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A Program in Transition


 

We work best when we remember who hired us and why. As hospital medicine matures, the goals of those who write the paychecks will continue to shape programs, even when this basic economic truth may be obscured by a program’s fast growth. That is why the 10 hospitalists at Nashua-based Southern New Hampshire Medical Center (SNHMC) work differently than their peers in other systems. They are employed by a unique joint venture of New Hampshire’s two largest multispecialty medical groups: Foundation Medical Partners of Nashua and Lebanon-based Dartmouth-Hitchcock.

The 10 SNHMC hospitalists (left to right): back row: Matthew Brier, MD, MPH, Bernard Kim, MD, Ajay Nanvati, MD, Stewart Fulton, DO. Third row: Susan Alicia Hilburn, MD, Ashima Handa, MD, Ashwin Swami, MD. Second row: Joohahn John Kim, MD, Amena Nazeer, MD. Front: Suneetha Kamilla, MD

The 10 SNHMC hospitalists (left to right): back row: Matthew Brier, MD, MPH, Bernard Kim, MD, Ajay Nanvati, MD, Stewart Fulton, DO. Third row: Susan Alicia Hilburn, MD, Ashima Handa, MD, Ashwin Swami, MD. Second row: Joohahn John Kim, MD, Amena Nazeer, MD. Front: Suneetha Kamilla, MD

Population Growth

The SNHMC hospital medicine group filled a definite need. As Tom Wilhelmson, SNHMC’s CEO and president explains it, Nashua’s population has grown tremendously—25% in the 1980s and an additional 14% in the 1990s—thanks to an influx of young families and industries relocating to business-friendly New Hampshire. During the growth spurt the area needed doctors—particularly primary care physicians. To attract physicians, in 1992 the hospital helped form Foundation Medical Partners (FMP), a large multispecialty group. Based on a private practice model, FMP physicians now cover 22 suburbs in the primary and nine in secondary service areas that serve 225,000 people. SNHMC is FMP’s safety net, negotiating malpractice rates, giving physicians access to capital, and helping with cash flow when a big payer is slow.

The hospital and FMP grew steadily, boosting hospital market share from 40% in the 1980s to 62% today. Michael Marshall, MD, medical director of the 134-physician FMP, saw it thrive.

“We were opening offices farther and farther from the hospital,” he recalls. “In 2002, when doctors’ drive times exceeded 30 minutes, we realized that hospitalists could relieve primary care doctors from hospital work.”

Doubling the number of hospitalists so quickly raised new issues. Divided into two teams of five, each group had little contact with the other team or with their FMP partners. To bridge the divide, shortly after the hospitalist cadre grew to 10, administrators threw an after-hours cocktail party for medical staff to build camaraderie among all FMP physicians.

Issues, Options, and Resolutions

SNHMC and FMP considered these options for starting a hospitalist program:

Issue: Starting a hospitalist program from scratch.

Options:

  • Hire them as hospital employees;
  • Contract with a regional or national hospitalist company;
  • Encourage formation of a hospital medicine group;
  • Worry about Dartmouth-Hitchcock starting a program; or
  • Make hospitalists FMP partners.

Resolution: Hospitalists would be FMP partners; therefore, approach Dartmouth-Hitchcock about a joint venture hospitalist program.

At the time, Dartmouth-Hitchcock, New Hampshire’s only academic medical center and FMP’s chief competition had made significant inroads in Nashua. Dartmouth-Hitchcock embraced the joint venture along with an even split of any necessary subsidies. In 2003 Wilhelmson and Dr. Marshall hired Stewart Fulton, DO, and a second career physician straight from residency, as their hospitalist medical director.

Dr. Fulton was the solo hospitalist and had a goal of assuming hospital duties for 20+ family care physicians in his first year:

Issue: Freeing a large number of primary care physicians from hospital rounds.

Specific problems:

  • Dr. Fulton’s pager went off incessantly;
  • He was inundated with work;
  • He routinely worked 12-hour days and longer; and
  • Many FMP physicians still made hospital rounds and covered call to handle patient volume.

Resolution: Hire more hospitalists.

Expert Advice on Managing Growth

Handling a hospitalist program’s growth effectively is a minefield—one that managers should navigate with guidance from change masters. Here are some pointers from experts:

John Nelson, MD, director of the hospitalist practice for Overlake Hospital of Bellevue, Wash., and columnist for “Practice Management,” (see p. 69) says:

  • The popular 7-on/7-off schedule might paradoxically increase burnout. “Such a schedule has the doctor working a low number of days over the year, leading to the need to see many patients during the seven days on to keep the practice economically viable,” he explains. “Some doctors on this schedule live their lives only on their days off, leading to increased resentment of work.”
  • In most cases “a patient volume cap is a bad idea for a whole practice such that non-hospitalists are obligated to help out … ,” he says. “Such a cap creates the appearance of the hospitalist practice operating like a team of residents. The other doctors probably don’t have a cap and you don’t want to stand out as the group that has to have outside help.”
  • Hospitalist practices that are growing eventually need a separate night shift because increased patient volume makes it increasingly unreasonable to take calls from home.
  • Good compensation helps with recruitment, but has little to do with long-term job satisfaction. Focusing on practice dynamics rather than pay may ensure happy doctors and thriving practices.

Billie Blair, PhD, president/CEO of Leading and Learning, Inc. of Temecula, Calif., offers these insights:

  • A business plan that projects patient/staffing loads, break-even points, and so forth as a roadmap to growth management is necessary.
  • Application of predictive algorithms is necessary for rapid growth areas (e.g., patient volume, peak admission times, number of referring physicians).
  • Creation of a flexible staffing plan in advance must be done to accommodate uneven growth in the early years.
  • Use of directed management coaching can support hospitalist leaders.
  • Hospitalists need strong in-house education program or regular training opportunities to address growth and greater levels of program complexity.—MP

Suneetha Kammila, MD, straight out of residency, became FMP’s second hospitalist. “All was chaos,” recalls Dr. Kammila. “The hospital was very busy; there was no proper system to get the census or see lab work; and we ran from floor to floor. I stayed because Stewart [Fulton] and I worked well together, and I thought we’d eventually succeed.”

Issue: Adding a second hospitalist.

Potential results:

  • Hospitalists could see more patients;
  • Inadequate systems could not be changed this soon;
  • Specialists could be enlisted to deal with the volume of patients.

Resolution: Hire more hospitalists.

Soon after Dr. Kammila’s arrival, FMP added a third hospitalist who didn’t gel. “We increased our patient volume, but the third hire wasn’t a good communicator and didn’t fit. I couldn’t leave the hospital until 8 p.m. most days and I was exhausted,” says Dr. Fulton.

Joohahn John Kim, MD, became the replacement third hospitalist and meshed with Drs. Fulton and Kammila. Soon two additional hospitalists came on board. Eighteen months into the program, there were five hospitalists—a critical mass.

Issue: Growing the hospitalist group to critical mass and beyond.

Results:

  • More bodies enabled hospitalists to have defined shifts;
  • The laid-back personalities of the hospitalists emerged, and they forged a strong collegiality;
  • They covered several more office practices;
  • They began to interact more with other hospitalists and less with specialists;
  • The groundwork was set for more growth; and
  • Growth to 10 hospitalists would enable the seven on/seven off coverage that everyone wanted.

Doubling the number of hospitalists so quickly raised new issues. Divided into two teams of five, each group had little contact with the other team or with their FMP partners. To bridge the divide, shortly after the hospitalist cadre grew to 10, administrators threw an after-hours cocktail party for medical staff to build camaraderie among all FMP physicians.

Issue: Communication and continuity of care were not optimal.

Specific problems:

  • The two hospitalist teams didn’t work together;
  • Hospitalists and their office-based colleagues didn’t know each other;
  • Productivity needed to be discussed; and
  • Some long-term patients were unhappy about being treated by hospitalists rather than their primary physicians.

Resolution: More networking events to bring physicians together, along with daily e-mails from hospitalists to primary care physicians.

More contact among physicians revealed other issues. Terry Buchanan, MD, an FMP family practice physician whose three-provider office is several miles from SNHMC, is relieved that hospitalists freed him from hospital work. However, he says, “Not having hospital work gives a better quality of life, but we’ve lost income [from hospitalized patients] that we’re expected to recover with more outpatients.”

Another concern is losing clinical skills associated with acute care. “I don’t feel I’d be as marketable if I wanted a career change,” he adds.

Unique Metrics

No matter what the yardstick, measuring a hospital medicine program’s value is tough, particularly one transitioning to 24/7 coverage. Still, the familiar metrics of reducing average length of stay (ALOS), cutting costs, and quality improvement are not SNHMC’s ultimate gauge. In fact, ALOS has increased, from 4.15 days in 2004 to 4.26 days in 2005. Yet FMP and Dartmouth-Hitchcock gladly continue underwriting the gap between hospitalist compensation and revenues—a gap of about $30,000 per capita annually.

Issue: Customary hospitalist metrics are not the sole drivers at SNHMC.

Specific problems:

  • Average length of stay was up;
  • Cost cutting was not a predominant metric;
  • Volume and productivity were not chief metrics; and
  • Joint venture partners continued to subsidize the hospitalist program.

Resolution: The medical groups continue to support the hospitalist program as it adjusts to 24/7, with a commitment to add four more hospitalists.

New Hampshire: Hospital Medicine Growth Area

According to the Nashua Telegraph (10/4/2005), hospitalist programs have grown steadily in the past several years. SNHMC went from one to 10 hospitalists in less than three years, while cross-town rival St. Joseph Hospital hired four in less than one year. There are six more hospitalist programs employing 29 physicians in New Hampshire’s major cities.—MP

Downplaying customary metrics doesn’t mean that SNHMC’s hospitalists don’t compare favorably with their peers. They do. On CMS core measures for four congestive heart failure indicators, SNHMC outperforms its state counterparts by 73% versus 65%; on community-acquired pneumonia guidelines by 54%-46%; and on surgical infection prevention by 64%-53%. Only on the six benchmarks for treating myocardial infarction does SNHMC fall short, by 85% to the 89 for other New Hampshire hospitals.

The Growth Conundrum

Moving to 24/7 coverage has challenged SNHMC, as it has other hospitalist programs. Dead time at night, when the ED and hospital floors fall silent, has to be paid for. So do the peaks and valleys of patient load.

Issue: Patient load variability makes hospitalist programs costly.

Specific Problems:

  • Admissions and discharges can bunch and create bottlenecks; and
  • Hospitalists are too busy at times and not seeing enough patients at other times.
SNHMC hosts networking events for physicians to improve communication between hospitalists and specialists/primary care physicians.

SNHMC hosts networking events for physicians to improve communication between hospitalists and specialists/primary care physicians.

Resolution: For SNHMC, examine possible response to variability, including:

  • Hire/redeploy nurses and/or secretaries for discharge paperwork;
  • Create a four-hour chest pain unit staffed by physician assistants;
  • Re-examine seven on/seven off staffing. Does another model work better?
  • Create a convenient care center separate from the ED;
  • Hire moonlighters for night shifts;
  • Serve more referring physicians to boost productivity; and/or
  • Enlist pulmonologists to assist with ED surges.

Having peeked beneath the surface of SNHMC’s hospitalist program’s performance what lies at the heart of its success—or of its failure? By conventional vision, it’s curious; ALOS actually increased, 30+ internists still cover their hospitalized patients, admissions peaks and valleys, and program subsidies for the foreseeable future.

None of that fazes Sue DeSocio, FMP’s president and COO, who laments the dearth of benchmarking tools that accurately reflect the impact of hospitalist programs.

AT SNHMC patient satisfaction and hospitalist job satisfaction are high and RN turnover is 12% lower than other New Hampshire hospitals.

“At the beginning, we were sure we had everything down pat. We’d keep the hospitalists very busy and with a complement of four, we’d break even. Not even close,” she says. But she judges the program a success, as do Dr. Marshall and Wilhelmson, because it addressed FMP’s family practice physicians’ need to focus on their outpatient practices and avoid hospital work.

Patient satisfaction and hospitalist job satisfaction are high and RN turnover is nearly 12% lower than other New Hampshire hospitals. SNHMC avoided a hospitalist turf war with a successful joint venture with its chief competitor, and, perhaps most importantly, incorporated the hospitalists into FMP’s multi-specialty practice rather than taking the easy way out with outside contracting. Or you check with Drs. Fulton and Kammila, who plunged into the chaos of a start-up, worked impossibly long days, and are still there today because they believe in how they’re practicing medicine. TH

Marlene Piturro regularly writes “Practice Profiles” for The Hospitalist.

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