The best strategy to use in avoiding this pitfall is to identify the most important services for hospitalists to provide, keeping the list relatively small initially (e.g., admit unassigned emergency medical patients, accept referrals from primary care physicians, and perform consults from other doctors). Other services, such as co-management of some surgical admissions, can be added as hospitalist staffing allows and after hospitalists have had an opportunity to participate in deciding which services are the most appropriate to add.
6) Excessive workload, leading to hospitalist dissatisfaction: A variety of factors can lead to excessive hospitalist workloads or patient volumes. The most common reason (mentioned above) is referral volume that grows faster than staff can be added. In other cases, hospitalists can make the mistake of scheduling each doctor to work relatively few annual days or shifts; this practice results in a high workload for each day worked, even though the annual patient volume may not be excessive.
Hospitalists, like other professionals, seek balance in their jobs. The biggest threat to this goal is an excessive workload, which can hinder a hospitalist’s ability to devote adequate attention to ensuring the satisfaction of the patient and the referring physician. It also limits the hospitalist’s ability to assume non-clinical responsibilities like protocol development and hospital committees. Some data suggest that, at some point, an increasing patient load begins to result in an increased length of stay. And, over time, it is likely to result in poor job satisfaction, burnout, and turnover among physicians in the group.
7) Insufficient financial support: SHM survey data from 2006 show that, in addition to collected professional fees, 97% of hospitalist practices receive financial support and/or services in kind. This money usually comes from the hospital in which the hospitalists work. The few practices that don’t receive such support usually have some combination of the following factors:
- Hospitalists who work only weekday hours;
- Hospitalists who are not responsible for emergency, unassigned patients; and
- A hospital with an excellent payer mix.
Practices that accept all the unassigned medical admissions from the ED and keep a doctor in the hospital 24 hours a day for seven days a week usually have professional fee collections that fall far short of the amount needed to pay competitive salaries. They usually need financial support from a source such as their hospital to supplement their fee collections. Without it, they must maintain high patient volumes to collect professional fee revenue that is adequate to pay reasonable salaries and benefits to the doctors. These practices are at risk of poor performance or collapse.
To Succeed, Avoid Failure
So why go to the trouble of starting over when you can get it right the first time? Setting clear and realistic expectations from the beginning gives any hospitalist practice a better chance of succeeding. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.