Hospitals face a range of critical issues and need members of their medical staff to assume a role in addressing them. These concerns include declining payments and pressures on the bottom line; staffing shortages and dissatisfaction; questions about quality and patient safety; constantly changing technologies; employer and consumer demands for performance metrics; capacity constraints; and increased competition from independent, niche providers of clinical services.
Many physicians are no longer able or willing to serve on hospital committees or play a leadership role for the medical staff. As a result of the pressures of lost income, managed care requirements, on-call responsibilities, and competition for patients, as well as life-style concerns, many physicians are reluctant to perform volunteer work that hospitals used to take for granted. A 2004 survey of CEOs and physician leaders at 55 hospitals in the Northeast conducted by Mitretek, a healthcare consulting firm, noted that “volunteerism is dead.” Physicians expect to be paid for time spent on hospital business. Sixty-four percent of the respondents said their hospitals compensate physicians to serve as officers or department heads (1).
“It used to be that most doctors needed the hospital to be successful; now that is not the case,” says Larry Wellikson, MD, CEO of the Society of Hospital Medicine (SHM), the national professional society for hospitalists. Trends have shifted and a growing number of specialists do not even practice in the hospital (2).
Hospitalists: Stepping Up to the Medical Staff Leadership Challenge
Wellikson predicts that doctors on the hospital’s “home team” – hospitalists, intensivists, and emergency department physicians – will assume more prominent positions on hospital committees. Hospitalists emerge as strong candidates for providing medical staff leadership for the following reasons:
- Hospitalists spend the majority of their time in the in-patient environment, making them familiar with hospital systems, policies, services, departments, and staff.
- Hospitalists are inpatient experts who possess clinical credibility when addressing key issues regarding the inpatient environment.
- Many hospitalists are hospital employees who can understand the tradeoffs involved in balancing the needs of the institution with those of the medical staff. Even hospitalists not employed by the hospital have an intimate knowledge of the issues that the hospital is facing and are invested in finding solutions to these problems.
Figure 1. describes a range of roles that a hospitalist could assume and a range of topics that a hospitalist could address in providing medical staff leadership in a hospital.
The left side of the diagram describes three leadership roles that a hospitalist might play in the hospital. First, a hospitalist can volunteer to participate on a hospital committee, either as a member of the committee or as its chairperson. Second, a hospitalist can volunteer to work on a hospital project, either in a staff/expert role or in the role of project leader. Third, a hospitalist can assume a direct administrative role in the hospital, directing a service or program.
Whether it is through a committee, project, or direct administrative responsibility, a hospitalist has the knowledge and expertise to become involved in a wide range of hospital issues. As characterized on the right side of Figure 1, these topics include:
- Practice Guidelines: Many hospitals have adopted practice guidelines as a tool for improving the quality and efficiency of care. When properly developed, guidelines can improve patient safety, facilitate the adoption of best practices, and reduce hospital costs. Hospitalists can be asked to participate in all aspects of guideline development, including research, authorship, implementation, outcome measurement, and on-going revision and educational efforts.
- Utilization Review: Hospitals or medical groups routinely arrange for physicians to perform utilization review or improve the utilization review process. A hospitalist can: 1) facilitate the discharge process for individual patients, reducing length of stay and hospital costs; and 2) globally improve throughput by identifying and addressing system problems that create inefficiencies in the patient care or discharge process (e.g., paperwork or dictations not completed on time, poor communication across healthcare team disciplines, administrative deficiencies that delay therapies, etc.).
- Patient Satisfaction: Hospitals are increasingly being asked to capture and disseminate performance metrics so that employers and consumers can make informed decisions about their provider of choice. Patient satisfaction is a key measure of a hospital’s performance. Hospitalists can become engaged in efforts to review patient satisfaction survey results, identify problems, and propose/implement solutions.
- Quality Improvement: Many hospitals look to hospitalists to become involved in or lead the hospital’s quality improvement (QI) efforts. Specific activities may include championing individual QI projects, working with QI staff to develop and analyze outcomes data, educating colleagues regarding new projects and protocols, etc.
- Patient Safety: Preventing harmful errors from occurring in the inpatient environment has become a major priority for the hospitals across the country. Identifying the causes of these errors and developing methods of error prevention require detailed investigations and analyses of the diagnostic and/or treatment process. Increasingly, hospitalists are being asked to provide leadership to patient safety initiatives.
- Compliance: Hospitals must comply with many federal, state, and local rules and regulations. For example, a great deal of coordination and planning is required to meet the requirements of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Health Insurance Portability and Accountability Act (HIPAA) of 1996, and/or the Accreditation Council for Graduate Medical Education (ACGME). In some hospitals, hospitalists assume leadership roles in these compliance efforts.
- Disaster Planning: Hospitals need to demonstrate the ability to respond to a range of potential crises, including those related to bioterrorism, industrial accidents, and natural disasters (e.g., hurricanes, tornados, and earthquakes). In light of their knowledge of patient flow, hospitalists can be asked to work with emergency physicians to do disaster planning for the hospital and the local region.
- Information Systems: Several organizations have issued reports identifying information technology as a critical tool for improving healthcare quality (e.g., Institute of Medicine [IOM], the Leapfrog Group, eHealth Initiative, the Markle Foundation, and the Federal Office of the National Coordinator for Health Information Technology). Hospitals are being encouraged and incentivized to implement electronic health records (EHRs) and computerized physician order entry (CPOE) systems. Implementing these systems requires significant clinical input. Many hospitals have asked hospitalists to champion and lead the implementation process of new information systems.
- Nursing/Physician Assistant Staffing: There exists a wide range of roles for nurses and physician assistants in the inpatient setting. Every institution needs to find a staffing model that is efficient, effective, and results in provider satisfaction. Hospitalists are considered leaders of the inpatient medical team and can be asked to help design and evaluate staffing models.