Bill Fletcher, CHCC’s director of outcomes and research, has the numbers to support hospitalist efficiency. He explains that hospitalists’ contribution margin, the amount their service line contributes toward overhead, exceeds $500 per patient. With 12,000 inpatients a year, a ballpark estimate of the hospitalists’ contribution if they only saw 60% of them would be $3.6 million, although Fletcher wouldn’t confirm specifics.
“The hospitalists’ contribution is golden. Unlike cardiac surgery, whose high costs could never generate such [a] margin, the hospitalists create enormous value for us,” says Fletcher.
A key efficiency component is compliance with clinical pathways. Fletcher tracks CHCC’s performance against national standards (www.leap froggroup.org) and with its own pathways. “We don’t measure our hospitalists’ performance a lot because they’re so integrated into the hospital,” he says. “But we look at compliance with our 25 clinical pathways [by examining] each case, by [looking at] diagnosis, and [by making sure] it fits the pathway.”
Here’s how the hospitalists stacked up:
Suntrapak reckons the process works. “Our hospitalists are giving excellent, efficient care—particularly with high-volume diagnoses such as asthma, appendectomy, and bronchiolitis,” he notes. With regard to adherence to pathways, Dr. Calhoun says, “If we worked in a vacuum, I wouldn’t like that kind of tracking, but we realize how much is saved by using them.”
In addition to hospitalists standardizing treatment for 25 conditions as a way to promote efficiency, the physicians find that pathways and standing orders free nurses by clearly delineating clinical responsibilities. “Pathways allow nurses to do what they’re trained and authorized to do. By spelling this out clearly, the pathways have cut our pager calls by 50 percent,” notes Dr. Calhoun.
On a systemic level, hospitalists contribute by analyzing data and then recommending ways in which CHCC’s precious resources can be allocated most effectively. For example, this year hospitalists are serving on four bed management subcommittees dedicated to streamlining patient throughput, attempting to flatten barriers to moving kids efficiently from the emergency department (ED) to general floors or ICU and through discharge. Dr. Calhoun’s work group is penning criteria for prioritizing the list of potential recipients of CHCC’s next scarce available bed—will it be a small community hospital, a doctor’s office, or a tertiary care hospital?
Scheduling, a Pleasant Surprise
The hospitalists work a 12-hour block schedule, with seven days on and seven days off, but Dr. Fields says “it works for us because it feels like we have the luxury of a lot of time off.” The doctors are good friends, going scuba diving, traveling, and camping together, and their kids have playdates. Dr. Fields admits that doctors near burnout in the hectic winter months when census climbs, but the friendships among colleagues pull them through. “If someone’s mother is dying, or their children are sick, they know that they’re covered because we’re friends,” he says.
Paul Parker, MD, a group member who commutes from San Diego, does the scheduling three months in advance so that the physicians can plan their lives. All hospitalists have one vacation request guaranteed, and holiday coverage is distributed equitably.
Dr. Diaz points to the positive effect of one unusual twist—starting rotations on Friday. “You learn about patients from your colleagues before the weekend, knowing that major procedures won’t happen until Monday,” he says. “It promotes efficiency, because you can discharge patients on Friday without discharging on Saturday or Sunday, which gets complicated.”
Other ideas that promote efficiency and job satisfaction include running code blues from the ICU, spending only one-half day admitting from the ED, giving night shifts to the doctors who like them, and serving as teaching attendings.