Practice Economics

The Buck Starts Here


Some of the best companies in America started in a garage or a basement with an individual who had a great idea and the ability to grow it into a progressively larger business.

“It takes a leader with different capabilities to take a company to the next level,” says Martin Buser, MPH, FACHE, a partner with Hospitalist Management Resources LLC in San Diego, which has helped more than 350 HM programs nationwide in the past 15 years. “It’s an attitude of never stop learning, an ability to look at issues from 30,000 feet instead of ground zero so you can see the whole picture.”

Similarly, the most important predictor of an HM program’s success is its director, Buser says. If directors know how to communicate, innovate, facilitate, problem-solve, and inspire, they are much more likely to run a high-performing hospitalist program, says David Lee, MD, MBA, FACP, FHM, vice chairman of the Hospital Medicine Department at Ochsner Health System in New Orleans.

If group directors lack the skills and fail to adapt to change, the program’s outlook is far from certain. “We unfortunately get involved with these programs,” Buser says. “It’s painful to see.” Bad behavior is nothing new to the hospital setting, and HM is not immune to poor management. The following are common examples of bad behaviors and how groups can avoid the mishaps.

Scenario No. 1 : Great Clinician, Nice Person, Weak Advocate

Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, “If we do that, the ramifications are such that it’s just not going to work.”

—Martin Buser, MPH, FACHE, partner, Hospitalist Management Resources LLC, San Diego

The case: Earlier this year, medical center administrators asked the hospitalist program to do more with less, explaining the hospital was having a bad financial year. Administration approached the HM director, an exceptional, gregarious clinician who was named to the position years ago to help the program gain acceptance. The director agreed to indefinitely postpone two much-needed hirings, deciding it was better to share in the sacrifice than protest the cuts to the program’s budget. Hospitalists have since been working more shifts without a pay increase, and burnout symptoms have emerged with no signs of a thaw in the hiring freeze.

Expert advice: Buser says the “weak advocate” is a common issue among hospitalist groups, many of which he says are “going to hell” when he gets a rescue call. When a hospital is facing financial hardship, it is imperative that the HM director stand up for the program by explaining in detail the ramifications of each level of budget cuts. That’s because administrators might not realize the long-term damage that would result from such actions, he says. Being a strong, savvy advocate is even more important now since the financial future of many hospitals is ominous.

“With all of our hospitalist clients, we ask the CFO what is happening in the future…and the numbers are phenomenal,” says Buser. “They are seeing reductions of $10 million to $30 million off their bottom line.”

Administrators’ knee-jerk reaction is to cut costs. But there is another option: Grow the hospital out of its financial difficulties. It is up to the HM director to show administrators how the HM group has strategically gained them market share and how it will continue to do so. Good directors are in near constant contact with administrators, demonstrating the value their hospitalist program brings to the hospital, Buser says.

“You’re having regular meetings with the administrator, you’re producing the dashboard on a regular basis, you’re giving him trends that are going on,” he explains. “Show that you understand the hospital’s issues. Certain things you want to compromise on, but other things you have to say, ‘If we do that, the ramifications are such that it’s just not going to work.’”

Scenario No. 2 : Recruiting Roulette

A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit.

—David Friar, MD, SFHM, CEO, Hospitalists of Northern Michigan, Traverse City

The case: The HM director felt pressure to hire. The program’s hospitalists were seeing two to three patients a day more than they should have been, and hospital administrators were worried the program was losing ground to the other hospitalist group in the community. Using an outside recruiter, the director hired two adept physicians with stellar CVs after an expedited review process that included a background check, a few phone interviews, and day of in-person interviews with some administrators and a hospitalist on the team. Now, nearly a year later, one of the physicians is about to leave because her family doesn’t like the community, and the other new hire’s abrasive personality has caused considerable damage to the team’s cohesion.

Expert advice: A big part of an HM program’s value is how it practices as a unified team, and directors need to recognize how vital the “team fit” is to hospitalists, says David Friar, MD, SFHM, CEO of Hospitalists of Northern Michigan in Traverse City.

“A bad team fit is often worse than being short-staffed because it can literally destroy the team spirit,” he says.

Directors should have a standardized recruitment process that includes a comprehensive background screening where references are closely checked, a round of interviews by people outside the HM program (nurses and referring physicians), and substantial time spent with hospitalists in the program, says Bryce Gartland, MD, FHM, associate director of the hospital medicine division and medical director of care coordination at Emory Healthcare in Atlanta.

“We put [candidates] with one of our physicians to actually go around the hospital,” he says. “It’s amazing to me the number of things you can pick up by that broader exposure that you may not pick up sitting in a room with a candidate across the table for an hour.”

If a recruitment service is used, the director must describe the HM program in detail to the recruiter and even have them meet hospitalists on the staff, Dr. Friar says.

“Sending them a memo saying ‘We need three new hospitalists ASAP’ isn’t helping them find you the perfect candidate,” he says. “Even the best recruiter can only do a great job for you if they really know your team and what it is you need in a candidate.”

A director also is well served to make recruiting a family event where spouses and even children are part of the interview process.

“By including the entire family and then supporting them after the move, we are much more likely to recruit providers that will stay good members of our team for years to come,” Dr. Friar says.

Scenario No. 3 : Amitte Diem

If you don’t get buy in from your staff, the change is doomed to fail from the beginning.

—John Bulger, DO, FACP, FHM, chief quality officer, director, hospital medicine service line, Geisinger Health System, Danville, Pa.

The case: For months, the medical center has been receiving an increased number of referrals from outlying hospitals, and no end is in sight. The extra patient load, much of it involving complex cases, has agitated the medical center’s staff, particularly the specialists, and they’ve begun to complain to hospital administrators. Seeking an ally, the specialists reach out to the HM director to present their case. Without doing independent analysis, the HM director sides with the specialists. Hospital administrators, facing growing resistance, work to decrease the referrals and are successful.

Expert advice: Consider working in the opposite direction, one that might turn a referral challenge into a profitable opportunity, Buser says. One of his firm’s clients, after thorough research, established a transfer center and set up an activation fee for the specialists who took the referrals. Hospitalists admitted about 90% of the cases, called consults, and named specialists so they received full fee-for-service at Medicare rates if they saw uninsured patients.

“That hospital is now making about $78 million a year, and the medical staff is saying, ‘How can we grow this?’” Buser says. “Here’s an example of how the hospital medicine director was key to turning the bad into something good.”

Because physicians tend to be reticent to change, it’s critical for hospitalist directors who want to seize an opportunity to thoroughly plan out how the change will occur and to prepare for potential obstacles along the way, says John Bulger, DO, FACP, FHM, chief quality officer and director of the hospital medicine service line for Geisinger Health System in Danville, Pa.

“You really need to be prepared with your rationale of why you’re doing it, if there’s data behind why you’re doing it, what the data is that’s driving it, and really what you hope to do with that change,” he says. “If you don’t get buy in from your staff, the change is doomed to fail from the beginning.”

Directors must embrace being a change agent if they want their HM programs to continue to be successful. In the minds of many hospital administrators, a program is only as good as its last achievement.

“It’s kind of like, ‘What have you done for me lately?’” Buser says. “You want to stay ahead of the curve and be alert to what’s going on and not be caught keeping your eyes off the ball and, as a result, not moving your program forward.”

Scenario No. 4 : Fumbling the Handoff

Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation.

—Daniel Cusator, MD, MBA, vice president, Camden Group, El Segundo, Calif.

The case: The medical center’s monthly data for the past year has shown that hospitalists are taking care of their patients efficiently and getting them out of the hospital more quickly. However, mixed in with the positive numbers is a stubbornly high 30-day readmission rate. Indeed, some primary care groups and referring geriatricians have begun to grouse to the HM director about the discharge notes, complaining they aren’t as comprehensive as they would like.

Plus, the notes always arrive via office fax, which makes them more likely to get misplaced and harder to receive when doctors are out of the office.

Expert advice: Handoffs from discharge to pickup are where a lot of complications, errors, and safety issues arise, and poor handoffs are one of the largest drivers of readmission rates, especially in the elderly patient population, says Daniel Cusator, MD, MBA, vice president of the Camden Group, a healthcare consulting firm in El Segundo, Calif.

If the hospitalist director doesn’t provide the leadership and resources to help the HM team better coordinate with patients’ regular doctors, handoffs won’t be a priority throughout the group.

The HM director must recognize that the term “discharge note” is a misnomer.

What referring physicians really want is a care plan, which includes information about testing done in the hospital, testing that might be needed in the outpatient setting, medications the patient is on, complications the patient had in the hospital, potential problems to monitor, and any necessary follow-up, says Dr. Cusator, formerly the chief medical officer of clinical integration at Providence Health & Services in Southern California.

PCPs also want the care plan transmitted in their preferred method, whether that is text messaging, HIPAA-compliant email messaging, secure messaging, or fax.

“What I’ve seen some hospitalist groups do is create a menu capability for each of the physicians to choose their preferred method of notification of discharge of their patient,” Dr. Cusator says. Results suggest such a menu leads to improved physician satisfaction and reduced patient complications after discharge, he adds.

With today’s technological innovations, HM directors are unlimited in their ability to improve handoffs between their team and patients’ PCPs and specialists, Dr. Cusator says. Some HM directors, for example, are leading efforts to link electronic medical records systems to hospital-based health information exchange hubs that are accessible to physicians in the community.

“Notes and clinical information are submitted to this health information exchange and made available to any of the physicians who are caring for the patient almost immediately upon dictation and notation,” he says.

Scenario No. 5 : Protect Your Assets

There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.

—David Lee, MD, MBA, FACP, FHM, vice chairman, Hospital Medicine Department, Ochsner Health System, New Orleans.

The case: A physician isn’t sure she wants a career in hospital medicine. She finds the specialty rewarding but is looking for a different challenge, something beyond exclusively seeing patients. The HM director notices the physician has an aptitude for finding ways to do tasks more efficiently.

The director privately thinks the physician would be a good fit for a quality improvement project that’s about to start but doesn’t pursue it. The HM team just added a primary care group, and its patient census is quickly rising, requiring the hospitalists to devote their entire shifts to patient care. Within the year, the physician leaves the team for a fellowship program outside hospital medicine.

Expert advice: There are three communities in hospital medicine, Dr. Bulger says: people who want to be hospitalists, people who are passing through on their way to something else, and people who sit somewhere in the middle.

HM directors, he says, should do everything they can to develop not only the career hospitalists but also those on the fence.

“A lot of them you can turn into people who are going to be hospitalists if they are doing something that is rewarding for them,” Dr. Bulger says. “Many times rewarding for them is being involved more in the leadership of the group, being involved in quality improvement projects, really seeing how they can impact the care for populations of patients—and not just the patient who happens to be sitting in front of them.”

It’s incumbent on HM group leaders to link hospitalists with mentors and help them find a niche, Dr. Lee says. It keeps people interested and makes them feel part of a group.

“They need to feel they belong,” he says. “There has to be a cohesiveness in order for your department to excel. You have to protect your assets in the group, which is your physicians.”

Sending hospitalists to professional development training, such as SHM’s Leadership Academy (see “Leadership Academy Adds ‘Women in HM Issues’ to Schedule,” p. 9) or QI-focused webinars offered by SHM or the Institute of Healthcare Improvement, and following up with day-to-day coaching is a solid physician-development strategy, Dr. Gartland says. By virtue of their job, hospitalists are expected to lead and manage people in interactions with the ED, primary care, non-physician providers, nursing staff, and beyond, he says.

Directors also have to stop assuming that competent physicians are competent managers. “A lot of physicians don’t have those core skill sets, and we’ve got to pay conscious attention toward spending time dedicated to developing those,” Dr. Gartland says.

If directors don’t make professional development a priority or provide hospitalists with the flexibility to do non-clinical activities, retention may become an issue, Dr. Bulger says. “They could leave and go somewhere else,” he says, yet perhaps the more significant danger is losing hospitalists to programs and specialties outside hospital medicine.

Lisa Ryan is a freelance writer based in New Jersey.


As hospitals position themselves for healthcare reform, they increasingly will turn to HM for strategies on how to provide high-quality patient care at a lower cost, Buser says. To meet hospitals’ needs and enhance the value of their programs, hospitalist directors should consider adopting these strategies recommended by HM leaders:

  • Align compensation with the HM program’s goals. For example, if quality improvement is the priority, directors should financially reward hospitalists on quality performance, Dr. Lee says.
  • Boost support staff and functions. For example, directors should ensure their team has access to the hospital’s case managers, who can handle discharge logistics so the hospitalist can focus on clinical issues, Dr. Cusator says.
  • Control program growth. To borrow a popular line from the movie Field of Dreams: “If you build it, they will come.” Directors should be deliberate with group expansion and ensure enough staff is in place before adding to their referral base or adding a new service line, Dr. Bulger says. This reduces hospitalist burnout and preserves the group’s quality of patient care.
  • Define two to three targets for success in the upcoming year and concentrate on accomplishing them. Start by consolidating what your team is working on, says Steven Deitelzweig, MD, SFHM, chairman of the Department of Hospital Medicine at Ochsner Health System in New Orleans. Pick too many things to master, and you end up excelling in none, he adds.
  • Evaluate performance beyond a scorecard. Using constructive criticism grounded with examples, HM directors should provide feedback about what a physician is doing well and what can be done better so they can improve, Dr. Gartland says.
  • Foster creative problem solving by including hospitalists in decisions. Directors should encourage the expression of different opinions and ideas, which helps the program avoid “group think” and allows innovation to occur, Dr. Lee says.
  • Galvanize the new generation. To retain young physicians and make them feel part of the program, directors should learn how they communicate, how they work, and how they view work, Dr. Lee says.
  • Help your hospital accurately measure reimbursement and mortality rates. Directors should make coding a priority and provide hospitalists with the tools they need to capture correct ICD-9 and CPT codes for their patients, Dr. Cusator says.
  • Identify missing core capabilities and dedicate resources for it. For example, if HM programs have a high census of chronically ill and end-of-life patients, directors should assist the hospital in establishing a palliative care or hospice program, Dr. Cusator says.

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