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A Work in Progress


 

Most hospitalist programs start when hospital administrators realize that having physicians dedicated exclusively to inpatient care is a great idea. Administrators then recruit a lead hospitalist—perhaps a stellar performer straight from residency, a community doctor closing his office, or a doctor located through a specialty staffing group.

Colorado Permanente Medical Group (CPMG), backed by a brand as powerful as Starbucks or Nordstrom, did things differently. So imbued with the Permanente culture are its physicians that its hospitalist group arose organically from physicians serving Denver’s Exempla St. Joseph Hospital and Boulder Community Hospital. (See “Kaiser Permanente Culture,” below.)

Kaiser Permanente Culture

Kaiser Permanente physicians belong to an organization so large that outsiders have trouble grasping its reach and scope. A 2004 study comparing Permanente medical group doctors with physicians in independent practice associations and cottage industry practices showed why.

It found that Permanente physicians value quality-oriented, system-level care management tools to a much greater degree than other physicians. In the study, 22% of primary care physicians in California practiced with Permanente, 16% with other groups of 11 or more physicians, 44% were in groups of one to 10 and participated in at least one Independent Practice Association (IPA), and 18% represented the “cottage industry” sector-solo or small groups with no IPA participation.

Sixty percent of Permanente physicians received practice pattern information, while less than 25% of cottage industry doctors did. Almost all Permanente primary care physicians (PCPs) who received such information described it as very or somewhat useful, versus 79% of PCPs in other groups.

The PCPs revealed their mindset in questions about cost versus quality.

The authors concluded that “Physicians in large, integrated Permanente medical groups have adopted and used value system-level care management tools, much more so than physicians in IPA settings or traditional cottage-industry practices.”—MP

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“Thirty years ago Permanente explored building their own versus finding a cost-effective hospital. They chose us, and their clinic doctors rounded on what grew to 70% of our department of medicine patients,” says Robert Gibbons, MD, St. Joseph’s residency program director. “Then they saw they needed to provide full-time inpatient coverage—the advent of the hospitalist program. Soon many CPMG clinic doctors disappeared, but the quality of medicine remained the same.”

Regional Department Chief Lauren Fraser, MD, oversees the now-mature hospitalist program, which keeps growing in size, complexity, and competence. “We’re always a work in progress, and that’s good,” she says.

According to Joe Heaton, MD, currently a Good Samaritan hospitalist and formerly CPMG regional department chief, CPMG’s primary care departments targeted three areas for better care early in 1995: streamlining patient scheduling, developing a centralized call center, and starting a hospitalist program.

The hospitalist program aimed for cost neutrality by limiting staffing at both hospitals to the same full-time equivalents (FTEs). To avoid forcing physicians into unwelcome assignments, the department offered its 70 internal medicine and 30 family practice doctors four tracks:

  1. Track A meant full-time hospital work;
  2. Track B offered a 50-50 hospital-clinic split;
  3. Track C provided for a 70% clinic, 30% hospital schedule; and
  4. Track D was full-time clinic work.

The family medicine department opted out of hospital duty, while the internists tracked themselves as follows: eight each for full-time hospital and half-time hospital duty, 34 for 30% hospital time, and 20 for full-time clinic. Fortunately, the tracks chosen matched the hospitals’ needs, and the program was off and running by July 1995.

“At the time, our group’s size created one of the largest hospitalist programs, allowing us to provide 24/7 coverage with at least two physicians on site,” says Dr. Heaton of the launch.

The hospitalist program had immediate measurable impact. Average length of stay dropped by 15%, and Track A and C physicians had similar utilization measures, suggesting that the model of care delivery was the key driver—rather than the amount of time physicians spent in the hospital. Dr. Gibbons was impressed with the hospitalist group’s results, noting that St. Joseph’s average reduced length of stay of 0.7 to one full day was consistent with national benchmarks. Because CPMG sees only Permanente patients, St. Joseph eventually contracted with two other hospitalist groups: the Exempla Faculty Inpatient Team, which covers half of its unassigned patients, and Midtown Inpatient Medicine, private internists who cover the other half of the unassigned patients, co-manage with orthopedic surgeons, and cover for internal medicine groups that no longer make hospital rounds.

The CPMG hospitalist program had immediate measurable impact. Average length of stay dropped by 15%, and Track A and C physicians had similar utilization measures, suggesting that the model of care delivery was the key driver—rather than the amount of time physicians spent in the hospital.

CPMG hospitalists also covered Boulder Community Hospital in Denver’s rapidly expanding suburbs until 2005, when CPMG’s contract expired. All six hospitalists moved to nearby Exempla’s new Good Samaritan Hospital, where patient volume grew quickly from 25-30 patients a day to 80; 90% of the patients are Permanente members. Hospitalist staffing jumped to 13 FTEs (19 physicians). “We recruited very aggressively, including lots of locum tenens and moonlighters to cover the booming volume,” explains Brian Thom, MD, assistant regional department chief, Good Samaritan Hospital.

CMPG FAST FACTS

  • Mission: A private, salaried multi-specialty physician group, partnered with Kaiser Foundation Health Plan to form Kaiser Permanente
  • Members served: 405,000 in Denver/Boulder region
  • Health plan staff: 4,500
  • Physicians: 700
  • Medical offices (clinics): 18
  • Department of Hospital Medicine, CPMG:
  • Started in 1995;
  • Number of hospitalists: 50 full-time equivalent physicians (FTEs), 54 physicians; and
  • Board certification: 51 in internal medicine, two in internal medicine/pediatrics, one in family practice.
  • Hospitals served:
    • Exempla St. Joseph Hospital, Denver: 565 beds over 10 floors; 130 years old; residency programs in internal medicine, family practice, OB/GYN, and surgery; hospitalist daily census: 120-150 patients, 40-60 admissions
    • Exempla Good Samaritan, Lafayette, Colo.: 172 beds with a patient capacity of 350; community hospital; hospitalist daily census: 60-80 patients, 20 admissions.
CMS Quality Indicators click for large version

click for large version

More Measures

In addition to length of stay, CPMG tracks the percentage of patients discharged in less than 24 hours, readmission rates, and disease-specific mortality by provider. All hospitalists get regular reports of department averages and statistical analyses of individual physicians. “This may be controversial, but we must look at outliers to see if [the problem is] case mix, such as many hospice patients, or something else,” says Dr. Heaton.

Striving for high levels of clinical expertise and consistency is a CPMG hallmark. Working for a medical behemoth in the Denver area, CPMG doctors—whether clinic-based or hospitalists—have a huge opportunity to integrate care and to co-manage many conditions with their colleagues. Hospitalists also staff the ICUs. In 2000, William Kinnard, MD, CPMG’s ICU co-director, commented that the group’s use of data-driven protocols allowed hospitalists to practice effectively in ICUs.

As for patient satisfaction, Dr. Heaton admits to “struggling for good measures,” noting that CPMG tackled it head-on in 1999 when Executive Medical Director Jack Cochran, MD, addressed the level of patient tenacity it took to navigate CPMG. Physician career satisfaction was sinking from long chaotic workdays that left both patients and doctors frustrated. By re-engineering scheduling and visit processes, Dr. Cochran made things run more smoothly. Other initiatives included an eight-hour physician-patient interaction course, video vignettes starring CPMG doctors illustrating communication techniques, and formal physician-to-physician coaching. Dr. Fraser still sends new hires to the course, recognizing that good communication satisfies both patients and physicians.

Scheduling: Every Program’s Mt. Everest

Because of the hospitalist program’s size and longevity, physicians have experimented extensively with scheduling. As do many groups, it started with seven 12-hour days on/seven days off blocks, which proved dissatisfying both personally and professionally.

“We experimented with scheduling to find what was sustainable for physicians and provided patient continuity,” says Dr. Fraser. “We’ve found that six eight-hour days in a row of rounding works best.”

Scheduling has evolved to the point that hospitalists provide the following to meet the hospitalist’s, the group’s, and the hospital’s needs: a dedicated triage physician 24/7 to handle calls from all sources of patient flow, two hospitalists on site at all times, eight-hour rounding days, and call physicians who admit and cross-cover after 4 p.m. Average daily census (ADC) is 10-12, plus one or two admissions. While that appears low, if CPMG hospitalists worked 12-hour shifts, their ADC would be 13-16, consistent with national norms.

“Dropping to eight-hour, as opposed to 12-hour, days keeps the job sustainable and helps doctors avoid burnout,” says Dr. Fraser. “However, we work more days per month, an average of 20-22.”

Overall, the scheduling strategy is working. “The majority of physicians who started over a decade ago remain, including many mid-life hospitalists in their 40s and 50s,” she adds. Physicians, rather than administrators, handle scheduling. Dr. Fraser has found that physicians can accept that third triage shift in a month (or an extra night shift when they’re short-handed) when another physician is filling the slots.

AMI Clinical Outcomes and Physician Perception

To move medicine from cottage industry to science requires research, such as the following Permanente study. Lead researcher David Magid, MD, MPH, of Kaiser Permanente’s Denver Clinical Research Unit assessed the relationship between age and the quality of medical care provided to patients presenting with acute myocardial infarction (AMI) at emergency rooms.

In a two-year retrospective study of 2,216 patients presenting with AMI, Permanente researchers correlated administration of provision of aspirin, beta-blockers, and reperfusion therapy with patients’ age. Overall, 80.5% of patients received aspirin, 60.3% got beta-blockers, and 77.8% were given reperfusion therapy. After adjusting for demographics and clinical factors, 15% fewer older patients received aspirin therapy, 23% fewer got beta-blockers, and only 70% fewer received perfusion. The authors concluded that older patients presenting to the ED with AMI received lower quality medical care than younger patients.—MP

Other Features

All CPMG hospitalists can participate in St. Joseph’s residency program as “teaching attendings” for one month. From them, residents learn to co-manage care and participate in interdisciplinary rounds with nurses and social workers. Physicians note that residents make a hospitalist’s life smoother.

“At Good Sam, we do all our own procedures, unlike St. Joe’s, where they have residents. With our patient volumes, there’s little breathing room, especially when we have to cover non-Kaiser patients,” says Dr. Thom. Eventually, residents will rotate through Good Samaritan as well as St. Joseph.

One of the advantages of working in a brand-new hospital like Good Samaritan is establishing systems from scratch. That includes the new hospital’s electronic medical record (EMR), which is integrated with CPMG’s outpatient EMR. “We set up our own systems, complete with order sets and protocols,” explains Dr. Thom. “Considering that 90% of our patients are CPMG members, this gives us a high level of integration, clinically and electronically.”

Challenges Ahead

Despite CPMG’s size and stellar track record, challenges remain. Dr. Fraser identifies them as salaries that rank last within the group, making recruiting difficult; a hard time providing adequate back-up if a physician is unexpectedly absent; adjustments to fluctuations in patient census; time pressures of hospital committee work; and identification of an optimal scheduling model that fosters continuity of care yet provides a sustainable work life.

How to CONTACT CPMG

10350 East Dakota Avenue

Denver, CO 80231

www.kaiserpermanente.org (click “Colorado”)

The group’s size has drawbacks, which Dr. Heaton identifies as the potential for a physician to not feel mission critical or to hide, and that communication and face-to-face meetings get complicated.

“Overall, the program can always use fine tuning, but we love who we work with and have the ultimate respect for our colleagues, which is the true benchmark of the quality of a medical career,” concludes Dr. Fraser. TH

Marlene Piturro regularly writes “Practice Profile.”

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