The purported benefits of hospital medicine, including reduced lengths of stay, cost savings and quality improvement for the hospital, and higher satisfaction for primary care physicians and patients, have been widely discussed. But are these positive outcomes always ensured when a hospital or a medical group decides to start a hospitalist program?
If the program is launched without adequate planning, a viable business plan, sufficient staffing, or other basic components of any successful business enterprise, the results may disappoint. The program may not deliver desired outcomes in terms of quality or cost savings. Hospitalist staff may become disillusioned, overworked, or burned out and then leave. The program might even fail, which is doubly problematic once physicians and hospital administrators have gotten used to the advantages of having hospitalist coverage in their facility.
What Not to Do … and How to Fix It
A hospitalist service started by Lewis-Gale Clinic, a multi-specialty medical group in Salem, Va., and practicing at 521-bed Lewis-Gale Medical Center, experienced serious problems after its launch in 1997.
“Our program initially wasn’t a true hospitalist program per se, but more like a service provided to internists in the medical group,” says Harsukh Patolia, MD, the hospitalist program’s medical director. “I was the first person hired. I made it clear that I wanted to be a hospitalist. But there were not many models available for us to base our program on.”
Demand was great from clinic physicians, who no longer had time to see their patients at the hospital, says Dr. Patolia. Three additional hospitalists were hired, but by 1999, one had left and the others were stressed out and overworked. “We were working very hard,” he says. But the program was dependent on locum tenens physicians to fill shifts, and quality was starting to suffer. “I’m not sure we were on the brink of failure, but there was a lot of dissatisfaction.”
Jon Ness, then the medical group’s administrator, identified a problem with the hospitalist service soon after he started work in Salem in 1999. “My sense was that both the hospital and medical staff really wanted the program and didn’t want to see it fail. But they didn’t understand why we were having so many challenges with it,” he says. “The first thing we did was a thorough clinical and administrative review of the program. The more information I collected, the more concerned I got.”
Recognizing that there wasn’t enough expertise within the organization to sort out the problems, Ness contacted Colorado Springs, Colo., consultant Roger Heroux of Hospitalist Management Resources, LLC. Additionally, he approached Lewis-Gale Medical Center’s new CEO, James Thweatt, who also realized that there was a problem with the program.
“If they hadn’t come to me, I would have gone to them with my recommendation for a consultant,” adds Thweatt. Basically, there were serious lacks in terms of logistical support for the service, of clarity in its strategic goals, and of authority for the practice’s leadership, while its relationship with the rest of the clinic was also deteriorating.
“With the changing face of healthcare, a viable hospitalist program was a necessity,” Thweatt says. He also had to satisfy the demands of physicians—not only those belonging to the group practice but also independent primary care practitioners in the community—or else they might take their patients to a competing hospital.
Ness and Heroux surveyed physicians about their needs and desires for the program, visiting a number of key physicians in their offices. Another challenge they handled was to negotiate a contract with the hospital for the hospitalists’ services, including a subsidy to reflect their 24/7 coverage in the hospital. Then they needed to agree on appropriate quality and financial performance measures by which to gauge the program’s success.