ANP 654 DQ 1/2

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ospitalists assume patients understand their presence at the bedside. More effort in explaining the role of the hospitalist as the internal medicine physician or family medicine physician who is responsible for patient care while the patient is in the hospital is essential. Once patients understand that the hospitalist is the physician assuming responsibility for everything from admission to discharge, including making patient rounds and ordering all needed tests and procedures it helps them understand why the hospitalist is caring for them. An important component of the dialog is that the patient understands that their primary care provider (PCP) is informed of their progress and resumes care for the patient postdischarge.

With the Centers for Medicare and Medicaid Services moving from a fee-for-service to a fee-for-value payor, the hospitalist takes on an important role in coordination of care with a focus on population health. Today there is a deeper understanding of the importance of managing population health to drive the health of the community that a health system serves. Central to this movement is the need for robust measurement systems that enable us to concentrate on the outcomes of a population instead of individual silos within the delivery system. Hospitalists are in unique position to deliver on the Institute of Medicine’s “Triple Aim,” targeting better health for the population, better quality and patient experience of care while lowering the cost of care. With more than 50% of all health care spending generated from the acute care admission through the 90-day postacute period, the hospitalists team is ideally suited to manage care from the emergency department (ED) to postacute care.

The highest performing hospitalist groups can bring value to the populations they serve through predictable outcomes. Hospitals would benefit from bringing hospitalists into the discussion about population health and overall performance improvement in acute and postacute care management. Many hospital Accountable Care Organizations (ACOs) have not focused on a postacute care strategy, where much of the variability and costs occur in the 90-day period following discharge nor have they recognized the role hospitalists can play in tackling this issue. Improving performance across the acute episode of care is best achieved with a comprehensive hospitalist infrastructure that incorporates physician development, leadership support and incorporation of evidence- based data to measure performance and drive continuous quality improvement. High- performing hospitalist teams that hardwire these elements into their practice will drive performance improvements and grow their practice.

This chapter explores the specific components essential to building, growing, and managing a thriving hospitalist practice with staying power in light of the new fee-for- value environment.

STRATEGIC PLANNING It is important to have a strategic plan for the practice around growth and the types of hospitals and programs best aligned with agreed upon goals and objectives. For example, strategic planning may require not aligning with all groups requesting support of the hospitalist team. If a group does not fit your strategic profile or geography, it may be best to decline the opportunity to manage a program. Depending on the goals of the practice, certain approaches may not promote patient satisfaction or continuity of care goals. For

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example, when a hospital simply wants your team to cover admissions during the “off hours” that residents are not covering patients and then transfer patients back to residents or surgeons during “peak hours”. These practices work against the goals of improving the patient experience of care and can erode coordination of care. Obstacles of geographic distance requiring a day of travel of the core management team present an additional burden that may make it best to pass up the opportunity to service a hospital if key management team members cannot be present on a regular basis. Each hospitalist group should critically evaluate whether the growth in a new hospital makes sense based on the values and goals of the hospitalist practice, in addition to the hospital seeking hospitalist services.

STRATEGIC PLANNING PROCESS Before starting a hospitalist practice, determine factors that predict the success or failure. Identify the business and financial motivators required to build, expand, and manage a hospitalist service. These factors should incorporate the needs of the hospital and community the practice it serves.

PRACTICE POINT The hospitalist practice must start with a strategic planning process.

What are the goals of the practice? What are the needs of the hospital? How feasible is it to recruit to the location? What outcomes and metrics are expected by the hospital? Can the practice commit to the hospital’s performance expectations?

In order to build a hospitalist practice, hospital leaders should:

Define the scope of services. Articulate the vision, mission, values, and key value drivers (KVDs) of the practice. Establish the employment model and compensation strategy to drive performance. Determine the size and cost of the program.

After a program is up and running, successful practices may be faced with unprecedented growth. Hospital leaders will need to:

Set expectations and priorities for growth. Define key stakeholders. Plan for growth. Assess the evolving needs of the service, such as using advance practitioner providers (NPs and PAs). Determine the skills in a hospitalist practice and the need for additional provider training.

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Determine whether the requested skill set of providers by hospital administration coincides with the ability to recruit to the program. Reassess the compensation model as the needs of the service change. For example, hospitalists with the skills to provide ICU procedures will cost more per shift than general medical hospitalists.

From the building stage forward, there is a constant need for outstanding management to ensure a hospitalist practice thrives by using the steps provided in the following tables: (Tables 23-1, 23-2, and 23-3)

TABLE 23-1 Building a Hospitalist Program: Key Factors to Consider

Characteristics Examples Recruiting • Is the location conducive to recruiting hospitalists?

Do they need to recruit a leader? Compensation plan • What is the market rate? Number of encounters/physician • What is the number of patients at 7 AM census?

• What total number of patient encounters will physicians manage per day?

• What is the acuity of patients in the mix? Schedule • Is a traditional block schedule feasible?

• Do you offer additional vacation days? Management support • What local support is required?

• What regional support is required? Tools to support communications, charge capture, scheduling, metrics

• How will hospitalists record charges? • Is there a convenient method to communicate to

PCPs? • How will you demonstrate improvement in

performance? • How will the group demonstrate quality?

Clinical processes development • What best practices does the group adopt? • How do the processes impact care?

TABLE 23-2 Growing a Hospitalist Program: Core Values and Goals

Characteristics Examples Quality • Measure length of stay

• Measure readmissions rate • Measure CMS core measures • Measure time of discharge • Measure case mix index

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Satisfaction • Measure patient satisfaction • Measure nursing satisfaction • Measure PCP satisfaction • Measure specialist satisfaction • Measure administrative staff satisfaction

Efficiency • Determine how to improve admission and discharge efficiency

Innovation • What tools can be developed to support the team’s core values?

Teamwork • Determine how the team interacts with monthly and quarterly meetings.

• How do you organize in teams? • What is the role of advance practice providers?

Leadership • Is there a leadership development training path? • Is there a medical director or chief hospitalist on the site? • Are there regional leaders for clinical and business

operations? Financial • Does the group charge a fee for services?

• What are the overhead costs to manage the practice? • Is there a clear return on investment for the hospital to retain

services of the group? Integrity • What guidance does the team provide to the physicians in

the group? • How do we manage the impact of actions, values, methods,

measures, principles, expectations, and outcomes of the team?

• What criteria are used to assess integrity of candidates? Research • Is the group involved in research?

• Is there support for data collection and analysis? • What funding is available to the group to support research?

PCP satisfaction • How does the group measure PCP satisfaction? • Does the group reach out to the PCPs? • How does the group track referrals from PCPs?

Nursing satisfaction • How does the group measure nursing satisfaction? • Does the group interface with nursing? • How does the group track nursing impact on outcomes?

Specialist satisfaction • How does the group measure specialist satisfaction? • Does the group reach out to the specialist? • How does the group track referrals from specialists?

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TABLE 23-3 Managing a Hospitalist Program: Key Strategies for Effective Management

Characteristics Examples Recruiting • How does the group identify new hires?

• Does the group use a recruiting agency? Overhead • What percentage of revenue is allocated to support

programs (overhead)? • Do costs incorporate utilization of advance practice

professionals, nurses, support staff, and locum tenens? Training • What allocation of resources does the group have for CME

training? • How are new group members trained? • How are leaders mentored?

Growth • Does the group want to expand? • Is the group capable of taking on additional patients at the

primary site? Service lines • Does the group focus on acute care contracts with

traditional hospitalists? • Does the group provide intensivists services? • Are there other service lines to consider: surgicalists,

laborists, academic hospitalists, post-acute care/transitional care?

Improvement strategies • Where is the group’s focus on quality? Efficiency? Satisfaction?

Define the right leadership and structure. Create an ownership mentality. Setting up the right processes. Tracking and reporting actionable data. Provider education focused on leadership excellence and performance management. Promoting outreach to the physician community and facilitating transitions of care.

BUILDING A HOSPITALIST PRACTICE Building a hospitalist practice starts with defining the prospective hospital partner’s needs for a hospitalist program. In many community hospitals, a hospitalist program is created to care for the unassigned patient population. But even the definition of an unassigned patient is subject to much interpretation. For example, at many hospitals in the Puget Sound region of Washington State, an unassigned patient is any patient showing up in the emergency department and requiring admission who does not have a primary care doctor that admits patients at the hospital. In contrast, in Orlando, Florida, an unassigned patient is only defined as a patient who has no primary care doctor. In Orlando, if a patient has a

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primary care provider but that doctor does not have admitting privileges, it is standard practice to call the primary care provider to identify who will care for the patient in the hospital.

PRACTICE POINT The needs assessment, from the perspective of the hospital might include:

PCP and/or surgical dissatisfaction Admission and management of unassigned patients Admission and management of overflow patients due to American College of Graduate Medical Education (ACGME) work hour restrictions High inpatient census and long average length of stay (ALOS) Low reported performance measures External regulation (rapid response teams, code teams, etc)

In addition to covering the unassigned patient population, many hospitalist services cover those primary care providers who do not want the responsibility of admitting their own patients. There are two main forms of coverage relationships: coverage arrangements for 24 hours per day, 7 days per week; and coverage which is more like a house staff model in which the hospitalist admits the patients but then turns the care back over to the PCP the next day. These latter models continue to decline in numbers because of difficulty with recruitment of high-quality providers motivated to build a meaningful career with a resident-type model.

Hospitalist programs may also be created to manage medical specialty and surgical patients, usually after establishment of the initial hospitalist program.

It is essential to determine which patients the hospitalist group will manage, the scope of services, and whether additional training for some of the program members will be required. According to the Medical Group Management Association and Society of Hospital Medicine 2014 State of Hospital Medicine Report (n = 4867) (see Figure 23-1).

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Figure 23-1 Specialty composition of survey respondents. (Source: 2014 State of Hospital Medicine Report. Reprinted with permission from the Society of Hospital Medicine.)

Eighty-three percent of practicing hospitalists are trained in internal medicine, 10% in family medicine, 7% in pediatrics, and 1% in med/peds. Data from the American Medical Group Association (n = 3700) report hospitalist training to represent 89% internal medicine, 6% family medicine, 5% pediatrics (did not ask about med/peds). When looking at the combined MGMA (community hospitals) and AMGA (academic hospitals) data, the distribution represents training spanning 80% internal medicine, 8.5% family medicine, 10% peds and 1% med/peds. The general trend represents and increased in hospitalists with family medicine training.

In most community hospitals today, hospitalists manage ICU patients. While there are just over 10,000 intensivist physicians in the United States, there is an increasing demand for critical care services to serve the aging population and extended life expectancy. Although the number of critical care physicians in training has been growing, it will be difficult to meet the patient demand with the rapidly aging population. Research indicates the increased demand creates a shortfall of intensivists equal to 35% by 2020, requiring hospitalists to step in to fill some of the demand. In general, the larger the hospital the less ICU medicine a hospitalist performs. Many hospitals have mandatory ICU consults after a set number of days or hours in the ICU or they provide specific guidelines on managing ventilated patients. The most popular model may be a hybrid arrangement in which access to a critical care physician occurs during the day and for emergencies but in-house at night. In such cases the hospitalist commonly does the work around admissions and daily visits with a consult and a follow-up visit by the pulmonary critical care physicians.

With the labor shortage being even more severe for critical care, hybrid models, along with the advent of telemedicine, are likely to take on even more ICU coverage responsibilities in the future. In general, leapfrog compliance guidelines drive a dedicated intensivist model, typically mandated in regional and tertiary hospitals.

“Code coverage” also defines the scope of the hospitalist practice. Many hospitals provide a separate code team, made up of the emergency medicine physician or in-house

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intensivist plus respiratory therapy, nurses, technicians, and pharmacists. Increasingly, hospitalists are being asked to partake in responding to the code process and arranging patient transfers to the ICU. In general, emergency physicians have more training and chances to keep their skills sharp around the procedures of a code, including intubation, starting central lines, and transvenous pacing. Typically, while an emergency medicine physician may respond first, a hospitalist with advanced cardiac life support training assumes leadership of the code.

Whether the hospitalist scheduled for the night shift is actually in the hospital or at home on call for emergencies also defines the scope of practice. Hospital-employed and hospital-contracted models tend to have in-house coverage while physicians who are part of a private fee-for-service group without a hospital contract tend to be available as an on- call physician available from home. Variables that impact the decision beyond economics include the volume of cross-coverage patients, the number of admissions per night, coexisting resident coverage, and the response time of the physician, if on call from home.

DEFINING THE TYPE OF EMPLOYMENT MODEL

There are several common employment models for hospitalist practices: employed by a private practice, by a hospital, by a multispecialty group, by a health plan/HMO, or a multisite or national practice. Among the multisite or national practice subgroups there are staffing solutions that specialize in emergency medicine, anesthesia, and a host of other physician specialists. Some of these multisite specialty practices will hire hospitalists who work as independent contractors alongside the specialist. Among the national hospitalist groups there is a wide spectrum of employment arrangements ranging from those offering ownership and partnership to those that operate solely with independent contractors.

DEFINING THE VISION, MISSION, VALUES, AND KEY VALUE DRIVERS OF YOUR PRACTICE

It is critically important to define the vision, mission and values of the practice from its inception. The leaders and hospitalists should take this task seriously. Schedule time to discuss and debate what is important to the group and leadership. The process of constructing your program’s mission and vision statement should not be taken lightly. This process can take weeks to develop. Start by establishing dedicated time and secure an environment that is conducive to having uninterrupted, frank discussions. Enlist the input of all team members.

A mission statement explains the overall purpose of the hospitalist practice. The mission statement articulates what the organization does right now, in the most general sense. In this way, the mission also sets parameters for what the organization, through omission, does not do. Example of a mission statement: “The Hospitalist Group of Hilltop builds healthy relationships between St. John’s Hospital and primary care providers in the community through public education and direct assistance services.”

By comparison, the vision statement articulates the future of the organization and the community that it serves. The vision statement, when compared with the current reality of the organization or the community, implies the work still needs to be accomplished. In this way, it lends credibility and motivation to the mission statement. Example of a vision statement: “The Hospitalist Group envisions a group practice that drives improvements in patient outcomes including evidence that reflects our value to hospitals in our community.”

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On a yearly basis the practice should define key value drivers that articulate the focus of the organization and those areas that require organizational focus in order for the business to grow. Key value drivers (KVDs) should be set by the leaders with input from the entire team. KVDs must be easy to remember, measurable, and achievable. The behaviors that support the key values should also be clearly defined. In doing so, those in the practice will have a clear understanding of expectations even prior to joining the practice. These behaviors should be reinforced through the compensation and promotion practices of the group to make the practice values meaningful and alive on a daily basis. Typically teams evaluate progress on KVDs monthly or quarterly.

ESTABLISHING METRICS AND SETTING NEW GOALS FOR PERFORMANCE AND OUTCOMES

Standard outcome metrics including average length of stay, core measures, case mix index, cost per case, and discharge efficiency are expected by hospital administration from the hospitalist group. It is essential to meet with the hospital and obtain agreement on which initiatives the hospitalist team will focus. Establish a data collection and reporting mechanism and the frequency of assessments. Practice metrics that are becoming increasingly important to hospitals include the Healthcare Cost and Utilization Project (called “H-CUP”). HCUP is a set of health care databases, software tools, and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality. Using the HCUP databases collates data collection from State organizations, hospital associations, private data organizations, and the Federal government creating a national data benchmark.

HCUP databases include the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information going back to 1988. These databases enable evaluation of cost and quality of health services, medical practice patterns, access to health care, and outcomes of treatments at the national, State, and local levels.

In addition to the standard outcome measures and HCUP data, it is useful to track and report other practice related trends, including PCP referral volume and referral patterns, patient satisfaction, physician recruiting efficiency, physician retention and 30-day same diagnosis readmission rates (Figure 23-2).

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Figure 23-2 A dashboard of standard outcome metrics organized by volume of patients, quality, utilization, satisfaction trend, and market data indicators including evaluating performance to HCUP data.

MARKETING YOUR HOSPITALIST SERVICES

The best marketing generates word-of-mouth public relations based on how satisfied your patients are as well as the nursing and other hospital staff. An effective campaign requires all hospitalists on the team to be fully engaged with the practice’s vision, mission and values.

In addition to the passive marketing that comes from word-of-mouth marketing, it is important to develop a marketing plan. A typical marketing plan for a practice includes initiatives that drive patient satisfaction to generating awareness in the community through PCP outreach. Create a budget that supports the plan.

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PRACTICE POINT Your marketing plan should include segments that target the following areas:

Identify your target markets: Decide which target markets you want to canvas. You can either target referrals in specific geographic areas or by targeting outreach to specialists. Develop a public relations plan: Launch a new program with press releases, open house events, or broadcast the addition to new physicians through flyers or direct mail campaigns. Create a promotion/awareness plan: You can develop practice-branded written articles on a variety of topics that convey answers to patients’ questions using topics such as What is a Hospitalist? or Improving Patient’s Health Literacy. Use these in a mailing to your community or have the hospital place your articles in their newsletter. Develop a social media campaign to highlight the culture of your practice to support recruiting and growth efforts. Develop patient satisfaction tools: Create large, oversized business cards with photos of physicians, hospitalist brochures with photos of engaged, friendly physicians; consider web-based information to share with patients. Create recruiting advertisements for physicians: Provide your recruiters with materials about the opportunity or special information about the location and hospital. Place them in hospitalist journals as print advertisements and classified ads. Conduct market research: Conduct market research in your local area to be sure you know what the local market is paying for hospitalists and places they practice and who might be interested in joining your practice in the area. Profile your team: Utilize a website and direct mail with photography of your team or host an open house or educational event. Develop a social media strategy: Share the culture of your team to encourage prospective referrals for service and for recruiting.

DESIGNING THE MODEL

It is essential to determine the size of the practice needed. The volume of patients who will be seen on a daily, nightly, and monthly basis determines the size of the practice. Next, assess the number of physicians required to meet the needs of the practice based on that estimated patient volume. The number of physicians depends on what is considered an acceptable workload of patients to manage per day, per night, and per month. To determine the number of patients, define the average number of admissions per day. If the emergency department uses a tracking tool, review the data to project the number of unassigned patients based on historical data. In many hospitals, these data are not accessible prior to initiating a program. Historically, the ward clerks simply entered the admitting physician’s name in the hospital information system without mention of the fact that the patient did not have a primary care physician. It is essential to have a way to track the types of patients by referral type (eg, by PCP, unassigned, or consultations) when the hospitalist program begins operation.

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In addition to determining the volume of unassigned patients, estimate the number of PCPs interested in turning over care. The only risk of double counting is if no hospitalist program existed before a new program starting up. Typically, in that scenario, the primary care provider was also likely cover unassigned patients.

After determining the number of admissions per year, divide the admissions by 365 days per year to obtain a rough estimate of the number of physicians required. Then take the average length of stay for the patients and add 1 extra for the day of discharge. Take this number and multiply it by the number of admissions per day to determine the 7:00 AM census. For example, if there are five admissions per day with an average 4-day length of stay, the 7:00 AM census would be calculated as 5 × (4 ALOS + 1) = 25 patients at 7:00 AM. With the 7:00 AM census determined, calculate the number of the physicians per morning required for the hospitalist program.

There is much debate over the most appropriate census for the physician who begins rounding at 7:00 AM. In general, based on a typical mix of a few ICU patients and the balance of the load being medical patients, a hospitalist can manage 15 patients safely and efficiently. This number varies considerably due to the different agendas, acuity of patients, concomitant responsibilities such as rapid response teams, code teams, teaching, and goals of practices. To achieve the objectives of early discharge, multiple visits a day and a considerable amount of committee involvement, hospitalists can maintain a census in the range of 14 to 15 patients. If the goal is productivity, and in some cases the use of advanced practitioner providers (APPs), the volume per hospitalist may be as high as 20 patients per day. Some practices define the census as the number of encounters per day, which include new admissions as well as discharges.

In a pure productivity-driven private practice model, the night shifts are often covered from home (eg, only coming back to the hospital for emergencies). This typically also means that the day-shift doctors might share night call, even after working all day. In many practices today, the night shift is covered by a separate physician, a nocturnist, due to the volume of admissions at night and the volume of cross-cover work needed.

In general, the billing revenue of a nocturnist hospitalist is lower than a day-shift hospitalist.

A highly prevalent hospital-employed and national group practice model includes a schedule in which the hospitalist physician is on duty for 12 hours, 7 days a week and the following week the physicians is off for 7 days. There are also hybrid arrangements in which the physician works about the same total number of hours per month but with shorter periods of time on duty. In such a model, a 7:00 AM census of 25 to 30 patients would likely have six full-time physicians. In contrast, a private group model may take every fourth night of call from home, which could be managed with four full-time physicians on the team. The marketplace supply and demand for physicians and goals of various clients (eg, a hospital, HMO, or payor) often dictates the type of model required.

DETERMINING THE COST AND DIRECT COST OF THE HOSPITALIST PROGRAM

Calculating the cost of a hospitalist program includes direct labor costs: salaries of the providers, benefits cost, malpractice coverage, and billing costs. The volume of patient visits, the payer mix, and the distribution of CPT codes reported determine the direct patient care revenues of the practice. The medical director who typically has responsibility for driving hospital outcomes determines any additional revenues. According to a survey conducted by the Society of Hospital Medicine in 2014, 89.3% of hospitalist programs

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required a subsidy or fee to help with the payer mix of the unassigned patients, night call coverage in-house, and for those organizations that focus on driving performance through service offerings. The ranges of fees hospitals pay range from $0 per year to $250,000 per physician annually. Fees are typically based on scope of work and payer mix.

SETTING THE COMPENSATION MODEL

In conjunction with determining the cost of the program, a compensation model must be established. In the past decade, two significant challenges drove hospitalist compensation: an imbalance of supply and demand, coupled with the rapid rise of salaries that began escalating in 2001. This phenomenon has created a significant compression in salaries. Often the least experienced physician’s compensation is closely aligned with the most experienced physicians in the practice. This compensation compression creates a dichotomy in the reward system on physician skill and experience levels creating challenging team dynamics. There are two primary models: a productivity model or a salary model. Many salary models also include a component of compensation focused on productivity and quality metrics as well as outcomes.

Recruiting a team of physicians and hiring a leader is a critical core competency for every hospitalist practice as discussed in Chapter 25. Acquiring effective recruiting techniques is an area of investment that should not be minimized or overlooked in the development of a strong hospitalist practice.

GROWING A HOSPITALIST PRACTICE SETTING PRIORITIES FOR GROWTH

Once the practice launches, priorities must be established for the growth of the hospitalist program. If the unassigned patients are already covered in the practice, the next step could be a myriad of other opportunities, including contracting with PCP practices. It is essential to understand the scope of growth and prepare in advance of the patients’ arrival. Many practices have failed or imploded by taking on more growth than they could handle. If there is a desire to handle 15 more patients per day with a 7 days on/7 days off model, it might be as simple as figuring out the need to hire two more physicians. However, if the program is already quite busy and adding three to four new admissions per day is in the growth plan, adding an admitting shift may be called for as well.

PRACTICE POINT Use these common areas of practice management and determine whether you are prepared to grow. Reflect about your hospitalist practice:

What are your priorities? What are your goals and core values? What effort can you invest to grow?

What are the expectations of external interests?

Performance measures.

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Satisfaction of outside primary care physician groups. The Joint Commission requirements. ACGME. Public performance reporting, obtaining ≥ 90% core measure scores.

What is your work environment saying about the practice?

Patient safety, quality, satisfaction. Efficiency of care. Career satisfaction that integrates core values. Service excellence and patient safety. Continuous quality improvement and innovation. Professional growth, leadership, and scholarship.

What are the expectations of hospital management?

Caring for unassigned/uncompensated patients. Reducing ALOS for top 10 DRGs by hospitalist discharge volume. 24/7 service demands. Reducing practice variation of hospitalists. Hospitalist training on palliative care, end-of-life, and other medical specialties. Development of a comanagement consulting service or a preoperative testing center. Improvement of patient ED to floor times. Care of admitted patients in the ED. Managing the chest pain unit or rapid admission team. Improvement of chart documentation for core measures (such as smoking cessation counseling). Improvement of billing for services provided. Leadership of rapid response teams for ill inpatients. Development of a transitional care program to address continuity of care in postacute facilities or providing care in the patient’s home.

Does the practice have these evaluations and measurements in place? Report card for hospitalists. Primary care physician survey. Multiyear strategic planning, quarterly reports. Hospitalist career satisfaction survey. Hospitalist annual retreat with management to establish goals. Develop a 3-year plan for a hospitalist service that mirrors the hospital’s multiyear plan. Create a meaningful, motivating, and achievable blueprint for clinical enterprise.

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Proactively support mission of patient care, quality improvement, and patient-centered care.

DEFINING KEY STAKEHOLDERS

The key stakeholders in the practice need to be clearly defined. Certainly, the doctors and advanced practice team members in the practice are key stakeholders, but in many practices the hospital administration is also a key stakeholder. Identifying priorities is much like a game of chess. For example, if you choose to help solve another primary care group’s needs before helping the orthopedic group with comanagement needs there may be repercussions. You should expect that the hospital administrator want to weigh in on how this decision impacts the hospital and its development plans.

INCORPORATING ADVANCED PRACTITIONER PROVIDERS

Another key decision for program growth is how to incorporate advanced practice providers in the practice. While this topic is covered in the literature, there are plenty of mixed opinions on the use of advanced practice providers in the inpatient setting. We have found two main areas of optimal benefit in our practices.

The first benefit for incorporating nurse practitioners (NPs) and physician assistants (PAs) is in very small programs of four full-time physicians with a daily census that can have dramatic swings around the average. The cost of an NP or PA provider is about one- half the labor cost of a physician, and this can be a cost-effective way to leverage the existing physician coverage.

There is also a benefit from the use of advanced practice providers (APPs) in very large programs, particularly in the management of surgical patients for their comorbid conditions. Many practices have incorporated APPs due to the physician shortage and a failure to recruit and retain high-quality physicians. One unique challenge is that many APP’s value comes from their experience. An APP practicing in the acute care setting for 10 years is much more likely to be able to function as a hospitalist than a new graduate APP. For hospitalist physicians, there is clearly value and competency in new a physician starting to work directly upon completing their training. It is crucial to understand both the state and hospital-specific by-laws associated with the use of NPs and PAs. Without such understanding, the proposed program plan could be rejected by the hospital. For example, if the rules state that the NPs’ work must be signed off and reviewed by a hospitalist it does not create the same workforce multiplier as a site where on the right patients, the NP can operate relatively independently.

TYPES OF PHYSICIANS IN THE PRACTICE

Another area of importance in growing a hospitalist practice involves the types of physicians utilized. It is becoming more common to have family medicine-trained hospitalists practicing alongside internal medicine hospitalists in the same practice. Much has been debated on this topic and today nearly 10% of hospitalists nationwide are family medicine trained. Factors that go into the determination to hire them include their comfort level with ICU patients and their experience managing the higher-level acuity patients. Another challenge is their ability to navigate the local politics associated with an internal medicine outpatient practice referring its inpatient practice to a family medicine physician.

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We have found that the experience of the provider trumps all board certification. There are plenty of internal medicine physicians unqualified to practice as hospitalists as well.

THE PROS AND CONS OF CAPS ON SERVICES

During the hospitalist practice growth phase, the group must be able to handle all of the new patients it agreed to accept or have a Plan B. Plan B might include a floodgate that closes in the form of a cap. This has been achieved at some hospitals to maintain safe and effective volumes. Two types of caps exist including those requiring a backup system. The backup system can be the existing hospitalists at a very high labor cost to a hospital or the new group of primary care physicians who have asked for coverage; this group may need to agree to provide occasional coverage at the hospital. The latter group of physicians tends to be a short-term patch; they can quickly lose their skills and credentialing in the inpatient setting. Ideally, if the hospitalist group has agreed to accept a new group of patients, they need to have the capacity 24 hours per day, 7 days per week. A “sick call” rotation to cover anticipated maternity and paternity leaves as well as unexpected absences may have the benefit of allowing hospitalists to focus on career development, especially quality improvement initiatives when they are not seeing patients, and not overwhelming them with service obligations.

MANAGING THE HOSPITALIST PRACTICE SELECTING THE RIGHT LEADERSHIP AND STRUCTURE

There is a shortage of high-quality physician leaders in the United States. To properly manage the practice, it is critical to appoint the most capable physician leader and establish an effective practice structure. The hospitalist leaders’ roles are complex; they not only serve the hospitalists’ team but also play significant roles within the hospital. In these roles, hospitalist directors are the most connected to how things work on a daily basis. Strong hospitalist physician leaders must lead by example. They must have effective organizational skills, be great communicators, and seek win-win situations for the hospitalist team, medical staff, and hospital. Hospitalist leaders also need to be aware of the professional goals of their members and delegate some responsibilities so that each member can also flourish and find a professional niche within the organization. Hospitalist directors may become isolated in their role, so it is important to ensure that they have advocates or mentors who can promote their agendas as well as provide counseling related to hospital politics. See Chapter 6: Leadership.

Many hospitalist programs include a version of shift work. This type of schedule combined with the Generation Y culture in medical school today, centered on work hours and patient volume restrictions, have led to a unique challenge in hospital medicine. Many physicians seek direct employment models. They place a very high level of value for time off. This can make it challenging to engage them in what matters to make a practice successful. Ensuring the right fit begins with the initial interview when performance expectations are clearly articulated.

CREATING AN OWNERSHIP MENTALITY

Like any small business, an ownership mentality is essential to the success of the hospitalist practice. It is ideal to introduce the importance of the ownership mentality expected during the hiring process. Those applicants who give solid examples of times in

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their career where they got involved, highlight scenarios when they did things because they thought no one else could do it better, and are passionate about those experiences is telling of their potential. These are typically indicators that the physician is the type of hospitalist who can make the practice excel. Defining the behaviors that support the values of the practice and then evaluating and rewarding those behaviors goes a long way to reinforcing what is important. For example, if participating in hospitalist committees is important and it can be rewarded as part of how the productivity dollars are allotted. Leading a hospital committee or playing a leadership role within the medical staff could be rewarded to an even greater extent.

SETTING UP THE RIGHT PROCESSES

Part of managing the practice is ensuring that the right processes are in place. Processes should be established for physician scheduling and daily case management meetings. Hospitalist processes should be highly sophisticated to drive improvements in utilization, documentation, discharge planning, and prospective quality metric monitoring. All of these processes require a tremendous amount of time, energy, and in many cases, technology and infrastructure to drive clinical and financial performance for the hospital and hospitalist practice.