Robert Donaldson, NPC
The research was so early on that the paper’s background section noted that “hospitalists are increasingly being used for inpatient care.”
“What we found, of course, was that they were providing an excellent service. They were well-trained, and you could get hospital people instead of having family-practice people managing the patients,” says nurse practitioner Robert Donaldson, NPC, clinical director of emergency medicine at Ellenville Regional Hospital in upstate New York and a veteran of working alongside hospitalists since the specialty arrived in the late 1990s. “We were getting better throughput times, better receipt of patients from our emergency rooms, and, I think, better outcomes as well.”
Growth Spurt
The refrain was familiar across the country as HM spread from health system to health system. Early results were looking good. The model was taking hold in more hospitals, both academic and community. Initial research studies supported the premise that the model improved efficiency without compromising quality or patient experience.
“My feeling at the time was this was a good idea,” Dr. Wachter says. “The trend toward our system being pushed to deliver better, more efficient care was going to be enduring, and the old model of the primary-care doc being your hospital doc … couldn’t possibly achieve the goal of producing the highest value.”
Dr. Wachter and other early leaders pushed the field to become involved in systems-improvement work. This turned out to be prophetic in December 1999, when patient safety zoomed to the national forefront with the publication of the Institute of Medicine (IOM) report “To Err Is Human.” Its conclusions, by now, are well-known. It showed between 44,000 and 98,000 people a year die from preventable medical errors, the equivalent of a jumbo jet a day crashing.
The impact was profound, and safety initiatives became a focal point of hospitals. The federal Agency for Health Care Policy and Research was renamed the Agency for Healthcare Research and Quality (ARHQ) to indicate the change in focus.
“When the IOM report came out, it gave us a focus and a language that we didn’t have before,” says Dr. Wachter, who served as president of SHM’s Board of Directors and to this day lectures at SHM annual meetings. “But I think the general sensibility that hospitalists are about improving quality and safety and patients’ experience and efficiency—I think that was baked in from the start.”
Two years later, IOM followed up its safety push with “Crossing the Quality Chasm: A New Health System for the 21st Century.” The sequel study laid out focus areas and guidelines to start reducing the spate of medical mistakes that “To Err Is Human” lay bare.
Hospitalists were seen as people to lead the charge for safety because they were already taking care of patients, already focused on reducing LOS and improving care delivery—and never to be underestimated, they were omnipresent, Dr. Gandhi says of her experience with hospitalists around 2000 at Brigham and Women’s Hospital in Boston.
“At least where I was, hospitalists truly were leaders in the quality and safety space, and it was just a really good fit for the kind of mindset and personality of a hospitalist because they’re very much … integrators of care across hospitals,” she says. “They interface with so many different areas of the hospital and then try to make all of that work better.”
Revenue Rules the Day
Dr. Gorman saw a different playing field in community hospitals where she worked. She was named chief medical officer for IPC Healthcare, Inc., in North Hollywood, Calif., in 2003 amid the push for quality and safety. And while the specialty’s early adoption of those initiatives clearly was a major reason for the exponential growth of hospitalists, Dr. Gorman doesn’t want people to forget that the cost of care was what motivated community facilities.