only work for so long, he points out. “You can’t continue to keep doing that as you’re being asked to see more and more patients, do more and more teaching, do more and more oversight, and still do it with the same number of people.”

Hospitalists’ great reputations for providing more efficient care and decreasing length of stay may convince institutions it’s worth it to change their staffing models and add more people. “Hospitals are running at capacity,” he says. “You still need quality.”

8) Improve communication: Pick up the phone. “One of the big things we’ve been working on is physician-to-physician communication,” Dr. Thoelke says. “That’s another problem area at many large academic institutions, and I think at most community institutions as well.”

Every consult should lead to a phone call, not just a note in a chart that another doctor might not see until the next day. It’s not only for courtesy’s sake: Dr. Thoelke believes that better, more direct communication will further decrease length of stay.

“You gather so much more information even in brief conversations from one doctor to another,” Dr. Thoelke says. “I object personally when I have a consultant schedule my patient for a test that they don’t make me aware of. I’m on the phone saying, ‘This is not appropriate.’ I’m the person who’s going to be dealing with the complications of this procedure. So I’m pushing back directly to physicians.”

He’s also working hand in hand with hospital administration to encourage a culture of communication.

A standardized hand-off of every patient, every time, would also help, says Dr. Landrigan.

“As it stands now, there’s a lot of looseness,” Dr. Landrigan says. Physicians sometimes assume that the next clinician can simply take over. “The reality is that when clinicians know the patients less well, care suffers.”

An SHM task force has created basic standards for hospitalists to use for hand-offs (The Hospitalist August 2007, p.18).

9) Meet face to face with all those involved when you want to make change. No matter what’s on your wish list for 2008, your chances of making it happen improve if you communicate directly, according to Dr. Ford.

“I would recommend this not just for hospital medicine, but for anything,” Dr. Ford says. “You really have to go and meet with people. You really have to communicate, and not just by e-mail. E-mail is a good way to set up times to meet.”

To build support for the changes he wanted to make at Temple when Cogent Healthcare began managing its hospitalist program, Ford brought everyone into the discussion, from medical department chairs to representatives from nursing, administration, the labs, and more. “All the key stakeholders,” he says.

Now, Temple’s overall culture focuses on the institution’s financial health as well as on patient health. It also has an observation unit run entirely by hospitalists, freeing residents to work on other cases and still comply with ACGME rules.

“We did get a lot of resistance,” Dr. Ford admits. “University faculty weren’t very receptive to having a non-university faction running this unit. We had to break down the stereotypes that we weren’t a for-profit monster. We had to gain the trust of the emergency department [and others] to allow us to take care of their patients.” TH

Liz Tascio is a journalist based in New York.

What’s on your wish list for 2008? For many hospitalists, the list is full of cultural changes they’d like to see sweep through their institutions, prying loose old, entrenched habits and replacing them with new, efficient methods and practices. They’re changes that would improve patient safety and care and create better working conditions for physicians.

Those ideas don’t have to remain wishes. We’ve compiled a list of some of the top changes hospitalists say they’d like to see in the coming year, including ideas for how to implement them and some success stories to prove change is possible. Of course, it’s not easy.

“We had to work, and we had to work hard,” says Dr. William Ford, MD, director of the hospitalist program at Temple University in Philadelphia. It took major collaboration and a lot of face-to-face talks to create the cultural shifts he wanted to see at Temple, which partnered with Cogent Healthcare in 2006. But the work paid off, winning support for an observation unit from key stakeholders, such as residency program leaders and nurses.

Dr. Ford’s experience might inspire hospitalists who wish to improve the following critical facets of how hospital medicine is done:

1) Integrate hospitalists into policy-making bodies of institutions. Hospitalists work right in the thick of things, yet don’t often have a voice in their institution’s strategic planning, says Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California, Irvine. Bringing hospitalists onto major committees would benefit everyone, he says.

Hospitalists have a vested interest in their institutions and a deep knowledge of it. They should be involved in operations, business development, and growth, Dr. Amin notes. That can mean growing the surgical business, increasing referrals, or meeting joint commission goals and requirements of the Accreditation Council for Graduate Medical Education (ACGME).

“Many of the bylaws of an institution have been created 10, 20 years ago, when there wasn’t such a thing as hospitalists,” so they don’t automatically get a seat at the table, Dr. Amin says.

But that should change, he argues, because today hospitalists affect every part of an institution. Hospitalists should sit on medical executive committees and contribute to discussions about bylaws, planning, business strategy, and more.

“The hospitalist is integral to helping a hospital improve operations and patient safety,” Dr. Amin says. “Having a permanent seat on the medical executive committee seems like a natural role for the hospitalist director to have.”

2) Reduce paperwork. Mark Thoelke, MD, clinical director of the hospitalist program and associate professor of medicine at Washington University School of Medicine in St. Louis, would love to put down his pen.

“I’ve been doing this job for 15 years now,” he says. “When I started, there was one piece of paper I’d fill out for admissions. [Now] we have to fill out 15 separate pieces of paper when we admit a patient to the hospital.”

Worthwhile and well-meaning patient process improvement groups tend to generate more paperwork for physicians, he points out.

“Nobody seems to want to complain about this because you’re going to be perceived as someone who’s against patient safety,” Dr. Thoelke says. “I feel very strongly about providing excellent patient care. But it makes it harder for me to take care of patients if I’m concerned about filling out multiple pieces of paper.”

To combat the paper flood, his institution has been using Lean Six Sigma, a business improvement strategy that addresses speed and quality. Admission forms are now in a single large packet available in one spot. Dr. Thoelke would like to see even more improvements.

“The end result of any committee is a new piece of paper that the physician has to fill out,” Dr. Thoelke says. “The perception is, it’s just one piece of paper. But it adds up to an incredible amount of time.”

3) Eliminate 24-hour shifts. Chris Landrigan, MD, MPH, studies the relationship between workplace safety and patient care, particularly the long hours residents tend to work.

In general, residents’ shifts are restricted to no more than 24 consecutive hours, plus up to six hours for paperwork and arranging patient care, according to the ACGME. Residents are to have 10-hour rest periods between duty shifts, and can work no more than 80 hours a week, averaged over four weeks.

“There’s no question that traditional shifts of 24 or more hours endanger residents and their patients,” says Dr. Landrigan director of the Sleep and Patient Safety Program, Brigham and Women’s Hospital, and research and fellowship director, Inpatient Pediatrics Service, Children’s Hospital Boston. “Twenty-four hour shifts are associated with an increased rate of serious medical errors, and residents frequently crash their cars on the way home from working these marathon shifts. In the last few years, I know of eight residents at Children’s alone who have had post-call crashes on the way home from work.”

In accordance with ACGME standards limiting residents’ work hours, hospitalists can encourage a cultural shift that would improve workplace safety and patient care, he says. “Hospitalists in some cases are the residency directors, or some of the key teachers, and have a lot of influence there,” he says. “They’re in a position to begin to challenge the traditional model, just as they have in other ways.”

Dr. Landrigan acknowledges this massive change will be slow to catch on, but it’s already started. At Brigham and Women’s Hospital, 24-hour shifts for surgical residents have been eliminated on most rotations, he says, and a few programs in New York, Ohio, and elsewhere have done the same. “The department of surgery at Brigham and Women’s viewed the data themselves, and they felt that this was an important issue,” Dr. Landrigan says. He plans to study the impact of eliminating 24-hour shifts in the surgical intensive care units at Brigham and Women’s.

4) Include leadership training in medical school curriculum. “When you go to medical school, you [learn] to make a diagnosis and interact with a patient essentially on a one-on-one level,” says Eric Howell, MD, assistant professor of medicine, faculty leader, Helen B. Taussig College, Johns Hopkins University School of Medicine in Baltimore, and the chairman of SHM’s leadership committee.

“But in the hospital, that teaching is almost counterproductive,” he explains. There, the physician-patient relationship expands into one with multiple players. The physician leads a team with the patient at its center that can include case managers, nurses, administrative staff, ancillary staff, social workers, and others.

Physicians get no training in school about how to manage multidisciplinary teams, or how to create change where change is needed; instead, they learn on the job, Dr. Howell says. At a summit in Chicago this fall, the Leadership Committee discussed the possibility of providing scholarships for residents to attend SHM’s leadership academies.

“That got a lot of positive reviews, even unofficially,” Dr. Howell says. “The other thing we’re doing is we’re trying to get the word out that many hospitalists have the tools to lead teams, and to manage teams, to non-hospitalist groups,” such as hospital administrators and the American College of Healthcare Executives. “We’re trying to get the word out that there are physicians in hospitals available to lead.”

5) Make “hospitalist” a specialty. Dr. Ford would like to see “hospitalist” recognized as a medical sub-specialty in 2008. As specialists, hospitalists would have specific training requirements and other benefits, he says.

“Right now, we’re a big black box,” Dr. Ford says. “There are no clearly defined guidelines for what we can and can’t do.”

A formal credential for hospitalists is closer to reality. The American Board of Internal Medicine (ABIM) has officially approved the creation of a Focused Recognition for Hospital Medicine through its Maintenance of Certification (MOC) system. The ABIM’s formal proposal to the American Board of Medical Specialties (ABMS) is expected to be approved by September 2008. SHM began pursuing certification three years ago and intends to reach out to the pediatric and family medicine boards so certification can be available to all hospitalists.

The move would help make “hospitalist” a more recognizable term in the medical community and in the public arena, says Dr. Ford. “We’re not just your stereotypical general practice doctor. I think we’re more than that. I’d like to promote more of a global perspective of what hospitals are: We make the best use of resources as well as provide the most up-to-date care.”

6) Break down silos and collaborate more. “Medicine in general really is traditionally a siloed field, and at our institution there has been a lot of effort to break down those silos and work collaboratively,” Dr. Howell says.

In 1999 and 2000, the Johns Hopkins Bayview Medical Center, where Dr. Howell works, addressed a major patient throughput issue by bringing together two large groups for negotiation: the emergency department (ED) and the department of medicine. Together they reduced ED waiting time by 90 minutes, Dr. Howell says. The collaborative process received national recognition and resulted in joint publications. They did it again seven years later, this time bringing five large groups to the negotiating table and reducing the wait time even more.

“Each of those groups had to give up something,” such as control over the process, and they had to agree to greater transparency, Dr. Howell concedes. “But in return, they got a lot more.”

Bayview used collaboration again to tackle the issue of ambulance diversion, known as Red Alert, to dramatic effect. In fiscal year 2006, the campus had 2,025 Red Alert hours. The following year, it was 503. Fiscal year 2008 had, as of October, zero Red Alert hours.

“For years, we had been trying to solve the problems individually,” Dr. Howell says. “Imagine if everybody were approaching problems from the teamwork perspective right away. This is a cultural shift that’s going to have to change, and I think it’s going to take a long time. But for hospitalist medicine, these things are already happening.”

7) Improve staffing and retention rates. It almost doesn’t matter how sophisticated hospital culture is overall if the institution still battles one crucial weakness: burnout.

“There is a true burnout factor to hospitalists,” Dr. Amin says. “A lot of institutions are challenged with having the appropriate staffing of hospitalists. Part of that boils down to economics.”

Dr. Amin understands that bumping up staffing is tough to promote when the additions don’t correspond with increased revenue. An appropriate staffing model takes into account a number of variables, including patient load, vacation schedules, and non-clinical duties such as teaching, academics, research, administration, and quality-improvement efforts, he says.

Hiring hospitalists is not like hiring a new primary care doctor or another specialist who might attract new patients to the institution, he says. “A hospitalist program will have the same volume of patients that need to be covered regardless. If a hospitalist goes on vacation, one can’t close the hospital.”

Yet stop-gap measures, such as double shifts when someone’s on vacation, only work for so long, he points out. “You can’t continue to keep doing that as you’re being asked to see more and more patients, do more and more teaching, do more and more oversight, and still do it with the same number of people.”

Hospitalists’ great reputations for providing more efficient care and decreasing length of stay may convince institutions it’s worth it to change their staffing models and add more people. “Hospitals are running at capacity,” he says. “You still need quality.”

8) Improve communication: Pick up the phone. “One of the big things we’ve been working on is physician-to-physician communication,” Dr. Thoelke says. “That’s another problem area at many large academic institutions, and I think at most community institutions as well.”

Every consult should lead to a phone call, not just a note in a chart that another doctor might not see until the next day. It’s not only for courtesy’s sake: Dr. Thoelke believes that better, more direct communication will further decrease length of stay.

“You gather so much more information even in brief conversations from one doctor to another,” Dr. Thoelke says. “I object personally when I have a consultant schedule my patient for a test that they don’t make me aware of. I’m on the phone saying, ‘This is not appropriate.’ I’m the person who’s going to be dealing with the complications of this procedure. So I’m pushing back directly to physicians.”

He’s also working hand in hand with hospital administration to encourage a culture of communication.

A standardized hand-off of every patient, every time, would also help, says Dr. Landrigan.

“As it stands now, there’s a lot of looseness,” Dr. Landrigan says. Physicians sometimes assume that the next clinician can simply take over. “The reality is that when clinicians know the patients less well, care suffers.”

An SHM task force has created basic standards for hospitalists to use for hand-offs (The Hospitalist August 2007, p.18).

9) Meet face to face with all those involved when you want to make change. No matter what’s on your wish list for 2008, your chances of making it happen improve if you communicate directly, according to Dr. Ford.

“I would recommend this not just for hospital medicine, but for anything,” Dr. Ford says. “You really have to go and meet with people. You really have to communicate, and not just by e-mail. E-mail is a good way to set up times to meet.”

To build support for the changes he wanted to make at Temple when Cogent Healthcare began managing its hospitalist program, Ford brought everyone into the discussion, from medical department chairs to representatives from nursing, administration, the labs, and more. “All the key stakeholders,” he says.

Now, Temple’s overall culture focuses on the institution’s financial health as well as on patient health. It also has an observation unit run entirely by hospitalists, freeing residents to work on other cases and still comply with ACGME rules.

“We did get a lot of resistance,” Dr. Ford admits. “University faculty weren’t very receptive to having a non-university faction running this unit. We had to break down the stereotypes that we weren’t a for-profit monster. We had to gain the trust of the emergency department [and others] to allow us to take care of their patients.” TH

Liz Tascio is a journalist based in New York.

What’s on your wish list for 2008? For many hospitalists, the list is full of cultural changes they’d like to see sweep through their institutions, prying loose old, entrenched habits and replacing them with new, efficient methods and practices. They’re changes that would improve patient safety and care and create better working conditions for physicians.

Those ideas don’t have to remain wishes. We’ve compiled a list of some of the top changes hospitalists say they’d like to see in the coming year, including ideas for how to implement them and some success stories to prove change is possible. Of course, it’s not easy.

“We had to work, and we had to work hard,” says Dr. William Ford, MD, director of the hospitalist program at Temple University in Philadelphia. It took major collaboration and a lot of face-to-face talks to create the cultural shifts he wanted to see at Temple, which partnered with Cogent Healthcare in 2006. But the work paid off, winning support for an observation unit from key stakeholders, such as residency program leaders and nurses.

Dr. Ford’s experience might inspire hospitalists who wish to improve the following critical facets of how hospital medicine is done:

1) Integrate hospitalists into policy-making bodies of institutions. Hospitalists work right in the thick of things, yet don’t often have a voice in their institution’s strategic planning, says Alpesh Amin, MD, MBA, FACP, professor and chief, general internal medicine, executive director and founder of the hospitalist program at the University of California, Irvine. Bringing hospitalists onto major committees would benefit everyone, he says.

Hospitalists have a vested interest in their institutions and a deep knowledge of it. They should be involved in operations, business development, and growth, Dr. Amin notes. That can mean growing the surgical business, increasing referrals, or meeting joint commission goals and requirements of the Accreditation Council for Graduate Medical Education (ACGME).

“Many of the bylaws of an institution have been created 10, 20 years ago, when there wasn’t such a thing as hospitalists,” so they don’t automatically get a seat at the table, Dr. Amin says.

But that should change, he argues, because today hospitalists affect every part of an institution. Hospitalists should sit on medical executive committees and contribute to discussions about bylaws, planning, business strategy, and more.

“The hospitalist is integral to helping a hospital improve operations and patient safety,” Dr. Amin says. “Having a permanent seat on the medical executive committee seems like a natural role for the hospitalist director to have.”

2) Reduce paperwork. Mark Thoelke, MD, clinical director of the hospitalist program and associate professor of medicine at Washington University School of Medicine in St. Louis, would love to put down his pen.

“I’ve been doing this job for 15 years now,” he says. “When I started, there was one piece of paper I’d fill out for admissions. [Now] we have to fill out 15 separate pieces of paper when we admit a patient to the hospital.”

Worthwhile and well-meaning patient process improvement groups tend to generate more paperwork for physicians, he points out.

“Nobody seems to want to complain about this because you’re going to be perceived as someone who’s against patient safety,” Dr. Thoelke says. “I feel very strongly about providing excellent patient care. But it makes it harder for me to take care of patients if I’m concerned about filling out multiple pieces of paper.”

To combat the paper flood, his institution has been using Lean Six Sigma, a business improvement strategy that addresses speed and quality. Admission forms are now in a single large packet available in one spot. Dr. Thoelke would like to see even more improvements.

“The end result of any committee is a new piece of paper that the physician has to fill out,” Dr. Thoelke says. “The perception is, it’s just one piece of paper. But it adds up to an incredible amount of time.”

3) Eliminate 24-hour shifts. Chris Landrigan, MD, MPH, studies the relationship between workplace safety and patient care, particularly the long hours residents tend to work.

In general, residents’ shifts are restricted to no more than 24 consecutive hours, plus up to six hours for paperwork and arranging patient care, according to the ACGME. Residents are to have 10-hour rest periods between duty shifts, and can work no more than 80 hours a week, averaged over four weeks.

“There’s no question that traditional shifts of 24 or more hours endanger residents and their patients,” says Dr. Landrigan director of the Sleep and Patient Safety Program, Brigham and Women’s Hospital, and research and fellowship director, Inpatient Pediatrics Service, Children’s Hospital Boston. “Twenty-four hour shifts are associated with an increased rate of serious medical errors, and residents frequently crash their cars on the way home from working these marathon shifts. In the last few years, I know of eight residents at Children’s alone who have had post-call crashes on the way home from work.”

In accordance with ACGME standards limiting residents’ work hours, hospitalists can encourage a cultural shift that would improve workplace safety and patient care, he says. “Hospitalists in some cases are the residency directors, or some of the key teachers, and have a lot of influence there,” he says. “They’re in a position to begin to challenge the traditional model, just as they have in other ways.”

Dr. Landrigan acknowledges this massive change will be slow to catch on, but it’s already started. At Brigham and Women’s Hospital, 24-hour shifts for surgical residents have been eliminated on most rotations, he says, and a few programs in New York, Ohio, and elsewhere have done the same. “The department of surgery at Brigham and Women’s viewed the data themselves, and they felt that this was an important issue,” Dr. Landrigan says. He plans to study the impact of eliminating 24-hour shifts in the surgical intensive care units at Brigham and Women’s.

4) Include leadership training in medical school curriculum. “When you go to medical school, you [learn] to make a diagnosis and interact with a patient essentially on a one-on-one level,” says Eric Howell, MD, assistant professor of medicine, faculty leader, Helen B. Taussig College, Johns Hopkins University School of Medicine in Baltimore, and the chairman of SHM’s leadership committee.

“But in the hospital, that teaching is almost counterproductive,” he explains. There, the physician-patient relationship expands into one with multiple players. The physician leads a team with the patient at its center that can include case managers, nurses, administrative staff, ancillary staff, social workers, and others.

Physicians get no training in school about how to manage multidisciplinary teams, or how to create change where change is needed; instead, they learn on the job, Dr. Howell says. At a summit in Chicago this fall, the Leadership Committee discussed the possibility of providing scholarships for residents to attend SHM’s leadership academies.

“That got a lot of positive reviews, even unofficially,” Dr. Howell says. “The other thing we’re doing is we’re trying to get the word out that many hospitalists have the tools to lead teams, and to manage teams, to non-hospitalist groups,” such as hospital administrators and the American College of Healthcare Executives. “We’re trying to get the word out that there are physicians in hospitals available to lead.”

5) Make “hospitalist” a specialty. Dr. Ford would like to see “hospitalist” recognized as a medical sub-specialty in 2008. As specialists, hospitalists would have specific training requirements and other benefits, he says.

“Right now, we’re a big black box,” Dr. Ford says. “There are no clearly defined guidelines for what we can and can’t do.”

A formal credential for hospitalists is closer to reality. The American Board of Internal Medicine (ABIM) has officially approved the creation of a Focused Recognition for Hospital Medicine through its Maintenance of Certification (MOC) system. The ABIM’s formal proposal to the American Board of Medical Specialties (ABMS) is expected to be approved by September 2008. SHM began pursuing certification three years ago and intends to reach out to the pediatric and family medicine boards so certification can be available to all hospitalists.

The move would help make “hospitalist” a more recognizable term in the medical community and in the public arena, says Dr. Ford. “We’re not just your stereotypical general practice doctor. I think we’re more than that. I’d like to promote more of a global perspective of what hospitals are: We make the best use of resources as well as provide the most up-to-date care.”

6) Break down silos and collaborate more. “Medicine in general really is traditionally a siloed field, and at our institution there has been a lot of effort to break down those silos and work collaboratively,” Dr. Howell says.

In 1999 and 2000, the Johns Hopkins Bayview Medical Center, where Dr. Howell works, addressed a major patient throughput issue by bringing together two large groups for negotiation: the emergency department (ED) and the department of medicine. Together they reduced ED waiting time by 90 minutes, Dr. Howell says. The collaborative process received national recognition and resulted in joint publications. They did it again seven years later, this time bringing five large groups to the negotiating table and reducing the wait time even more.

“Each of those groups had to give up something,” such as control over the process, and they had to agree to greater transparency, Dr. Howell concedes. “But in return, they got a lot more.”

Bayview used collaboration again to tackle the issue of ambulance diversion, known as Red Alert, to dramatic effect. In fiscal year 2006, the campus had 2,025 Red Alert hours. The following year, it was 503. Fiscal year 2008 had, as of October, zero Red Alert hours.

“For years, we had been trying to solve the problems individually,” Dr. Howell says. “Imagine if everybody were approaching problems from the teamwork perspective right away. This is a cultural shift that’s going to have to change, and I think it’s going to take a long time. But for hospitalist medicine, these things are already happening.”

7) Improve staffing and retention rates. It almost doesn’t matter how sophisticated hospital culture is overall if the institution still battles one crucial weakness: burnout.

“There is a true burnout factor to hospitalists,” Dr. Amin says. “A lot of institutions are challenged with having the appropriate staffing of hospitalists. Part of that boils down to economics.”

Dr. Amin understands that bumping up staffing is tough to promote when the additions don’t correspond with increased revenue. An appropriate staffing model takes into account a number of variables, including patient load, vacation schedules, and non-clinical duties such as teaching, academics, research, administration, and quality-improvement efforts, he says.

Hiring hospitalists is not like hiring a new primary care doctor or another specialist who might attract new patients to the institution, he says. “A hospitalist program will have the same volume of patients that need to be covered regardless. If a hospitalist goes on vacation, one can’t close the hospital.”

Yet stop-gap measures, such as double shifts when someone’s on vacation, only work for so long, he points out. “You can’t continue to keep doing that as you’re being asked to see more and more patients, do more and more teaching, do more and more oversight, and still do it with the same number of people.”

Hospitalists’ great reputations for providing more efficient care and decreasing length of stay may convince institutions it’s worth it to change their staffing models and add more people. “Hospitals are running at capacity,” he says. “You still need quality.”

8) Improve communication: Pick up the phone. “One of the big things we’ve been working on is physician-to-physician communication,” Dr. Thoelke says. “That’s another problem area at many large academic institutions, and I think at most community institutions as well.”

Every consult should lead to a phone call, not just a note in a chart that another doctor might not see until the next day. It’s not only for courtesy’s sake: Dr. Thoelke believes that better, more direct communication will further decrease length of stay.

“You gather so much more information even in brief conversations from one doctor to another,” Dr. Thoelke says. “I object personally when I have a consultant schedule my patient for a test that they don’t make me aware of. I’m on the phone saying, ‘This is not appropriate.’ I’m the person who’s going to be dealing with the complications of this procedure. So I’m pushing back directly to physicians.”

He’s also working hand in hand with hospital administration to encourage a culture of communication.

A standardized hand-off of every patient, every time, would also help, says Dr. Landrigan.

“As it stands now, there’s a lot of looseness,” Dr. Landrigan says. Physicians sometimes assume that the next clinician can simply take over. “The reality is that when clinicians know the patients less well, care suffers.”

An SHM task force has created basic standards for hospitalists to use for hand-offs (The Hospitalist August 2007, p.18).

9) Meet face to face with all those involved when you want to make change. No matter what’s on your wish list for 2008, your chances of making it happen improve if you communicate directly, according to Dr. Ford.

“I would recommend this not just for hospital medicine, but for anything,” Dr. Ford says. “You really have to go and meet with people. You really have to communicate, and not just by e-mail. E-mail is a good way to set up times to meet.”

To build support for the changes he wanted to make at Temple when Cogent Healthcare began managing its hospitalist program, Ford brought everyone into the discussion, from medical department chairs to representatives from nursing, administration, the labs, and more. “All the key stakeholders,” he says.

Now, Temple’s overall culture focuses on the institution’s financial health as well as on patient health. It also has an observation unit run entirely by hospitalists, freeing residents to work on other cases and still comply with ACGME rules.

“We did get a lot of resistance,” Dr. Ford admits. “University faculty weren’t very receptive to having a non-university faction running this unit. We had to break down the stereotypes that we weren’t a for-profit monster. We had to gain the trust of the emergency department [and others] to allow us to take care of their patients.” TH

Liz Tascio is a journalist based in New York.

When Manjusha Gupte, MD, had her second child, she realized that parenting and working full-time as a hospitalist was going to be too much.

“My husband is a hospitalist as well, so since there’s two in the family, we needed to get our time a little better situated with the kids,” she says.

She and another hospitalist, also a mother, approached their program director at Gaston Memorial Hospital, a busy community hospital in Gastonia, N.C., about going part-time.

Since then, the two physicians have shared a full-time job. Dr. Gupte works three or four consecutive shifts a week, two weeks a month. She still sees a full complement of patients—about 20 at a time—and she gets to spend more time with her daughter, 4, and her son, almost 2.

“Most hospitalist programs are scared,” Dr. Gupte says. “They think there won’t be continuity of care for patients, or it’s going to be disruptive to other doctors who are full-time. I have not yet heard of anybody complaining about continuity of care.”

Even though hiring part-timers and job-sharers raises these and other concerns, it’s increasingly important to offer this kind of scheduling flexibility, industry experts say.

“Hospital medicine, more than many other specialty, tends to attract people who care a lot about lifestyle,” says Leslie Flores, MHA, Nelson/Flores Associates. “A practice that isn’t willing to be flexible and consider part-time is sort of shooting itself in the foot.”

Before deciding whether to hire part-time or job-sharing hospitalists, there are many factors to consider, such as how to handle benefits and malpractice insurance and how to make sure a part-timer with a private practice doesn’t draw patients away from the hospital’s crew of referring doctors—intentionally or not.

There are benefits to the hospital: It’s easier to provide vacation and gap coverage, it’s less likely the full-time hospitalists will burn out, and in some cases, a part-time specialist can provide services the hospital didn’t offer.

“We’re real advocates of part-time hospitalists,” Flores says. “I think the benefits really outweigh the risks.”

The Benefits

A part-time hospitalist can be anyone from a physician who cuts back to 75% of her hours so she can spend more time with her kids, to a resident or fellow who signs up for a few shifts a month. A job-sharer splits a full-time job with another physician, sometimes sharing office space and even a malpractice insurance policy.

Part-timers can free full-time hospitalists to participate on committees, conduct research, teach, attend a conference or seminar, take a sabbatical, or simply pursue outside interests, says Kenneth Simone, DO, who founded and served as director for 10 years of a hospitalist program in Maine. He is now president of Hospitalist and Practice Solutions, a consultancy, in Brewer, Maine.

“Also, they’re extremely helpful when the practice is in an expansion mode,” Dr. Simone says. “If they want to bring in two or three more referring providers’ practices, you can utilize the part-timers to help with the extra work so you don’t overwork your staff.”

Though it’s less common these days, a new hospitalist program may meet with resistance from local doctors. Offering those doctors part-time shifts can help ease the transition.

“They’re worried about what’s going to happen to their inpatient skills, what their patients may think, and their income,” says Steven Nahm, vice president of the Camden Group, a hospitalist consultancy and management company with offices in Chicago and El Segundo, Calif. As part-timers, these doctors keep current with inpatient care and can gauge the impact of the program on their practices.

A respected local physician who comes in part-time also lends credibility and gives medical staff a greater sense of confidence in the program, Nahm says. Dr. Simone calls these part-timers ambassadors.

One Example

The hospitalist program at Hudson Valley Hospital Center in Cortlandt Manor, N.Y., began in July 2005 at the request of local doctors. The program, Hospital Medicine Associates, contracts with the hospital and has its own billing system. It has eight full-time hospitalists, and as of about six months ago, four hospitalists sharing two full-time positions. They even share malpractice insurance because New York state law allows for half-policies. The part-timers work under pro-rated policies because they work fewer hours.

Allowing doctors to job-share seemed like common sense, says Richard Becker, MD, who leads the program.

“If you have good physicians, you want to keep them,” he says. “Having two doctors share shifts gives you flexibility. If one is sick or ill or on vacation, the other can come in and take care of it. You never have to worry about that position.”

While most programs have a few part-time physicians, it’s rare to see a program fully staffed by part-timers or job-sharers, Nahm says.

“Generally, they’re transition steps toward a program staffed by full-time hospitalists,” he says.

It can take more than a year to staff a program, especially for medical centers that aren’t in a city with a medical school. Now that more hospitals want to start hospitalist programs—and quickly—it helps to bring in part-timers to support an incomplete team, says Betty Abbott, chief operating officer of Eagle Hospital Physicians in Atlanta, Ga., a hospitalist consultancy that serves the southeast and Atlantic states.

“It used to be you had three to nine months to start a program, and now many people are saying, ‘We’d like to have it next Monday,’ ” Abbott says.

Some smaller or rural hospitals run part-time-only hospitalist programs because it’s the only option that makes economic sense, or because they have trouble recruiting full-time hospitalists. In these cases, part-timers can give a much-needed boost to admissions.

“The doctors typically in the community don’t want to work on weekends,” says Alan Himmelstein, FACMPE, president of Hospital Care Consultants Inc. (HCC) in San Antonio, Texas. “So if they see a patient in their office on a Thursday that has pneumonia, they will opt to either transfer to a bigger city, or treat the patient in an outpatient setting, which is not optimal. With the hospitalist there, the hospital can take that patient.”

Competition, Commitment

Two of the major concerns about part-time and job-sharing hospitalists are that they won’t be as committed to the program as other hospitalists, or that they’ll attract patients to their own private practice—away from referring physicians.

“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.

“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?

“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”

Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.

“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”

To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.

“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”

Continuity of Care

Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.

If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.

To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.

“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.

“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”

Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.

Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.

“The nature of our job is such that it’s fairly easy to coordinate that,” says Daniel J. Brotman, MD, FACP, director of the hospitalist program there. “It creates sort of auxiliary staffing.”

The hospitalist program at Johns Hopkins started in 2002. Part-timers tend to work nights and weekends and get a lot of flexibility; they sign up for shifts instead of working a guaranteed schedule. Continuity of care is rarely an issue because full-time staff provides that, Dr. Brotman says.

“We divide labor into somebody who’s doing admissions and someone who’s taking care of the patients day to day,” he says. “The person who’s doing admissions can be anybody who’s competent to do so and doesn’t need to be someone who’s available the next day to take care of the patients.”

So far, hand-offs have been smooth, Dr. Brotman says, partly because the transfer of information about Hopkins’ complex tertiary-care patients is thorough by necessity. While good communication is important for all hospitalists, it’s especially important for part-timers and job-sharers, Dr. Simone says. In addition to requiring thorough notes and communication, he suggests finding out ahead of time whether a part-timer will be available to answer questions during off hours.

“Are they flexible so they can come in a heartbeat if you need them?” Dr. Simone says. By the same token, referring physicians have to commit to doing a verbal hand-off to the hospitalists, and hospitalists have to commit to sending a report when the patients are handed back, Abbott says.

When HCC tried establishing a hospitalist program that covered only weekend shifts, Himmelstein says, tight turnarounds on Monday mornings and spotty cell phone service in rural areas made it too hard to coordinate hand-offs.

Other Issues

There are other factors to consider before bringing in full-time hospitalists or job-shares, such as billing.

“They’re working as a hospitalist for a week, and one of their private patients comes in to be admitted,” Nahm says. “Are they seeing that patient as a hospitalist or are they seeing that patient outside of the program, as their own patient?”

The same issue can come up with a pulmonary or infectious disease specialist, for example. If she consults on other patients during her shift, is she doing so as a hospitalist or in her private practice?

“I find it best if you just take the philosophy that you’re buying this physician’s time, and anything this physician does on the clock for you is considered a service of the hospitalist group—and all billing and collection and revenue, in other words, go back to the hospitalist group,” Nahm says.

Also, a part-time hospitalist may face competing demands for his or her time.

“Sometimes they come in and they’re lacking focus because they’re tired—they’ve been up all night moonlighting in the ED,” Dr. Simone says. “Or they pace themselves because they know tomorrow and for the next four days, they’re on call for their private practice.”

Despite the practical issues part-timers bring, Dr. Simone points out, they tend to increase a program’s flexibility and efficiency, allow the hospital to offer more value, lower burnout, and increase job satisfaction.

Dr. Gupte wants more programs to start hiring part-time hospitalists—especially to help families like hers, where both parents are busy physicians.

“I think that makes a big difference in family care,” she says. “People sometimes think that we won’t be as intense or as focused when you’re doing the part-time thing. I don’t think that’s true.” TH

Liz Tascio is a freelance journalist based in New York City.

When Manjusha Gupte, MD, had her second child, she realized that parenting and working full-time as a hospitalist was going to be too much.

“My husband is a hospitalist as well, so since there’s two in the family, we needed to get our time a little better situated with the kids,” she says.

She and another hospitalist, also a mother, approached their program director at Gaston Memorial Hospital, a busy community hospital in Gastonia, N.C., about going part-time.

Since then, the two physicians have shared a full-time job. Dr. Gupte works three or four consecutive shifts a week, two weeks a month. She still sees a full complement of patients—about 20 at a time—and she gets to spend more time with her daughter, 4, and her son, almost 2.

“Most hospitalist programs are scared,” Dr. Gupte says. “They think there won’t be continuity of care for patients, or it’s going to be disruptive to other doctors who are full-time. I have not yet heard of anybody complaining about continuity of care.”

Even though hiring part-timers and job-sharers raises these and other concerns, it’s increasingly important to offer this kind of scheduling flexibility, industry experts say.

“Hospital medicine, more than many other specialty, tends to attract people who care a lot about lifestyle,” says Leslie Flores, MHA, Nelson/Flores Associates. “A practice that isn’t willing to be flexible and consider part-time is sort of shooting itself in the foot.”

Before deciding whether to hire part-time or job-sharing hospitalists, there are many factors to consider, such as how to handle benefits and malpractice insurance and how to make sure a part-timer with a private practice doesn’t draw patients away from the hospital’s crew of referring doctors—intentionally or not.

There are benefits to the hospital: It’s easier to provide vacation and gap coverage, it’s less likely the full-time hospitalists will burn out, and in some cases, a part-time specialist can provide services the hospital didn’t offer.

“We’re real advocates of part-time hospitalists,” Flores says. “I think the benefits really outweigh the risks.”

The Benefits

A part-time hospitalist can be anyone from a physician who cuts back to 75% of her hours so she can spend more time with her kids, to a resident or fellow who signs up for a few shifts a month. A job-sharer splits a full-time job with another physician, sometimes sharing office space and even a malpractice insurance policy.

Part-timers can free full-time hospitalists to participate on committees, conduct research, teach, attend a conference or seminar, take a sabbatical, or simply pursue outside interests, says Kenneth Simone, DO, who founded and served as director for 10 years of a hospitalist program in Maine. He is now president of Hospitalist and Practice Solutions, a consultancy, in Brewer, Maine.

“Also, they’re extremely helpful when the practice is in an expansion mode,” Dr. Simone says. “If they want to bring in two or three more referring providers’ practices, you can utilize the part-timers to help with the extra work so you don’t overwork your staff.”

Though it’s less common these days, a new hospitalist program may meet with resistance from local doctors. Offering those doctors part-time shifts can help ease the transition.

“They’re worried about what’s going to happen to their inpatient skills, what their patients may think, and their income,” says Steven Nahm, vice president of the Camden Group, a hospitalist consultancy and management company with offices in Chicago and El Segundo, Calif. As part-timers, these doctors keep current with inpatient care and can gauge the impact of the program on their practices.

A respected local physician who comes in part-time also lends credibility and gives medical staff a greater sense of confidence in the program, Nahm says. Dr. Simone calls these part-timers ambassadors.

One Example

The hospitalist program at Hudson Valley Hospital Center in Cortlandt Manor, N.Y., began in July 2005 at the request of local doctors. The program, Hospital Medicine Associates, contracts with the hospital and has its own billing system. It has eight full-time hospitalists, and as of about six months ago, four hospitalists sharing two full-time positions. They even share malpractice insurance because New York state law allows for half-policies. The part-timers work under pro-rated policies because they work fewer hours.

Allowing doctors to job-share seemed like common sense, says Richard Becker, MD, who leads the program.

“If you have good physicians, you want to keep them,” he says. “Having two doctors share shifts gives you flexibility. If one is sick or ill or on vacation, the other can come in and take care of it. You never have to worry about that position.”

While most programs have a few part-time physicians, it’s rare to see a program fully staffed by part-timers or job-sharers, Nahm says.

“Generally, they’re transition steps toward a program staffed by full-time hospitalists,” he says.

It can take more than a year to staff a program, especially for medical centers that aren’t in a city with a medical school. Now that more hospitals want to start hospitalist programs—and quickly—it helps to bring in part-timers to support an incomplete team, says Betty Abbott, chief operating officer of Eagle Hospital Physicians in Atlanta, Ga., a hospitalist consultancy that serves the southeast and Atlantic states.

“It used to be you had three to nine months to start a program, and now many people are saying, ‘We’d like to have it next Monday,’ ” Abbott says.

Some smaller or rural hospitals run part-time-only hospitalist programs because it’s the only option that makes economic sense, or because they have trouble recruiting full-time hospitalists. In these cases, part-timers can give a much-needed boost to admissions.

“The doctors typically in the community don’t want to work on weekends,” says Alan Himmelstein, FACMPE, president of Hospital Care Consultants Inc. (HCC) in San Antonio, Texas. “So if they see a patient in their office on a Thursday that has pneumonia, they will opt to either transfer to a bigger city, or treat the patient in an outpatient setting, which is not optimal. With the hospitalist there, the hospital can take that patient.”

Competition, Commitment

Two of the major concerns about part-time and job-sharing hospitalists are that they won’t be as committed to the program as other hospitalists, or that they’ll attract patients to their own private practice—away from referring physicians.

“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.

“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?

“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”

Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.

“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”

To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.

“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”

Continuity of Care

Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.

If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.

To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.

“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.

“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”

Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.

Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.

“The nature of our job is such that it’s fairly easy to coordinate that,” says Daniel J. Brotman, MD, FACP, director of the hospitalist program there. “It creates sort of auxiliary staffing.”

The hospitalist program at Johns Hopkins started in 2002. Part-timers tend to work nights and weekends and get a lot of flexibility; they sign up for shifts instead of working a guaranteed schedule. Continuity of care is rarely an issue because full-time staff provides that, Dr. Brotman says.

“We divide labor into somebody who’s doing admissions and someone who’s taking care of the patients day to day,” he says. “The person who’s doing admissions can be anybody who’s competent to do so and doesn’t need to be someone who’s available the next day to take care of the patients.”

So far, hand-offs have been smooth, Dr. Brotman says, partly because the transfer of information about Hopkins’ complex tertiary-care patients is thorough by necessity. While good communication is important for all hospitalists, it’s especially important for part-timers and job-sharers, Dr. Simone says. In addition to requiring thorough notes and communication, he suggests finding out ahead of time whether a part-timer will be available to answer questions during off hours.

“Are they flexible so they can come in a heartbeat if you need them?” Dr. Simone says. By the same token, referring physicians have to commit to doing a verbal hand-off to the hospitalists, and hospitalists have to commit to sending a report when the patients are handed back, Abbott says.

When HCC tried establishing a hospitalist program that covered only weekend shifts, Himmelstein says, tight turnarounds on Monday mornings and spotty cell phone service in rural areas made it too hard to coordinate hand-offs.

Other Issues

There are other factors to consider before bringing in full-time hospitalists or job-shares, such as billing.

“They’re working as a hospitalist for a week, and one of their private patients comes in to be admitted,” Nahm says. “Are they seeing that patient as a hospitalist or are they seeing that patient outside of the program, as their own patient?”

The same issue can come up with a pulmonary or infectious disease specialist, for example. If she consults on other patients during her shift, is she doing so as a hospitalist or in her private practice?

“I find it best if you just take the philosophy that you’re buying this physician’s time, and anything this physician does on the clock for you is considered a service of the hospitalist group—and all billing and collection and revenue, in other words, go back to the hospitalist group,” Nahm says.

Also, a part-time hospitalist may face competing demands for his or her time.

“Sometimes they come in and they’re lacking focus because they’re tired—they’ve been up all night moonlighting in the ED,” Dr. Simone says. “Or they pace themselves because they know tomorrow and for the next four days, they’re on call for their private practice.”

Despite the practical issues part-timers bring, Dr. Simone points out, they tend to increase a program’s flexibility and efficiency, allow the hospital to offer more value, lower burnout, and increase job satisfaction.

Dr. Gupte wants more programs to start hiring part-time hospitalists—especially to help families like hers, where both parents are busy physicians.

“I think that makes a big difference in family care,” she says. “People sometimes think that we won’t be as intense or as focused when you’re doing the part-time thing. I don’t think that’s true.” TH

Liz Tascio is a freelance journalist based in New York City.

When Manjusha Gupte, MD, had her second child, she realized that parenting and working full-time as a hospitalist was going to be too much.

“My husband is a hospitalist as well, so since there’s two in the family, we needed to get our time a little better situated with the kids,” she says.

She and another hospitalist, also a mother, approached their program director at Gaston Memorial Hospital, a busy community hospital in Gastonia, N.C., about going part-time.

Since then, the two physicians have shared a full-time job. Dr. Gupte works three or four consecutive shifts a week, two weeks a month. She still sees a full complement of patients—about 20 at a time—and she gets to spend more time with her daughter, 4, and her son, almost 2.

“Most hospitalist programs are scared,” Dr. Gupte says. “They think there won’t be continuity of care for patients, or it’s going to be disruptive to other doctors who are full-time. I have not yet heard of anybody complaining about continuity of care.”

Even though hiring part-timers and job-sharers raises these and other concerns, it’s increasingly important to offer this kind of scheduling flexibility, industry experts say.

“Hospital medicine, more than many other specialty, tends to attract people who care a lot about lifestyle,” says Leslie Flores, MHA, Nelson/Flores Associates. “A practice that isn’t willing to be flexible and consider part-time is sort of shooting itself in the foot.”

Before deciding whether to hire part-time or job-sharing hospitalists, there are many factors to consider, such as how to handle benefits and malpractice insurance and how to make sure a part-timer with a private practice doesn’t draw patients away from the hospital’s crew of referring doctors—intentionally or not.

There are benefits to the hospital: It’s easier to provide vacation and gap coverage, it’s less likely the full-time hospitalists will burn out, and in some cases, a part-time specialist can provide services the hospital didn’t offer.

“We’re real advocates of part-time hospitalists,” Flores says. “I think the benefits really outweigh the risks.”

The Benefits

A part-time hospitalist can be anyone from a physician who cuts back to 75% of her hours so she can spend more time with her kids, to a resident or fellow who signs up for a few shifts a month. A job-sharer splits a full-time job with another physician, sometimes sharing office space and even a malpractice insurance policy.

Part-timers can free full-time hospitalists to participate on committees, conduct research, teach, attend a conference or seminar, take a sabbatical, or simply pursue outside interests, says Kenneth Simone, DO, who founded and served as director for 10 years of a hospitalist program in Maine. He is now president of Hospitalist and Practice Solutions, a consultancy, in Brewer, Maine.

“Also, they’re extremely helpful when the practice is in an expansion mode,” Dr. Simone says. “If they want to bring in two or three more referring providers’ practices, you can utilize the part-timers to help with the extra work so you don’t overwork your staff.”

Though it’s less common these days, a new hospitalist program may meet with resistance from local doctors. Offering those doctors part-time shifts can help ease the transition.

“They’re worried about what’s going to happen to their inpatient skills, what their patients may think, and their income,” says Steven Nahm, vice president of the Camden Group, a hospitalist consultancy and management company with offices in Chicago and El Segundo, Calif. As part-timers, these doctors keep current with inpatient care and can gauge the impact of the program on their practices.

A respected local physician who comes in part-time also lends credibility and gives medical staff a greater sense of confidence in the program, Nahm says. Dr. Simone calls these part-timers ambassadors.

One Example

The hospitalist program at Hudson Valley Hospital Center in Cortlandt Manor, N.Y., began in July 2005 at the request of local doctors. The program, Hospital Medicine Associates, contracts with the hospital and has its own billing system. It has eight full-time hospitalists, and as of about six months ago, four hospitalists sharing two full-time positions. They even share malpractice insurance because New York state law allows for half-policies. The part-timers work under pro-rated policies because they work fewer hours.

Allowing doctors to job-share seemed like common sense, says Richard Becker, MD, who leads the program.

“If you have good physicians, you want to keep them,” he says. “Having two doctors share shifts gives you flexibility. If one is sick or ill or on vacation, the other can come in and take care of it. You never have to worry about that position.”

While most programs have a few part-time physicians, it’s rare to see a program fully staffed by part-timers or job-sharers, Nahm says.

“Generally, they’re transition steps toward a program staffed by full-time hospitalists,” he says.

It can take more than a year to staff a program, especially for medical centers that aren’t in a city with a medical school. Now that more hospitals want to start hospitalist programs—and quickly—it helps to bring in part-timers to support an incomplete team, says Betty Abbott, chief operating officer of Eagle Hospital Physicians in Atlanta, Ga., a hospitalist consultancy that serves the southeast and Atlantic states.

“It used to be you had three to nine months to start a program, and now many people are saying, ‘We’d like to have it next Monday,’ ” Abbott says.

Some smaller or rural hospitals run part-time-only hospitalist programs because it’s the only option that makes economic sense, or because they have trouble recruiting full-time hospitalists. In these cases, part-timers can give a much-needed boost to admissions.

“The doctors typically in the community don’t want to work on weekends,” says Alan Himmelstein, FACMPE, president of Hospital Care Consultants Inc. (HCC) in San Antonio, Texas. “So if they see a patient in their office on a Thursday that has pneumonia, they will opt to either transfer to a bigger city, or treat the patient in an outpatient setting, which is not optimal. With the hospitalist there, the hospital can take that patient.”

Competition, Commitment

Two of the major concerns about part-time and job-sharing hospitalists are that they won’t be as committed to the program as other hospitalists, or that they’ll attract patients to their own private practice—away from referring physicians.

“This is a big factor,” Nahm says. “You should have a policy that a part-timer who has an outpatient practice cannot accept hospitalist patients into their practice for a period of at least one year. That’s the biggest concern for using part-timers, because they are a potentially competitive threat.” Even the suspicion that it might happen can be enough to persuade local physicians to refer their patients elsewhere. To ward off concerns, the hospital can implement a policy to instruct patients upon discharge to make an appointment with their primary physician. Some hospitals go so far as to book the appointments on behalf of patients.

“It gets tricky sometimes because patients may really like their hospitalist,” Flores acknowledges. Some programs bring in only part-time hospitalists who don’t have a private practice, or hire specialists who want to keep up their general medicine skills but aren’t a threat to primary care physicians. But what about levels of commitment?

“Part-timers, just by the nature of being part-time, aren’t as emotionally connected to the practice,” Flores says. “You don’t get the same level of buy-in, or maybe the same kinds of camaraderie.”

Dr. Gupte, the job-sharing physician at Gaston Memorial, says she and her partner may be even more focused and intense than full-time hospitalists because they know they have just three or four days to care for their patients.

“We just kind of go in and say, ‘Now I need to know this [and] this; this needs to be done,’” Dr. Gupte says. “I need to get them discharged in two or three days, what’s the plan? The weekend’s coming.”

To encourage commitment to the program, Nahm suggests including dedicated part-timers—those who work a significant number of shifts per month—in your productivity and quality compensation plan. Part-timers should also have the same orientation and training as full-timers, and be required to attend all hospitalist group meetings, Nahm says.

“One of the benefits of the hospitalist is that they know the ins and outs, the ups and downs of the hospital,” Dr. Simone says. “If I’m not going to the medical staff meetings and to my committee meetings, I’m not going to have adequate information—and that may make me less effective as a hospitalist.”

Continuity of Care

Job-sharing works well for Hudson Valley Hospital Center, but allowing physicians to come in for just a few shifts a month doesn’t sound as appealing, Dr. Becker says.

If a hospital uses part-timers only sporadically, “that opens the chances for errors and for patient dissatisfaction,” he says.

To counter this, a hospital might hire only part-timers who can work consecutive shifts. Or it might use doctors who are available sporadically to support the program other ways.

“Dr. A is willing to provide 12 shifts per month but only wants to work two or three days a week,” Dr. Simone says. “You probably want to utilize him or her as an admitting doctor or a float, not a rounder, since patient continuity may be negatively affected.

“Dr. B is willing to provide 12 shifts per month and doesn’t mind working several days in a row; for example, six or 10 or 12 consecutive days. That schedule offers wonderful continuity, and this provider can be utilized as a rounder, following patients from admission through discharge.”

Even physicians who fill in only when volume is high—perhaps in four- or six-hour shifts in the evenings or on weekends—can benefit some hospitals, Abbott says; that support might make it easier to recruit full-timers.

Johns Hopkins Medicine in Baltimore supplements its nine full-time hospitalists with part-timers.

“The nature of our job is such that it’s fairly easy to coordinate that,” says Daniel J. Brotman, MD, FACP, director of the hospitalist program there. “It creates sort of auxiliary staffing.”

The hospitalist program at Johns Hopkins started in 2002. Part-timers tend to work nights and weekends and get a lot of flexibility; they sign up for shifts instead of working a guaranteed schedule. Continuity of care is rarely an issue because full-time staff provides that, Dr. Brotman says.

“We divide labor into somebody who’s doing admissions and someone who’s taking care of the patients day to day,” he says. “The person who’s doing admissions can be anybody who’s competent to do so and doesn’t need to be someone who’s available the next day to take care of the patients.”

So far, hand-offs have been smooth, Dr. Brotman says, partly because the transfer of information about Hopkins’ complex tertiary-care patients is thorough by necessity. While good communication is important for all hospitalists, it’s especially important for part-timers and job-sharers, Dr. Simone says. In addition to requiring thorough notes and communication, he suggests finding out ahead of time whether a part-timer will be available to answer questions during off hours.

“Are they flexible so they can come in a heartbeat if you need them?” Dr. Simone says. By the same token, referring physicians have to commit to doing a verbal hand-off to the hospitalists, and hospitalists have to commit to sending a report when the patients are handed back, Abbott says.

When HCC tried establishing a hospitalist program that covered only weekend shifts, Himmelstein says, tight turnarounds on Monday mornings and spotty cell phone service in rural areas made it too hard to coordinate hand-offs.

Other Issues

There are other factors to consider before bringing in full-time hospitalists or job-shares, such as billing.

“They’re working as a hospitalist for a week, and one of their private patients comes in to be admitted,” Nahm says. “Are they seeing that patient as a hospitalist or are they seeing that patient outside of the program, as their own patient?”

The same issue can come up with a pulmonary or infectious disease specialist, for example. If she consults on other patients during her shift, is she doing so as a hospitalist or in her private practice?

“I find it best if you just take the philosophy that you’re buying this physician’s time, and anything this physician does on the clock for you is considered a service of the hospitalist group—and all billing and collection and revenue, in other words, go back to the hospitalist group,” Nahm says.

Also, a part-time hospitalist may face competing demands for his or her time.

“Sometimes they come in and they’re lacking focus because they’re tired—they’ve been up all night moonlighting in the ED,” Dr. Simone says. “Or they pace themselves because they know tomorrow and for the next four days, they’re on call for their private practice.”

Despite the practical issues part-timers bring, Dr. Simone points out, they tend to increase a program’s flexibility and efficiency, allow the hospital to offer more value, lower burnout, and increase job satisfaction.

Dr. Gupte wants more programs to start hiring part-time hospitalists—especially to help families like hers, where both parents are busy physicians.

“I think that makes a big difference in family care,” she says. “People sometimes think that we won’t be as intense or as focused when you’re doing the part-time thing. I don’t think that’s true.” TH

Liz Tascio is a freelance journalist based in New York City.