Practice Management

Rounding to make the hospital go ‘round

Hospitalists and performance incentive measures


 

No matter how you spin it, hospitalists are key to making the world of the hospital go ‘round, making their daily work of paramount interest to both hospitals and health systems.

In an effort to drive quality, safety, and efficiency, hospitals most commonly measure hospitalist work and reward it through ties to compensation. There are several trends in performance incentive metrics highlighted by the SHM 2020 State of Hospital Medicine (SoHM) Report. As hospitals support the subsidy required for hospitalist salaries, there is an increasing ask for hospitalist groups to partner with hospital operations to achieve certain goals. The lever of compensation, when appropriately applied to meaningful metrics, is one way of promoting desired behaviors.

Hospitalists are the primary attending physicians for patients in the hospital while also bridging the patient and their needs to the services of other subspecialists, allied health professionals, and when needed, postacute services. In this way, patients are efficiently moved along the acute care experience with multiple process and outcome measures being recorded along the way.

Some of these common performance incentive measures are determined by the Centers for Medicare and Medicaid Services while others may be of interest to third party payers. Often surrogate markers of process metrics (i.e. order set usage for certain diagnoses) are measured and incentivized as a way of directionally measuring small steps that each hospitalist can reliably control toward a presumably associated improvement in mortality or readmissions, for instance. Still other measures such as length of stay or timely completion of documentation have more to do with hospital operations, regulatory governance, and finance.

There are a variety of performance incentive metrics reported in the 2020 SoHM Report. Survey respondents could choose all measures that applied as compensation measures for their group in the past year. The most common metrics reported include patient satisfaction (48.7%), citizenship (45.8%), accuracy or timeliness of documentation (32.8%), and clinical process measures (30.7%).

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It is important to acknowledge that most of these metrics are objective measurements and can be measured down to the individual physician. However, some of the objective measures, such as patient satisfaction data, must rely on agreed upon methods of attribution – which can include anything from attributing based on admitting physician, discharging attending, or the attending with the greatest number of days (i.e. daily charges) seeing the patient. Because of challenges with attribution, groups may opt for group measurement of metrics for some of the compensation metrics where attribution is most muddy.

For performance incentive metrics that may be more subjective, such as citizenship, it is important for hospitalist leaders to consider having a method of determining a person’s contribution with a rubric as well as some shared decision making among a committee of leaders or team members to promote fairness in compensation.

Hospital leaders must also recognize that what is measured will lead to “performance” in that area. The perfect example here is the “early morning discharge time/orders” which is a compensation metric in 27.6% of hospitalist groups. Most agree that having some early discharges, up to maybe 25%-30% of the total number of discharges before noon, can be helpful with hospital throughput. The trick here is that if a patient can be discharged that early, it is likely that some of those patients could have gone home the evening prior. It is important for hospitalist physician leaders and administrators to think about the behaviors that are incentivized in compensation metrics to ensure that the result is indeed helpful.

Dr. Tresa Muir McNeal, division director of inpatient medicine at Baylor Scott & White Medical Center in Temple, Tex.

Dr. Tresa Muir McNeal

Other hospitalist compensation metrics such as readmissions are most effectively addressed if there are multiple physician teams working toward the same metric. Hospitalist work does effect readmissions within the first 7 days of discharge based on available evidence.1 Preventing readmissions from days 8-30 following discharge are more amenable to outpatient and home-based interventions. Also, effective readmission work involves collaboration among the emergency physician team, surgeons, primary care, and subspecialty physicians. So while having this as a compensation metric will gain the attention of hospitalist physicians, the work will be most effective when it is shared with other teams.

Overall, performance incentive metrics for hospitalists can be effective in allowing hospitals and hospitalist groups to partner toward achieving important outcomes for patients. Easy and frequent sharing of data on meaningful metrics with hospitalists is important to effect change. Also, hospital leadership can facilitate collaboration among nursing and multiple physician groups to promote a team culture with hospitalists in achieving goals related to performance incentive metrics.

Dr. McNeal is the division director of inpatient medicine at Baylor Scott & White Medical Center in Temple, Tex.

Reference

1. Graham, et al. Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients. Ann Intern Med. 2018 Jun 5;168(11):766-74.

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