Navigate the Winds of Change


When a Catholic group moved to buy Lutheran Medical Center in Wheat Ridge, Colo., just outside of Denver, hospitalist Steven Krebs, MD, had strong objections. Sisters of Charity of Leavenworth Health System already was part-owner of the 400-bed medical center. As the sole owner, it would require the hospital to follow Catholic rules regarding end-of-life care and reproductive health, meaning some medical services would be prohibited.

“It’s really the last hospital before you go into the mountains. There’s no real hospital facility until Vail, almost 100 miles up the road,” Dr. Krebs says. Patients who wanted a tubal ligation, an emergency contraceptive, or other medical services typically not offered in a Catholic hospital would have to travel to receive them—or not receive them at all.

After negotiations failed to produce a satisfactory outcome, Dr. Krebs took the drastic step of becoming part of a lawsuit to stop the sale. In May 2008, Colorado’s governor signed into law a bill that allows the state attorney general to review how the sale of a nonprofit hospital affects patient care. If he believes care will be affected, the attorney general may ask for more information from the sponsors of the transaction or require a public hearing be held before determining whether to approve the transaction.

The sale is pending.

There’s a benefit to being a hospitalist. You are in a unique position to exert influence on the hospital, because in some ways, both parties need the other to do well.

—Steven Krebs, MD, Lutheran Medical Center, Wheat Ridge, Colo.

In an ideal world, patients would get the same excellent care, no matter who owns or runs a hospital. A sale or a change in executive leadership wouldn’t alter the tone of a hospital. As the Colorado case shows, ownership and leadership matter.

Hospitalists who have been through a hospital sale or a change of leadership say it’s possible to influence the process from within, to benefit the hospital, the patients, and the hospitalists themselves, often through simple negotiation and clear communication.

Become a Resource, Partner for Leadership

Established hospitalist programs are in an especially strong bargaining position. “We have a track record we can point to,” says Brian Bossard, MD, director of Inpatient Physician Associates, whose medical center, BryanLGH in Lincoln, Neb., went through a search for a new CEO in early 2008. That track record includes a strong relationship between the hospitalist program and hospital administrators.

When the medical center considered formalizing its hospitalist program in 2002, for example, Dr. Bossard went with administrators to regional and national meetings. “Instead of having competing perspectives on what the costs of the program should be and what the value equation is, we came from a similar perspective,” he explains. “Since that time, that trust has been maintained by coming through on promises, whether it’s being able to manage the volumes or get good results.”

A strong foundation can lead to a well-integrated hospitalist program and positive relationships with the CEO and COO, Dr. Bossard adds. Though he considers the change in CEOs at BryanLGH “a little unsettling,” he says he’s confident his hospitalist program has the support of the hospital community. Perhaps as evidence of that, the hospital hiring committee considered input from hospitalists before making a final selection.

Dr. Bossard plans to present to the new CEO the hospitalist program’s accomplishments, goals, and potential challenges early on, so the CEO can get to know the program. “The [hospitalists] really should try to position themselves, in my view anyway, as sort of an insider with useful information, a leader they can go to to ask what’s really going on in the hospital,” Dr. Bossard says. “Hospitalist programs will grow so rapidly within hospital systems, taking care of 50% to 75%, to sometimes close to 100% of patients. They’re really great sources of information.”

Keep Lines of Communication Open

Strong relationships with hospital leadership creates a stable environment where hospitalists feel valued. It also helps ensure a program can weather almost any storm, says Julia Wright, MD, University of Wisconsin Hospital and Clinics hospitalist director and the director of hospital medicine at UW School of Medicine and Public Health in Madison, Wis. “Once you get to the point where you have value, a mission, a system of operations, and a delivery-of-care plan, then that might translate into some personal ownership in the program that could withstand a change in administration,” she says.

Dr. Wright, who took a five-person hospitalist program and has enlarged it to 13, says she understands the value of communication with hospital executives. She also has a game plan, should executive leadership at her hospital change. “The first thing I would do is sit down and discuss what my mission is,” she says. “Continued dialogue after that is really important.” The dialogue would include meeting with hospital administration regularly, as well as talking about objectives and ways to meet them. “I just know what’s worked to keep our program on track,” she says, “and it’s been very successful.”

Leverage a Change in Administration

At Meriter Hospital in Madison, Wis., Cate Ranheim, MD, director of the hospitalist program, found a change in administration actually benefitted her hospitalists. “Our previous administration was essentially a chief operating officer (COO) who approved—or more often—refused, every request for even the simplest things, from sinks to filing cabinets to call rooms,” she explains. “The former CEO was here for 30-plus years, as was the COO, and was virtually invisible within the institution.”

The COO was a strong advocate for the hospitalist group, but Dr. Ranheim says she still had to go through tough negotiations to get what the group needed. When a new CEO came in and announced an open-door policy, Dr. Ranheim jumped at the opportunity to be heard. “Whenever I need something for the group, I go directly to him, and I have never been refused anything because he knows I am not game-playing or negotiating,” she says. “If I say the group needs something, it really does.”

Dr. Ranheim’s experience actually is fairly common. Executive leadership or ownership changes often create “a window of opportunity to further some agendas,” Dr. Wright points out. “If there’s a group that’s been saying, ‘We really want to start this new initiative and just haven’t been able to get there yet,’ this might be the time to do that.”

Whether the transition is a good time can depend on how comfortable a hospitalist group feels with the new executive. “In my own experience, it’s all about personality,” Dr. Ranheim says. “As hospitalist director, I instantly trusted my new CEO, and that trust has never been violated in either direction.” She adds, “Of course, I still do get everything in writing.”

Pay Attention to National Standards

Whether hospitalists can bring about improvements during a hospital change of ownership or leadership isn’t just based on how much the program improves care or reduces costs at the facility. National standards also should come into play, Dr. Bossard says. “The hospitalist negotiator and the administration need to be comfortable with their command of what the data shows and what their standards are,” he cautions.

At Lutheran Medical Center in Colorado, Dr. Krebs felt strongly the change in ownership would cause patients hardship and go against national standards. Though both sides attempted to collect feedback and reach a compromise, neither came up with a solution that satisfied Dr. Krebs. He felt he had no choice but to seek legal action. (Exempla Healthcare, which manages the medical center, also sued to stop the sale).

“If the parent organization of Jehovah’s Witnesses took over a hospital and declared that no one could have a transfusion, no one would allow that,” Dr. Krebs argues. “If I have a patient that’s a Jehovah’s Witness, and they say, ‘I won’t have a transfusion,’ that’s very important. However, that person doesn’t have the right to impose their belief system on someone else.”

Dr. Krebs says he has the support of his medical community and his hospital, largely because, as a hospitalist, he’s been involved with the community all along. He says any hospitalist who hopes to influence standards of care should get involved, too, by sitting on or chairing a hospital committee, becoming an integral part of the medical community early on, and, above all, providing great care.

“If you leverage the facility you’re in to the Nth degree for income, you’re not going to be viewed as a partner, but as a vendor commodity, and you’ll have very little influence,” Dr. Krebs says. “There’s a benefit to being a hospitalist. You are in a unique position to exert influence on the hospital, because in some ways, both parties need the other to do well.” TH

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