Good Citizenship

John Nelson, MD, MHM

Hospital medicine is fortunate to have many very dedicated and professionally centered doctors who work enthusiastically to both provide excellent care to their patients and work to make their own practice and their hospital a better place. I am lucky to practice with many of them in our practice in Bellevue, Wash.

Yet a significant portion of hospitalists have chosen this work because they’re looking for relatively-low-commitment work. In essence, they see themselves as dating their practice rather than marrying it. Some of them might even say, “I thought I wanted a career. It turns out all I wanted was a paycheck.”

Most are skilled clinicians who find the energy to do a good job for the patients under their care but don’t have a mindset of owning their practice and investing time in making it perform better.

This gives rise to a dilemma: How can a practice turn these perfectly capable physicians into meaningfully engaged participants in the hospitalist practice itself and the hospital as a whole? What about a salary bonus based on good citizenship? Would that cause them to become more engaged and committed?

There is voluminous research and a whole row of books at your local Barnes & Noble that address these questions more completely that I can, so I’ll just share some real-world experience and insights from one book.

What Might a Citizenship Bonus Look Like?

There are a number of ways to consider designing a citizenship bonus. At a previous SHM practice-management course, Win Whitcomb, MD, MHM, presented one example from Mercy Medical Center in Springfield, Mass. (see Figure 1).

The following kinds of activities might be appropriate for a hospitalist to earn a citizenship bonus:

  • Active participation on approved hospital committees (e.g. the pharmacy and therapeutic committees) and regular input from and feedback to the hospitalist group (e.g. via e-mail) about relevant activities of the committee;
  • A project to improve clinical care (e.g. improved glycemic control, fall prevention, med reconciliation, discharge processes, readmission rates, ensuring follow-up of tests resulted after discharge, etc.);
  • A project to improve business operations—for example, improve our billing/coding accuracy. Such a project could be to develop a new progress note template and collect data regarding its use and effectiveness;
  • Work to improve communication and interaction with other hospital staff—for example, joint rounding with nurses, improve throughput, etc.; and
  • Project(s) to increase the group’s social cohesion and engagement with hospital initiatives and goals.

Figure 1. Mercy Medical Center, Springfield, Mass.: Hospitalist Citizenship Incentive (c. 2009)

  • Payout every six months.
  • Maximum payout is 4.4% base pay; 50% payout is 2.2% base pay.
  • To receive 100% of the payout:
    • Attend 80% or more of the QI team meetings;
    • Be physician champion and lead or co-lead the team; and
    • Report team information at designated hospitalist staff meetings:
      • Action plans for the team;
      • Team accomplishments; and
      • Data.
  • To receive 50% of the payout:
    • Attend at least 50% of the QI team meetings;
    • Be a physician champion; and
    • Provide a qualitative/descriptive report of work done.

Results after first year, 15 hospitalists:

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