The mission of the University HealthSystem Consortium, based in Chicago, is “to advance knowledge, foster collaboration, and promote change to help members succeed in their respective markets. UHC’s vision is to be a catalyst for change, accelerating the achievement of clinical and operational excellence.” (www.uhc.edu).
As part of UHC’s improvement and effectiveness initiatives, a benchmarking project (“Role of the Hospitalist 2006 Benchmarking Project Performance Scorecard”) was undertaken during the summer and fall of 2006 to examine what hospitalists nationwide do, as well as how they are incorporated into patient care and how they are funded by member hospitals. The benchmarking project articulated how hospitalist programs are measured and what they do to add value to their member organizations.
A seven-person steering committee was selected to provide guidance. Under the direction of Danielle Carrier, MBA, project manager, Operations Improvement; UHC, the committee developed a survey of hospitalist program characteristics, hospitalist value self-assessment, and hospitalist innovative strategies. Twenty-three member organizations participated.
The most common reason for starting a hospitalist program was improving efficiency and reducing length of stay through enhanced on-site availability; however, the impetus for hospitalist services has changed in 81% of responding organizations. The most common changes were increasing the focus on teaching and academic pursuits, quality, and safety, and providing coverage for services to facilitate Accreditation Council for Graduate Medical Education (ACGME) compliance, including co-management of surgical patients. The direction of change differed by the age of the program and the hospitalist model (teaching, non-teaching, and mixed models).
The benchmarking project articulated the value that hospitalist programs bring to their organizations:
- Quality improvement initiatives (development of protocols or pathways, standardization of care, medication reconciliation, enhanced glycemic control, and physician availability at care transitions such as ICU and emergency department [ED], as well as for pre-operative consults);
- Development of new services (palliative care programs, surgical co-management); and
- Improvement of the educational process (through more contact with faculty, multidisciplinary team rounding, curriculum development around the core competencies, hospitalist training programs, and practice-based learning).
Of the respondents, 95% report that hospitalists assume leadership roles in quality and safety initiatives. For the key stakeholders (senior administrator or department chair) the aspects of the hospitalist program that bring the most value are quality of care and safety, throughput and LOS, and expanded admission capacity and coverage.
Measures of success include length of stay, relative value units and service workload, teaching evaluations, admission and consult volume, costs and cost savings, core measures and national quality indicators, patient satisfaction, referring physician satisfaction, and academic productivity.
Information on hospitalist program funding indicated the following:
- Sole funding of salaries by the hospital: 45% of respondents; and
- Joint funding (hospital and another organization such as a medical school, a practice plan, or a clinical department): 50% of respondents.
Although no organization offers incentives for the program itself, 35% of organizations offer incentives for individual hospitalists. Incentives for individual hospitalists include productivity and relative value units, LOS, budget, quality measures, and weekend work. Two-thirds of organizations with individual incentives reported that the incentives have altered behavior or helped achieve program objectives.
The survey of workload and schedule was notable for the following:
- An annual average of 10 weeks of protected non-direct patient-care time per hospitalist is offered at 52% percent of programs;
- A full-time hospitalist spends an average of 23 weeks attending on inpatient units; and
- Time spent on average for hospitalists: 2.5% administrative, 4.9% quality, 5.3% research, 14.9% teaching, 2.6% outpatient care.
Areas in which the hospitalist program needs to play a stronger or increased role include quality improvement and patient safety, non-internal medicine services, clinical education, research, and leadership within the health system. There was no major variation among hospital administrator and chair of medicine responses. Program directors of three years or less identified quality improvement and standardizing care as areas that need more emphasis. Program directors of more than three years identified quality, research, and health system leadership as areas they’d like to gain a more significant role.
The most common impediment to the continuation and growth of hospitalist programs: attracting and retaining physicians, given the ratio of salary to workload, the level of burnout, and the lack of a defined career path. Attracting quality candidates with academic skills and/or the ability to lead and manage change was identified as a major impediment.
- Cultural and political issues;
- Inadequate commitment or support for the program;
- Lack of understanding with regard to the role of the hospitalist and the true value of the program;
- Lack of organizational clarity of program goals, expectations, and measures of success; and
- Improvement of academic and scholarly aspects of the program.
The “Role of the Hospitalist 2006 Benchmarking Project Performance Scorecard.” reported on the need to proactively manage the program direction and growth by developing and expanding lines of business, which may include:
- Non-internal medicine services such as co-management models, pre-operative clinics, and anticoagulation clinics;
- Palliative care services;
- Quality and safety improvement efforts;
- Facilitation of admissions from the emergency department and transfers both within and outside the network; and
- Care of extended care facility patients.
Hospitalist program satisfaction in academic models may be enhanced by increasing the academic and research presence and by supporting the role of the hospitalist in quality improvement. In addition, the project identifies the need to effectively manage increasing demand for hospitalists for other service lines.
Articulating the hospitalist program’s value is the first step in obtaining the resources to proactively manage the program’s direction and growth. UHC recommends clearly defining the hospitalist program goals, expectations, and measures of success. This requires obtaining input and buy-in from all key stakeholders and developing measures for all key aspects of the program, including intangible contributions. Key stakeholders should meet regularly with hospitalists to discuss program accomplishments. Hospitalist program representatives should assume leadership roles within the hospital and medical staff. For example, hospitalists should become members of the medical staff executive committee and the hospital’s operational committee, interwoven into the fabric of the hospital. It is also important to identify and monitor measures to support program funding and support, as well as to create a business case for new program roles.
Enhancing hospitalist career development and advancement is central to the recruitment and retention of experienced hospitalists. Development of effective recruitment and retention strategies includes creating a hospitalist career path, offering protected time for non-direct patient care activities, implementing innovative strategies to manage night and weekend coverage, defining and monitoring workload indicators, building reward and recognition programs, and implementing incentive programs. Training and education curriculum should focus on the needs of hospitalists and should include modules in areas of program growth such as palliative care and surgical co-management. TH