Doubling the number of hospitalists so quickly raised new issues. Divided into two teams of five, each group had little contact with the other team or with their FMP partners. To bridge the divide, shortly after the hospitalist cadre grew to 10, administrators threw an after-hours cocktail party for medical staff to build camaraderie among all FMP physicians.
Issue: Communication and continuity of care were not optimal.
Specific problems:
- The two hospitalist teams didn’t work together;
- Hospitalists and their office-based colleagues didn’t know each other;
- Productivity needed to be discussed; and
- Some long-term patients were unhappy about being treated by hospitalists rather than their primary physicians.
Resolution: More networking events to bring physicians together, along with daily e-mails from hospitalists to primary care physicians.
More contact among physicians revealed other issues. Terry Buchanan, MD, an FMP family practice physician whose three-provider office is several miles from SNHMC, is relieved that hospitalists freed him from hospital work. However, he says, “Not having hospital work gives a better quality of life, but we’ve lost income [from hospitalized patients] that we’re expected to recover with more outpatients.”
Another concern is losing clinical skills associated with acute care. “I don’t feel I’d be as marketable if I wanted a career change,” he adds.
Unique Metrics
No matter what the yardstick, measuring a hospital medicine program’s value is tough, particularly one transitioning to 24/7 coverage. Still, the familiar metrics of reducing average length of stay (ALOS), cutting costs, and quality improvement are not SNHMC’s ultimate gauge. In fact, ALOS has increased, from 4.15 days in 2004 to 4.26 days in 2005. Yet FMP and Dartmouth-Hitchcock gladly continue underwriting the gap between hospitalist compensation and revenues—a gap of about $30,000 per capita annually.
Issue: Customary hospitalist metrics are not the sole drivers at SNHMC.
Specific problems:
- Average length of stay was up;
- Cost cutting was not a predominant metric;
- Volume and productivity were not chief metrics; and
- Joint venture partners continued to subsidize the hospitalist program.
Resolution: The medical groups continue to support the hospitalist program as it adjusts to 24/7, with a commitment to add four more hospitalists.
Downplaying customary metrics doesn’t mean that SNHMC’s hospitalists don’t compare favorably with their peers. They do. On CMS core measures for four congestive heart failure indicators, SNHMC outperforms its state counterparts by 73% versus 65%; on community-acquired pneumonia guidelines by 54%-46%; and on surgical infection prevention by 64%-53%. Only on the six benchmarks for treating myocardial infarction does SNHMC fall short, by 85% to the 89 for other New Hampshire hospitals.
The Growth Conundrum
Moving to 24/7 coverage has challenged SNHMC, as it has other hospitalist programs. Dead time at night, when the ED and hospital floors fall silent, has to be paid for. So do the peaks and valleys of patient load.
Issue: Patient load variability makes hospitalist programs costly.
Specific Problems:
- Admissions and discharges can bunch and create bottlenecks; and
- Hospitalists are too busy at times and not seeing enough patients at other times.