John Nelson, MD, a hospitalist and consultant in Bellevue, Wash., co-founder of SHM, and columnist for The Hospitalist, points out some other common causes of hospitalist program collapse, including the failure to appreciate how rapidly the program will grow or to have a plan for how to deal with growth. “It doesn’t take a year to reach your projections,” he advises. “Suddenly, you’ve got a bigger caseload than the original doctors can handle. They get overwhelmed and burned out and then leave.”
If the hospitalists feel no ownership or personal investment in the practice’s success, they may develop a kind of civil service mentality about the job instead of a customer service mindset, says Dr. Nelson. Combine that with a straight salary instead of productivity incentives, and they may lack the necessary commitment to the program’s quality and growth.
“I also work as a consultant to help other hospitals start hospitalist practices. I’ve had a lot of experience with programs that never got off the ground,” he says. In one case, staff did an analysis to find out how much it would cost to support the program and then decided not to go forward. In that case, the hospital was reimbursed more on per diems than diagnosis-related groups, so reduced lengths of stay would not have benefited the facility.
In other cases, hospitals have not gone forward because of local medical politics or unfounded suspicions about hospital medicine. The dominant local multi-specialty group may insist on operating the hospitalist program itself, refusing to let anyone else do it. But the group makes unrealistic assumptions about workload or else wants to charge the same high overhead rate to the hospitalists that its clinic doctors pay, which is not feasible for a hospitalist program.
“I came to my current position because of a medical group that wanted to control the hospital medicine practice,” says Dr. Nelson. “But then they got busy and exhausted and wanted to quit being hospitalists. At that point, the hospital administrator panicked.”
Learn from Success
Thweatt believes that the hospitalist program at Lewis-Gale Medical Center, which now directly employs the hospitalists, is doing well, with seven full-time dedicated hospitalists. “Not that it’s always easy, but it’s no different than running any other business. If this program went away tomorrow, I think I’d be tarred and feathered by the medical staff,” he quips.
Dr. Patolia adds that the program has a compensation structure based entirely on productivity and a schedule that ensures 24-hour coverage. “We work as a team, and we depend on each other so much. We’re all committed people who want to be hospitalists,” he says. “Right now, I love being a hospitalist to such a degree that I can’t imagine doing anything else.”
Recently, a senior vice president from the hospital’s parent company, Hospital Corporation of America (HCA), visited Lewis-Gale to learn how to replicate its successful hospitalist program in all HCA hospitals.
Jon Ness, now chief operating officer of Billings Clinic in Billings, Mont., says one of the first things he did in his new job was to develop a hospitalist program. “I brought in Roger Heroux to do the evaluation,” he says. The process followed a familiar checklist: defining program goals, lining up clinic and hospital support, assessing manpower needs, and developing a data support system.
The Billings program was launched in January 2006 and today employs six full-time hospitalists. In contrast to the early days at Lewis-Gale, however, “we started out with a strong, deep business plan.”
For more information on the Fourth Generation hospitalist practice, contact Roger Heroux, Partner, Hospitalist Management Resources, LLC, 5490 Creighton Ct., Colorado Springs, CO 80918, 719/331-7119, or [email protected]. Visit the Society of Hospital Medicine Web site (www.hospitalmedicine.org) for information on practice management courses and other educational resources, including audiotapes of “Best Practices in Managing a Hospital Medicine Program.” TH