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Letters to the Editor
Pennsylvania group director sounds the call for hospitalist emancipation
Terms such as partners, associates, and K-1 are much less common in HM than other specialties. Instead, we are more familiar with such terms as medical director, employee, corporation-owned, hospital-owned, W-2. In most HM practices, there tends to be more of a hierarchal structure with unequal distribution of say and authority; 100% of the decision-making authority lies with two or three people in the group or organization.
I look around at my friends’ practices in other fields, the majority being privately owned with partnership track and equitable standing in the group, and I contrast that with what I see in nearly every HM group in my area. In HM, our fellow hospitalist must answer to his or her medical director, who then answers to the hospital administration. In many of the large, multistate corporations, the medical director answers to hospital administration as well as to a regional director, who then answers to the CMO of the corporation, who then answers to the CEO.
Rarely do you see a field of medicine that has such little autonomy. I believe it is time for hospitalists to step up to the plate and create practices in which we answer to ourselves and determine our own destinies.
Another phenomenon in HM demonstrates how everyone wants a piece of the HM action. In a 20-mile radius of where I practice, there are HM groups that have been started by specialists in other fields, including infectious disease, pulmonary, emergency medicine, and anesthesia. A cardiology acquaintance of mine recently started three hospitalist practices—single-handedly. These new additions are in addition to the HM groups started by hospital administrations and large multistate corporations.
The majority, but certainly not all, of these people or entities have very little understanding of what running a hospitalist practice entails. They might understand an HM practice to the extent that I understand how a hip replacement is done, procedurally, from my reading of a textbook or an operative note. Unless one currently practices or has recently practiced as a hospitalist, then it is difficult to fully grasp all the nuances of running an HM practice. Never have I seen a GI physician start up a cardiology group, nor have I seen an ER group start up an endocrine practice. Yet the majority of HM practices nationwide are started and controlled by entities other than the hospitalists themselves.
This recent epiphany has prompted me to sound the call for hospitalist emancipation. With a new generation of HM leaders, who now have both clinical and administrative experience in HM, it is time for hospitalists, not other specialists nor hospital administrators, to pave the course of our future in light of emerging healthcare reforms. Of course, we still need to work intimately with our parent hospitals, align our goals and vision, and be mindful of the construct in which HM is practiced. But I believe it is time for us to take control of our practices, because only we know what’s best for our patients and our fellow hospitalists.
Edward Ma, MD, hospitalist,
managing partner, Medical Inpatient Care Associates,
West Chester, Pa.,
president, The Hospitalist Consulting Group, LLC
ACGME not the only game in town for graduate medical education
I enjoy reading your column, but feel I must correct you regarding graduate medical education. You stated in your January 2011 column (“Turn to ACGME for Transfer, Resident Supervision Rules,” p. 39) that all U.S. postgraduate physician-training programs are governed by rules of the ACGME. Please note that there are hundreds of osteopathic postgraduate training programs throughout the country that are governed by the rules of the American Osteopathic Association and the osteopathic specialty colleges that sponsor these residencies and fellowships. If you need more information regarding this segment of postgraduate training, I would be more than happy to share more information with you.
Joanne Kaiser-Smith, DO,
FACOI, FACP, assistant dean,
Graduate Medical Education,
University of Medicine and Dentistry New Jersey,
School of Osteopathic Medicine, Stratford, N.J.
Dr. Hospitalist responds:
Dr. Kaiser-Smith: Thank you for your letter to the editor. You are absolutely correct. My intention was not to overlook the postgraduate training of osteopathic physicians, which, as you pointed out, is governed differently from the postgraduate allopathic training programs.
Thank you for sharing this information with our readers.
New Zealanders have pharmaceutical choice, but most choose subsidized meds
Dr. Williams’ excellent article (see “Hospitalist Down Under,” Feb-ruary 2011, p. 1) about his experiences at a country hospital in New Zealand and comparisons with the U.S. system has had a warm reception in this country. However, one statement he makes needs correction.
Dr. Williams states that if a drug was not available on the New Zealand “formulary” (the Pharmaceutical Schedule), then it is not available. The New Zealand government has separate drug evaluation (Medsafe) and funding (PHARMAC) agencies, each of which has different remits. Medsafe decides which medicines are safe and effective to use in New Zealand. PHARMAC decides which medicines will be funded by the government, and publishes this list in the Pharmaceutical Schedule.
Any Medsafe-approved drug can be prescribed for New Zealand patients, even those not on the schedule. About 20% of medicines used in New Zealand are purchased privately.
Our experience is that when faced with a choice, New Zealanders usually opt for government-funded medicines (those subsidized by PHARMAC). For this reason, the majority of medicines prescribed for New Zealand patients are funded by the government.
Thanks again for the excellent article.
Simon England,
communications manager,
PHARMAC, Wellington,
New Zealand
Pennsylvania group director sounds the call for hospitalist emancipation
Terms such as partners, associates, and K-1 are much less common in HM than other specialties. Instead, we are more familiar with such terms as medical director, employee, corporation-owned, hospital-owned, W-2. In most HM practices, there tends to be more of a hierarchal structure with unequal distribution of say and authority; 100% of the decision-making authority lies with two or three people in the group or organization.
I look around at my friends’ practices in other fields, the majority being privately owned with partnership track and equitable standing in the group, and I contrast that with what I see in nearly every HM group in my area. In HM, our fellow hospitalist must answer to his or her medical director, who then answers to the hospital administration. In many of the large, multistate corporations, the medical director answers to hospital administration as well as to a regional director, who then answers to the CMO of the corporation, who then answers to the CEO.
Rarely do you see a field of medicine that has such little autonomy. I believe it is time for hospitalists to step up to the plate and create practices in which we answer to ourselves and determine our own destinies.
Another phenomenon in HM demonstrates how everyone wants a piece of the HM action. In a 20-mile radius of where I practice, there are HM groups that have been started by specialists in other fields, including infectious disease, pulmonary, emergency medicine, and anesthesia. A cardiology acquaintance of mine recently started three hospitalist practices—single-handedly. These new additions are in addition to the HM groups started by hospital administrations and large multistate corporations.
The majority, but certainly not all, of these people or entities have very little understanding of what running a hospitalist practice entails. They might understand an HM practice to the extent that I understand how a hip replacement is done, procedurally, from my reading of a textbook or an operative note. Unless one currently practices or has recently practiced as a hospitalist, then it is difficult to fully grasp all the nuances of running an HM practice. Never have I seen a GI physician start up a cardiology group, nor have I seen an ER group start up an endocrine practice. Yet the majority of HM practices nationwide are started and controlled by entities other than the hospitalists themselves.
This recent epiphany has prompted me to sound the call for hospitalist emancipation. With a new generation of HM leaders, who now have both clinical and administrative experience in HM, it is time for hospitalists, not other specialists nor hospital administrators, to pave the course of our future in light of emerging healthcare reforms. Of course, we still need to work intimately with our parent hospitals, align our goals and vision, and be mindful of the construct in which HM is practiced. But I believe it is time for us to take control of our practices, because only we know what’s best for our patients and our fellow hospitalists.
Edward Ma, MD, hospitalist,
managing partner, Medical Inpatient Care Associates,
West Chester, Pa.,
president, The Hospitalist Consulting Group, LLC
ACGME not the only game in town for graduate medical education
I enjoy reading your column, but feel I must correct you regarding graduate medical education. You stated in your January 2011 column (“Turn to ACGME for Transfer, Resident Supervision Rules,” p. 39) that all U.S. postgraduate physician-training programs are governed by rules of the ACGME. Please note that there are hundreds of osteopathic postgraduate training programs throughout the country that are governed by the rules of the American Osteopathic Association and the osteopathic specialty colleges that sponsor these residencies and fellowships. If you need more information regarding this segment of postgraduate training, I would be more than happy to share more information with you.
Joanne Kaiser-Smith, DO,
FACOI, FACP, assistant dean,
Graduate Medical Education,
University of Medicine and Dentistry New Jersey,
School of Osteopathic Medicine, Stratford, N.J.
Dr. Hospitalist responds:
Dr. Kaiser-Smith: Thank you for your letter to the editor. You are absolutely correct. My intention was not to overlook the postgraduate training of osteopathic physicians, which, as you pointed out, is governed differently from the postgraduate allopathic training programs.
Thank you for sharing this information with our readers.
New Zealanders have pharmaceutical choice, but most choose subsidized meds
Dr. Williams’ excellent article (see “Hospitalist Down Under,” Feb-ruary 2011, p. 1) about his experiences at a country hospital in New Zealand and comparisons with the U.S. system has had a warm reception in this country. However, one statement he makes needs correction.
Dr. Williams states that if a drug was not available on the New Zealand “formulary” (the Pharmaceutical Schedule), then it is not available. The New Zealand government has separate drug evaluation (Medsafe) and funding (PHARMAC) agencies, each of which has different remits. Medsafe decides which medicines are safe and effective to use in New Zealand. PHARMAC decides which medicines will be funded by the government, and publishes this list in the Pharmaceutical Schedule.
Any Medsafe-approved drug can be prescribed for New Zealand patients, even those not on the schedule. About 20% of medicines used in New Zealand are purchased privately.
Our experience is that when faced with a choice, New Zealanders usually opt for government-funded medicines (those subsidized by PHARMAC). For this reason, the majority of medicines prescribed for New Zealand patients are funded by the government.
Thanks again for the excellent article.
Simon England,
communications manager,
PHARMAC, Wellington,
New Zealand
Pennsylvania group director sounds the call for hospitalist emancipation
Terms such as partners, associates, and K-1 are much less common in HM than other specialties. Instead, we are more familiar with such terms as medical director, employee, corporation-owned, hospital-owned, W-2. In most HM practices, there tends to be more of a hierarchal structure with unequal distribution of say and authority; 100% of the decision-making authority lies with two or three people in the group or organization.
I look around at my friends’ practices in other fields, the majority being privately owned with partnership track and equitable standing in the group, and I contrast that with what I see in nearly every HM group in my area. In HM, our fellow hospitalist must answer to his or her medical director, who then answers to the hospital administration. In many of the large, multistate corporations, the medical director answers to hospital administration as well as to a regional director, who then answers to the CMO of the corporation, who then answers to the CEO.
Rarely do you see a field of medicine that has such little autonomy. I believe it is time for hospitalists to step up to the plate and create practices in which we answer to ourselves and determine our own destinies.
Another phenomenon in HM demonstrates how everyone wants a piece of the HM action. In a 20-mile radius of where I practice, there are HM groups that have been started by specialists in other fields, including infectious disease, pulmonary, emergency medicine, and anesthesia. A cardiology acquaintance of mine recently started three hospitalist practices—single-handedly. These new additions are in addition to the HM groups started by hospital administrations and large multistate corporations.
The majority, but certainly not all, of these people or entities have very little understanding of what running a hospitalist practice entails. They might understand an HM practice to the extent that I understand how a hip replacement is done, procedurally, from my reading of a textbook or an operative note. Unless one currently practices or has recently practiced as a hospitalist, then it is difficult to fully grasp all the nuances of running an HM practice. Never have I seen a GI physician start up a cardiology group, nor have I seen an ER group start up an endocrine practice. Yet the majority of HM practices nationwide are started and controlled by entities other than the hospitalists themselves.
This recent epiphany has prompted me to sound the call for hospitalist emancipation. With a new generation of HM leaders, who now have both clinical and administrative experience in HM, it is time for hospitalists, not other specialists nor hospital administrators, to pave the course of our future in light of emerging healthcare reforms. Of course, we still need to work intimately with our parent hospitals, align our goals and vision, and be mindful of the construct in which HM is practiced. But I believe it is time for us to take control of our practices, because only we know what’s best for our patients and our fellow hospitalists.
Edward Ma, MD, hospitalist,
managing partner, Medical Inpatient Care Associates,
West Chester, Pa.,
president, The Hospitalist Consulting Group, LLC
ACGME not the only game in town for graduate medical education
I enjoy reading your column, but feel I must correct you regarding graduate medical education. You stated in your January 2011 column (“Turn to ACGME for Transfer, Resident Supervision Rules,” p. 39) that all U.S. postgraduate physician-training programs are governed by rules of the ACGME. Please note that there are hundreds of osteopathic postgraduate training programs throughout the country that are governed by the rules of the American Osteopathic Association and the osteopathic specialty colleges that sponsor these residencies and fellowships. If you need more information regarding this segment of postgraduate training, I would be more than happy to share more information with you.
Joanne Kaiser-Smith, DO,
FACOI, FACP, assistant dean,
Graduate Medical Education,
University of Medicine and Dentistry New Jersey,
School of Osteopathic Medicine, Stratford, N.J.
Dr. Hospitalist responds:
Dr. Kaiser-Smith: Thank you for your letter to the editor. You are absolutely correct. My intention was not to overlook the postgraduate training of osteopathic physicians, which, as you pointed out, is governed differently from the postgraduate allopathic training programs.
Thank you for sharing this information with our readers.
New Zealanders have pharmaceutical choice, but most choose subsidized meds
Dr. Williams’ excellent article (see “Hospitalist Down Under,” Feb-ruary 2011, p. 1) about his experiences at a country hospital in New Zealand and comparisons with the U.S. system has had a warm reception in this country. However, one statement he makes needs correction.
Dr. Williams states that if a drug was not available on the New Zealand “formulary” (the Pharmaceutical Schedule), then it is not available. The New Zealand government has separate drug evaluation (Medsafe) and funding (PHARMAC) agencies, each of which has different remits. Medsafe decides which medicines are safe and effective to use in New Zealand. PHARMAC decides which medicines will be funded by the government, and publishes this list in the Pharmaceutical Schedule.
Any Medsafe-approved drug can be prescribed for New Zealand patients, even those not on the schedule. About 20% of medicines used in New Zealand are purchased privately.
Our experience is that when faced with a choice, New Zealanders usually opt for government-funded medicines (those subsidized by PHARMAC). For this reason, the majority of medicines prescribed for New Zealand patients are funded by the government.
Thanks again for the excellent article.
Simon England,
communications manager,
PHARMAC, Wellington,
New Zealand
ONLINE EXCLUSIVE: Listen to HM experts discuss comanagement opportunities
Click here to listen to Dr. McKean
Click here to listen to Dr. Wachter
Click here to listen to Dr. Siegal
Click here to listen to Dr. Cheng
Click here to listen to Dr. Auerbach
Click here to listen to Dr. McKean
Click here to listen to Dr. Wachter
Click here to listen to Dr. Siegal
Click here to listen to Dr. Cheng
Click here to listen to Dr. Auerbach
Click here to listen to Dr. McKean
Click here to listen to Dr. Wachter
Click here to listen to Dr. Siegal
Click here to listen to Dr. Cheng
Click here to listen to Dr. Auerbach
ONLINE EXCLUSIVE: Comanagement Business Models
One of the emerging trends in comanagement by hospitalists (see “The Comanagement Conundrum,” p. 1, April 2011) is an expanded role in the perioperative care of surgical patients—extending from before the operation into rehabilitation. To be successful, hospitalists should think more broadly than the usual focus on medical needs immediately post-surgery, says Burke Kealey, MD, director of perioperative comanagement at Regions Hospital in St. Paul, Minn.
The perioperative service at Regions includes staffing of a pre-operative clinic, a partnership with the hospital’s anesthesia department, and use of a pre-operative patient checklist. Many primary-care physicians (PCPs) want to retain a role in the pre-operative assessments of their patients, so the Regions service has tried to partner with physicians in the community to work on standardizing the process.
Dr. Kealey, an SHM board member, was hired by Regions’ orthopedic department right out of residency in 1995 to do medical comanagement of its patients. His service later was absorbed into an emerging HM department. It has experimented with models including the use of nurse practitioners and physician assistants.
—Burke Kealey, MD, director of perioperative comanagement, Regions Hospital, St. Paul, Minn., SHM board member
Today, Regions dedicates three of its 16 full-time hospitalist teams to comanagement services, largely on the orthopedics floor, but also for cardiovascular surgery and urology. “As hospitalists, we can help to facilitate using the best, up-to-date medical knowledge” both before and after surgery, he says.
At the University of Rochester School of Medicine in New York, a group of fellowship-trained geriatric hospitalists has taken on comanagement of hip fracture patients at the Geriatric Fracture Center, leading to improved processes and patient outcomes.1 According to hospitalist Susan M. Friedman, MD, MPH, the program began as a collaboration between a geriatrician and an orthopedic surgeon. They found that their patients’ outcomes seemed to be better when they worked together on a case, so they sat down to talk about what they were doing and how to standardize it.
“From the start, they set the tone for how this is supposed work, and when it doesn’t, they find out why and address it,” Dr. Friedman says. The program does not use a formal service agreement, but there is a strong emphasis on co-ownership, mutual respect, and communication. “One thing that has helped us a lot is data-gathering,” she adds. The hip fracture comanagement has cut lengths of stay and readmissions by half and complications by one-third for the mostly elderly patients.
Larry Beresford is a freelance writer based in Oakland, Calif.
Reference
- Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of co-managed geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169(18):1712-1717.
One of the emerging trends in comanagement by hospitalists (see “The Comanagement Conundrum,” p. 1, April 2011) is an expanded role in the perioperative care of surgical patients—extending from before the operation into rehabilitation. To be successful, hospitalists should think more broadly than the usual focus on medical needs immediately post-surgery, says Burke Kealey, MD, director of perioperative comanagement at Regions Hospital in St. Paul, Minn.
The perioperative service at Regions includes staffing of a pre-operative clinic, a partnership with the hospital’s anesthesia department, and use of a pre-operative patient checklist. Many primary-care physicians (PCPs) want to retain a role in the pre-operative assessments of their patients, so the Regions service has tried to partner with physicians in the community to work on standardizing the process.
Dr. Kealey, an SHM board member, was hired by Regions’ orthopedic department right out of residency in 1995 to do medical comanagement of its patients. His service later was absorbed into an emerging HM department. It has experimented with models including the use of nurse practitioners and physician assistants.
—Burke Kealey, MD, director of perioperative comanagement, Regions Hospital, St. Paul, Minn., SHM board member
Today, Regions dedicates three of its 16 full-time hospitalist teams to comanagement services, largely on the orthopedics floor, but also for cardiovascular surgery and urology. “As hospitalists, we can help to facilitate using the best, up-to-date medical knowledge” both before and after surgery, he says.
At the University of Rochester School of Medicine in New York, a group of fellowship-trained geriatric hospitalists has taken on comanagement of hip fracture patients at the Geriatric Fracture Center, leading to improved processes and patient outcomes.1 According to hospitalist Susan M. Friedman, MD, MPH, the program began as a collaboration between a geriatrician and an orthopedic surgeon. They found that their patients’ outcomes seemed to be better when they worked together on a case, so they sat down to talk about what they were doing and how to standardize it.
“From the start, they set the tone for how this is supposed work, and when it doesn’t, they find out why and address it,” Dr. Friedman says. The program does not use a formal service agreement, but there is a strong emphasis on co-ownership, mutual respect, and communication. “One thing that has helped us a lot is data-gathering,” she adds. The hip fracture comanagement has cut lengths of stay and readmissions by half and complications by one-third for the mostly elderly patients.
Larry Beresford is a freelance writer based in Oakland, Calif.
Reference
- Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of co-managed geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169(18):1712-1717.
One of the emerging trends in comanagement by hospitalists (see “The Comanagement Conundrum,” p. 1, April 2011) is an expanded role in the perioperative care of surgical patients—extending from before the operation into rehabilitation. To be successful, hospitalists should think more broadly than the usual focus on medical needs immediately post-surgery, says Burke Kealey, MD, director of perioperative comanagement at Regions Hospital in St. Paul, Minn.
The perioperative service at Regions includes staffing of a pre-operative clinic, a partnership with the hospital’s anesthesia department, and use of a pre-operative patient checklist. Many primary-care physicians (PCPs) want to retain a role in the pre-operative assessments of their patients, so the Regions service has tried to partner with physicians in the community to work on standardizing the process.
Dr. Kealey, an SHM board member, was hired by Regions’ orthopedic department right out of residency in 1995 to do medical comanagement of its patients. His service later was absorbed into an emerging HM department. It has experimented with models including the use of nurse practitioners and physician assistants.
—Burke Kealey, MD, director of perioperative comanagement, Regions Hospital, St. Paul, Minn., SHM board member
Today, Regions dedicates three of its 16 full-time hospitalist teams to comanagement services, largely on the orthopedics floor, but also for cardiovascular surgery and urology. “As hospitalists, we can help to facilitate using the best, up-to-date medical knowledge” both before and after surgery, he says.
At the University of Rochester School of Medicine in New York, a group of fellowship-trained geriatric hospitalists has taken on comanagement of hip fracture patients at the Geriatric Fracture Center, leading to improved processes and patient outcomes.1 According to hospitalist Susan M. Friedman, MD, MPH, the program began as a collaboration between a geriatrician and an orthopedic surgeon. They found that their patients’ outcomes seemed to be better when they worked together on a case, so they sat down to talk about what they were doing and how to standardize it.
“From the start, they set the tone for how this is supposed work, and when it doesn’t, they find out why and address it,” Dr. Friedman says. The program does not use a formal service agreement, but there is a strong emphasis on co-ownership, mutual respect, and communication. “One thing that has helped us a lot is data-gathering,” she adds. The hip fracture comanagement has cut lengths of stay and readmissions by half and complications by one-third for the mostly elderly patients.
Larry Beresford is a freelance writer based in Oakland, Calif.
Reference
- Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of co-managed geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med. 2009;169(18):1712-1717.
Q&A with Hospitalist Administrator Amit Prachand
Amit Prachand, MEng
Division Administrator, Hospital Medicine
Northwestern Memorial Hospital and Feinberg School of Medicine,
Northwestern University, Chicago
Question: What motivated you to join SHM’s Administrators Task Force (ATF)?
A: I wanted to be able to directly interface with the community of leaders in similar administrator roles in order to obtain a stronger perspective of the role, its rewards and challenges, and of the creative solutions different practices have implemented to address issues relevant to hospital medicine and the overall healthcare delivery model. I was also relatively new to hospital medicine practice management, and even healthcare, so I wanted to put myself in the best position to soak in as much as possible as well as help facilitate the sharing of ideas amongst my new group of peers.
Q: How is the Administrators Task Force moving HM forward?
A: One of our main thrusts in the task force is to help expand the administrative membership in SHM. As hospitalist programs mature and the environment in which hospital medicine is practiced evolves, it is imperative that we develop the community, the infrastructure, and the tools required to partner with our stakeholders—both internal and external—to help lead hospital medicine forward.
Q: Has your participation in the Administrators Task Force helped your group?
A: The ATF has helped develop direct lines of communication with peers. This helps when it come to issues for which we are finding the best solutions for; areas such as on-boarding of new physicians, negotiations with hospitals, coding and billing improvement, and meaningful performance reporting.
Q: How is the task force helping hospitals improve patient care?
A: By having a peer group on the administrative side, I believe we are now able to more readily share ideas that support the ideas around patient-care improvement that are being shared amongst the physician membership.
One of the key roles we play as an administrator is to help develop the systems and structures that help improve patient care. That may range from advocating for physician representation on certain hospital committees to facilitating a process/QI project that involves hospitalists and other members of the extended patient-care team, such as physicians from other medical specialties, nursing, pharmacists, case management, bed management, environmental services, and information technology.
Q: How is the task force helping hospitals improve healthcare overall?
A: We are continually improving the infrastructure for administrators to share ideas and solutions to address overall healthcare issues (payment reform, readmissions, compliance, cost). It is through this infrastructure that we can identify best implementation practices of ideas. The webinar series (www.hospitalmedicine.org/roundtables) that we’ve developed addresses many of the issues that healthcare in general is facing. This series has exceeded expectations for participation and interest.
Q: What do you like most about your job as an administrator?
A: It is never dull, always exciting. From the firefighting to the long-term planning, the role keeps me on my toes. I enjoy being in a position that is so tightly intertwined with so many critical functions and disciplines across the medical center in a profession—hospital medicine—that is continuing to lead advances in healthcare delivery.
—Brendon Shank
Amit Prachand, MEng
Division Administrator, Hospital Medicine
Northwestern Memorial Hospital and Feinberg School of Medicine,
Northwestern University, Chicago
Question: What motivated you to join SHM’s Administrators Task Force (ATF)?
A: I wanted to be able to directly interface with the community of leaders in similar administrator roles in order to obtain a stronger perspective of the role, its rewards and challenges, and of the creative solutions different practices have implemented to address issues relevant to hospital medicine and the overall healthcare delivery model. I was also relatively new to hospital medicine practice management, and even healthcare, so I wanted to put myself in the best position to soak in as much as possible as well as help facilitate the sharing of ideas amongst my new group of peers.
Q: How is the Administrators Task Force moving HM forward?
A: One of our main thrusts in the task force is to help expand the administrative membership in SHM. As hospitalist programs mature and the environment in which hospital medicine is practiced evolves, it is imperative that we develop the community, the infrastructure, and the tools required to partner with our stakeholders—both internal and external—to help lead hospital medicine forward.
Q: Has your participation in the Administrators Task Force helped your group?
A: The ATF has helped develop direct lines of communication with peers. This helps when it come to issues for which we are finding the best solutions for; areas such as on-boarding of new physicians, negotiations with hospitals, coding and billing improvement, and meaningful performance reporting.
Q: How is the task force helping hospitals improve patient care?
A: By having a peer group on the administrative side, I believe we are now able to more readily share ideas that support the ideas around patient-care improvement that are being shared amongst the physician membership.
One of the key roles we play as an administrator is to help develop the systems and structures that help improve patient care. That may range from advocating for physician representation on certain hospital committees to facilitating a process/QI project that involves hospitalists and other members of the extended patient-care team, such as physicians from other medical specialties, nursing, pharmacists, case management, bed management, environmental services, and information technology.
Q: How is the task force helping hospitals improve healthcare overall?
A: We are continually improving the infrastructure for administrators to share ideas and solutions to address overall healthcare issues (payment reform, readmissions, compliance, cost). It is through this infrastructure that we can identify best implementation practices of ideas. The webinar series (www.hospitalmedicine.org/roundtables) that we’ve developed addresses many of the issues that healthcare in general is facing. This series has exceeded expectations for participation and interest.
Q: What do you like most about your job as an administrator?
A: It is never dull, always exciting. From the firefighting to the long-term planning, the role keeps me on my toes. I enjoy being in a position that is so tightly intertwined with so many critical functions and disciplines across the medical center in a profession—hospital medicine—that is continuing to lead advances in healthcare delivery.
—Brendon Shank
Amit Prachand, MEng
Division Administrator, Hospital Medicine
Northwestern Memorial Hospital and Feinberg School of Medicine,
Northwestern University, Chicago
Question: What motivated you to join SHM’s Administrators Task Force (ATF)?
A: I wanted to be able to directly interface with the community of leaders in similar administrator roles in order to obtain a stronger perspective of the role, its rewards and challenges, and of the creative solutions different practices have implemented to address issues relevant to hospital medicine and the overall healthcare delivery model. I was also relatively new to hospital medicine practice management, and even healthcare, so I wanted to put myself in the best position to soak in as much as possible as well as help facilitate the sharing of ideas amongst my new group of peers.
Q: How is the Administrators Task Force moving HM forward?
A: One of our main thrusts in the task force is to help expand the administrative membership in SHM. As hospitalist programs mature and the environment in which hospital medicine is practiced evolves, it is imperative that we develop the community, the infrastructure, and the tools required to partner with our stakeholders—both internal and external—to help lead hospital medicine forward.
Q: Has your participation in the Administrators Task Force helped your group?
A: The ATF has helped develop direct lines of communication with peers. This helps when it come to issues for which we are finding the best solutions for; areas such as on-boarding of new physicians, negotiations with hospitals, coding and billing improvement, and meaningful performance reporting.
Q: How is the task force helping hospitals improve patient care?
A: By having a peer group on the administrative side, I believe we are now able to more readily share ideas that support the ideas around patient-care improvement that are being shared amongst the physician membership.
One of the key roles we play as an administrator is to help develop the systems and structures that help improve patient care. That may range from advocating for physician representation on certain hospital committees to facilitating a process/QI project that involves hospitalists and other members of the extended patient-care team, such as physicians from other medical specialties, nursing, pharmacists, case management, bed management, environmental services, and information technology.
Q: How is the task force helping hospitals improve healthcare overall?
A: We are continually improving the infrastructure for administrators to share ideas and solutions to address overall healthcare issues (payment reform, readmissions, compliance, cost). It is through this infrastructure that we can identify best implementation practices of ideas. The webinar series (www.hospitalmedicine.org/roundtables) that we’ve developed addresses many of the issues that healthcare in general is facing. This series has exceeded expectations for participation and interest.
Q: What do you like most about your job as an administrator?
A: It is never dull, always exciting. From the firefighting to the long-term planning, the role keeps me on my toes. I enjoy being in a position that is so tightly intertwined with so many critical functions and disciplines across the medical center in a profession—hospital medicine—that is continuing to lead advances in healthcare delivery.
—Brendon Shank
Q&A with Hospitalist Administrator Kristi Gylten
Kristi Gylten, MBA
Director, Hospitalist Service,
Rapid City (S.D.) Regional Hospital
Question: What motivated you to join the Administrators Task Force (ATF)?
Answer: I wanted to have the opportunity to meet and network with my peers, and to be a part of developing resources and a place “on the map” for hospitalist administrators. The Administrators Task Force is bringing awareness to the administrative and business side of hospital medicine through the eyes of the hospitalist administrators.
Q: Has your participation on the task force helped out your group?
A: My group has benefited through the access and utilization of the available tools and resources to evaluate my own program, including tools like dashboards, job descriptions, patient communication, and marketing materials. The ATF has increased my awareness of the resources available, clinical and operational, to hospitalist groups, including my own.
Q: How is the ATF helping hospitals improve healthcare overall?
A: I believe the task force has its pulse on how healthcare could ideally be provided in the future. And, to me, it is extremely exciting to be part of the team that will help design the future of inpatient medicine and, in part, the continuum of care.
As hospitalist administrators, you have a close and collaborative relationship with the inpatient providers. And I think that because of that relationship and the fact that they live and breathe inpatient medicine, you are able to engage your team in improving many aspects of healthcare.
Q: What do you like most about your job as an administrator?
A: I like the wide variety of opportunities and challenges the role presents: human resources, contracting, recruitment, marketing and public relations, customer satisfaction, quality, and financials. The list goes on. No one day is like the previous, and it’s never dull. And most of all, I enjoy the challenge of strategizing and planning for the future of providing healthcare.
—Brendon Shank
Kristi Gylten, MBA
Director, Hospitalist Service,
Rapid City (S.D.) Regional Hospital
Question: What motivated you to join the Administrators Task Force (ATF)?
Answer: I wanted to have the opportunity to meet and network with my peers, and to be a part of developing resources and a place “on the map” for hospitalist administrators. The Administrators Task Force is bringing awareness to the administrative and business side of hospital medicine through the eyes of the hospitalist administrators.
Q: Has your participation on the task force helped out your group?
A: My group has benefited through the access and utilization of the available tools and resources to evaluate my own program, including tools like dashboards, job descriptions, patient communication, and marketing materials. The ATF has increased my awareness of the resources available, clinical and operational, to hospitalist groups, including my own.
Q: How is the ATF helping hospitals improve healthcare overall?
A: I believe the task force has its pulse on how healthcare could ideally be provided in the future. And, to me, it is extremely exciting to be part of the team that will help design the future of inpatient medicine and, in part, the continuum of care.
As hospitalist administrators, you have a close and collaborative relationship with the inpatient providers. And I think that because of that relationship and the fact that they live and breathe inpatient medicine, you are able to engage your team in improving many aspects of healthcare.
Q: What do you like most about your job as an administrator?
A: I like the wide variety of opportunities and challenges the role presents: human resources, contracting, recruitment, marketing and public relations, customer satisfaction, quality, and financials. The list goes on. No one day is like the previous, and it’s never dull. And most of all, I enjoy the challenge of strategizing and planning for the future of providing healthcare.
—Brendon Shank
Kristi Gylten, MBA
Director, Hospitalist Service,
Rapid City (S.D.) Regional Hospital
Question: What motivated you to join the Administrators Task Force (ATF)?
Answer: I wanted to have the opportunity to meet and network with my peers, and to be a part of developing resources and a place “on the map” for hospitalist administrators. The Administrators Task Force is bringing awareness to the administrative and business side of hospital medicine through the eyes of the hospitalist administrators.
Q: Has your participation on the task force helped out your group?
A: My group has benefited through the access and utilization of the available tools and resources to evaluate my own program, including tools like dashboards, job descriptions, patient communication, and marketing materials. The ATF has increased my awareness of the resources available, clinical and operational, to hospitalist groups, including my own.
Q: How is the ATF helping hospitals improve healthcare overall?
A: I believe the task force has its pulse on how healthcare could ideally be provided in the future. And, to me, it is extremely exciting to be part of the team that will help design the future of inpatient medicine and, in part, the continuum of care.
As hospitalist administrators, you have a close and collaborative relationship with the inpatient providers. And I think that because of that relationship and the fact that they live and breathe inpatient medicine, you are able to engage your team in improving many aspects of healthcare.
Q: What do you like most about your job as an administrator?
A: I like the wide variety of opportunities and challenges the role presents: human resources, contracting, recruitment, marketing and public relations, customer satisfaction, quality, and financials. The list goes on. No one day is like the previous, and it’s never dull. And most of all, I enjoy the challenge of strategizing and planning for the future of providing healthcare.
—Brendon Shank
The To-Don’t List
Last month, I wrote about the attributes of hospitalist practices that I associate with success. This month, I’ll do the opposite. That is, I’ll write about strategies your practice could, or even should, do without. Of course, all of these things are open to debate, and some thoughtful people might (and in my experience, probably will) arrive at different conclusions.
So I offer my list as food for thought, and if your practice relies on some of these strategies, you shouldn’t feel threatened by my opinion. But you might want to think about whether they’ve been made part of your practice by design, or if things just evolved this way without careful consideration of alternatives. I’ve listed them in no particular order.
Fixed-duration day shifts. My sense is that the majority of practices have a day shift with a predetermined start and end. That is, the hospitalist is expected to arrive and depart at the same time each day.
This seems to make a lot of sense, but it ignores the dramatic variations in workload a practice will have. For example, a practice that is appropriately staffed with four daytime hospitalists, and schedules each of them to work a 12-hour shift, provides 48 hours of daytime hospitalist manpower each day. But that will turn out to be precisely the right level of staffing only a few days a year. On all other days, daytime staffing will be optimal with a different number of hours. So it would make sense for the doctors to work more or less on those days.
Telling doctors that their shift always starts at the same time has significant lifestyle advantages. But it can inhibit the doctors who would be happy to start earlier to address more discharges early in the day and potentially go home earlier. So, just like most other doctors at your hospital have, why not let the doctors have significant latitude in when they start and stop working each day? In most cases, it might be necessary to have a time by which every doctor must be available to respond to pages (and one who must be on-site before the night doctor leaves), but they should feel free to actually arrive and start working when they choose. Most will make good choices and will likely feel a little more empowered and happy with their work.
And, at the end of the day, it might be reasonable to allow some of the day-shift doctors to leave when their work is done, and allow the others to stay to handle admissions until the night shift takes over. Those who leave early might still be required to respond to pages until a specified time.
Shifts that don’t involve rounding on “continuity” patients, such as night and evening (“swing”) shifts, usually should be arranged with predetermined start. I wrote in more detail on this topic in January 2007 and October 2010.
Contractual vacation provisions. Hospitalists should have significant amounts of time off. We work a lot of evenings, nights, and weekends, and we must have liberal amounts of time away from work. But for many practices, there is no advantage in classifying this time as vacation (or CME, etc.) time. In most cases, it makes the most sense to simply specify how much work (e.g. number of shifts) a doctor is to do each year and not specify a number of days or hours of vacation time. For more detail, read “The Vacation Conundrum” from March 2007.
If your practice has a vacation system that works well, then stick with it. But if you or your administrators are going nuts trying to categorize nonworking days between vacation and days the doctor simply wasn’t scheduled, then it might be best to stop trying. Just settle on the number of shifts (or some other metric) that a doctor is to work each year.
Tenure-based salary increases. It makes a lot of sense to pay doctors in most specialties an increasing salary based on his or her tenure with the practice. As they build a patient population and a referral stream, they generate more revenue and should benefit accordingly. But a new hospitalist who joins an existing group almost never has to build the referrals. In most cases, the group hired the doctor because the referrals are already coming and the practice needs more help, or the new doctor is replacing a departing one. So paying a new hospitalist a lower salary that increases automatically every few years isn’t really a raise earned by the doctor’s improved financial performance. Usually it’s just a system of withholding money that could be available for compensation for the doctor’s first few years in the practice. This lower starting salary might adversely impact recruiting. For more, see “Compensation Conundrum” from December 2009.
Poor roles for nonphysician providers (NPPs). I’ve worked with a lot of practices that have NPs and PAs (and, in some cases, RNs) who are doing what amounts to clerical work. They’re faxing discharge summaries, making calls to schedule patient appointments, dividing up the overnight admissions for the day rounders, etc.
Don’t make this mistake. Hire a secretary for that sort of work. And be sure that the roles occupied by trained clinicians (PAs, NPs, RNs, etc.) are professionally satisfying and will position them to make an effective contribution to the practice.
For more on this topic, see “The 411 on NPPs” from September 2008 and “Role Refinement” from September 2009; the latter features the perspective of Ryan Genzink, a thoughtful PA-C from Michigan.
Blinded performance reporting. First, make sure your practice provides regular, meaningful reports on each doctor’s performance and the group as a whole. This usually takes the form of a dashboard or report card. In my experience, too few practices do this. Make sure your group isn’t in that category.
Groups that do provide performance data often allow each doctor to see only his or her data. If data about other individuals in the group are provided, the names have often been removed. With exception of certain human resources issues (e.g. counseling a doctor to prevent termination), I think all performance data in the group should be shared by name with the whole group. In most practices, everyone should know by name which doctors are the high and low producers, each doctor’s compensation, and CPT coding practices (e.g. the portion of discharges coded at the high level).
When clinical performance can be attributed to individual providers, report those metrics openly, too. This usually creates greater cohesion within the group and helps foster a mentality of practice ownership. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
Last month, I wrote about the attributes of hospitalist practices that I associate with success. This month, I’ll do the opposite. That is, I’ll write about strategies your practice could, or even should, do without. Of course, all of these things are open to debate, and some thoughtful people might (and in my experience, probably will) arrive at different conclusions.
So I offer my list as food for thought, and if your practice relies on some of these strategies, you shouldn’t feel threatened by my opinion. But you might want to think about whether they’ve been made part of your practice by design, or if things just evolved this way without careful consideration of alternatives. I’ve listed them in no particular order.
Fixed-duration day shifts. My sense is that the majority of practices have a day shift with a predetermined start and end. That is, the hospitalist is expected to arrive and depart at the same time each day.
This seems to make a lot of sense, but it ignores the dramatic variations in workload a practice will have. For example, a practice that is appropriately staffed with four daytime hospitalists, and schedules each of them to work a 12-hour shift, provides 48 hours of daytime hospitalist manpower each day. But that will turn out to be precisely the right level of staffing only a few days a year. On all other days, daytime staffing will be optimal with a different number of hours. So it would make sense for the doctors to work more or less on those days.
Telling doctors that their shift always starts at the same time has significant lifestyle advantages. But it can inhibit the doctors who would be happy to start earlier to address more discharges early in the day and potentially go home earlier. So, just like most other doctors at your hospital have, why not let the doctors have significant latitude in when they start and stop working each day? In most cases, it might be necessary to have a time by which every doctor must be available to respond to pages (and one who must be on-site before the night doctor leaves), but they should feel free to actually arrive and start working when they choose. Most will make good choices and will likely feel a little more empowered and happy with their work.
And, at the end of the day, it might be reasonable to allow some of the day-shift doctors to leave when their work is done, and allow the others to stay to handle admissions until the night shift takes over. Those who leave early might still be required to respond to pages until a specified time.
Shifts that don’t involve rounding on “continuity” patients, such as night and evening (“swing”) shifts, usually should be arranged with predetermined start. I wrote in more detail on this topic in January 2007 and October 2010.
Contractual vacation provisions. Hospitalists should have significant amounts of time off. We work a lot of evenings, nights, and weekends, and we must have liberal amounts of time away from work. But for many practices, there is no advantage in classifying this time as vacation (or CME, etc.) time. In most cases, it makes the most sense to simply specify how much work (e.g. number of shifts) a doctor is to do each year and not specify a number of days or hours of vacation time. For more detail, read “The Vacation Conundrum” from March 2007.
If your practice has a vacation system that works well, then stick with it. But if you or your administrators are going nuts trying to categorize nonworking days between vacation and days the doctor simply wasn’t scheduled, then it might be best to stop trying. Just settle on the number of shifts (or some other metric) that a doctor is to work each year.
Tenure-based salary increases. It makes a lot of sense to pay doctors in most specialties an increasing salary based on his or her tenure with the practice. As they build a patient population and a referral stream, they generate more revenue and should benefit accordingly. But a new hospitalist who joins an existing group almost never has to build the referrals. In most cases, the group hired the doctor because the referrals are already coming and the practice needs more help, or the new doctor is replacing a departing one. So paying a new hospitalist a lower salary that increases automatically every few years isn’t really a raise earned by the doctor’s improved financial performance. Usually it’s just a system of withholding money that could be available for compensation for the doctor’s first few years in the practice. This lower starting salary might adversely impact recruiting. For more, see “Compensation Conundrum” from December 2009.
Poor roles for nonphysician providers (NPPs). I’ve worked with a lot of practices that have NPs and PAs (and, in some cases, RNs) who are doing what amounts to clerical work. They’re faxing discharge summaries, making calls to schedule patient appointments, dividing up the overnight admissions for the day rounders, etc.
Don’t make this mistake. Hire a secretary for that sort of work. And be sure that the roles occupied by trained clinicians (PAs, NPs, RNs, etc.) are professionally satisfying and will position them to make an effective contribution to the practice.
For more on this topic, see “The 411 on NPPs” from September 2008 and “Role Refinement” from September 2009; the latter features the perspective of Ryan Genzink, a thoughtful PA-C from Michigan.
Blinded performance reporting. First, make sure your practice provides regular, meaningful reports on each doctor’s performance and the group as a whole. This usually takes the form of a dashboard or report card. In my experience, too few practices do this. Make sure your group isn’t in that category.
Groups that do provide performance data often allow each doctor to see only his or her data. If data about other individuals in the group are provided, the names have often been removed. With exception of certain human resources issues (e.g. counseling a doctor to prevent termination), I think all performance data in the group should be shared by name with the whole group. In most practices, everyone should know by name which doctors are the high and low producers, each doctor’s compensation, and CPT coding practices (e.g. the portion of discharges coded at the high level).
When clinical performance can be attributed to individual providers, report those metrics openly, too. This usually creates greater cohesion within the group and helps foster a mentality of practice ownership. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
Last month, I wrote about the attributes of hospitalist practices that I associate with success. This month, I’ll do the opposite. That is, I’ll write about strategies your practice could, or even should, do without. Of course, all of these things are open to debate, and some thoughtful people might (and in my experience, probably will) arrive at different conclusions.
So I offer my list as food for thought, and if your practice relies on some of these strategies, you shouldn’t feel threatened by my opinion. But you might want to think about whether they’ve been made part of your practice by design, or if things just evolved this way without careful consideration of alternatives. I’ve listed them in no particular order.
Fixed-duration day shifts. My sense is that the majority of practices have a day shift with a predetermined start and end. That is, the hospitalist is expected to arrive and depart at the same time each day.
This seems to make a lot of sense, but it ignores the dramatic variations in workload a practice will have. For example, a practice that is appropriately staffed with four daytime hospitalists, and schedules each of them to work a 12-hour shift, provides 48 hours of daytime hospitalist manpower each day. But that will turn out to be precisely the right level of staffing only a few days a year. On all other days, daytime staffing will be optimal with a different number of hours. So it would make sense for the doctors to work more or less on those days.
Telling doctors that their shift always starts at the same time has significant lifestyle advantages. But it can inhibit the doctors who would be happy to start earlier to address more discharges early in the day and potentially go home earlier. So, just like most other doctors at your hospital have, why not let the doctors have significant latitude in when they start and stop working each day? In most cases, it might be necessary to have a time by which every doctor must be available to respond to pages (and one who must be on-site before the night doctor leaves), but they should feel free to actually arrive and start working when they choose. Most will make good choices and will likely feel a little more empowered and happy with their work.
And, at the end of the day, it might be reasonable to allow some of the day-shift doctors to leave when their work is done, and allow the others to stay to handle admissions until the night shift takes over. Those who leave early might still be required to respond to pages until a specified time.
Shifts that don’t involve rounding on “continuity” patients, such as night and evening (“swing”) shifts, usually should be arranged with predetermined start. I wrote in more detail on this topic in January 2007 and October 2010.
Contractual vacation provisions. Hospitalists should have significant amounts of time off. We work a lot of evenings, nights, and weekends, and we must have liberal amounts of time away from work. But for many practices, there is no advantage in classifying this time as vacation (or CME, etc.) time. In most cases, it makes the most sense to simply specify how much work (e.g. number of shifts) a doctor is to do each year and not specify a number of days or hours of vacation time. For more detail, read “The Vacation Conundrum” from March 2007.
If your practice has a vacation system that works well, then stick with it. But if you or your administrators are going nuts trying to categorize nonworking days between vacation and days the doctor simply wasn’t scheduled, then it might be best to stop trying. Just settle on the number of shifts (or some other metric) that a doctor is to work each year.
Tenure-based salary increases. It makes a lot of sense to pay doctors in most specialties an increasing salary based on his or her tenure with the practice. As they build a patient population and a referral stream, they generate more revenue and should benefit accordingly. But a new hospitalist who joins an existing group almost never has to build the referrals. In most cases, the group hired the doctor because the referrals are already coming and the practice needs more help, or the new doctor is replacing a departing one. So paying a new hospitalist a lower salary that increases automatically every few years isn’t really a raise earned by the doctor’s improved financial performance. Usually it’s just a system of withholding money that could be available for compensation for the doctor’s first few years in the practice. This lower starting salary might adversely impact recruiting. For more, see “Compensation Conundrum” from December 2009.
Poor roles for nonphysician providers (NPPs). I’ve worked with a lot of practices that have NPs and PAs (and, in some cases, RNs) who are doing what amounts to clerical work. They’re faxing discharge summaries, making calls to schedule patient appointments, dividing up the overnight admissions for the day rounders, etc.
Don’t make this mistake. Hire a secretary for that sort of work. And be sure that the roles occupied by trained clinicians (PAs, NPs, RNs, etc.) are professionally satisfying and will position them to make an effective contribution to the practice.
For more on this topic, see “The 411 on NPPs” from September 2008 and “Role Refinement” from September 2009; the latter features the perspective of Ryan Genzink, a thoughtful PA-C from Michigan.
Blinded performance reporting. First, make sure your practice provides regular, meaningful reports on each doctor’s performance and the group as a whole. This usually takes the form of a dashboard or report card. In my experience, too few practices do this. Make sure your group isn’t in that category.
Groups that do provide performance data often allow each doctor to see only his or her data. If data about other individuals in the group are provided, the names have often been removed. With exception of certain human resources issues (e.g. counseling a doctor to prevent termination), I think all performance data in the group should be shared by name with the whole group. In most practices, everyone should know by name which doctors are the high and low producers, each doctor’s compensation, and CPT coding practices (e.g. the portion of discharges coded at the high level).
When clinical performance can be attributed to individual providers, report those metrics openly, too. This usually creates greater cohesion within the group and helps foster a mentality of practice ownership. TH
Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants a national hospitalist practice management consulting firm (www.nelsonflores.com). He is course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program.” This column represents his views and is not intended to reflect an official position of SHM.
Cardiac Work-Up...
Managerial Muscle
Ajay Kharbanda, MBA, CMPE, is regional director of Arlington-based Texas Health Resources, a nonprofit healthcare system that serves 16 counties in North and Central Texas with 4,100 beds at 24 acute-care and short-stay hospitals. Kharbanda, chair of SHM’s Administrators Task Force, chatted with The Hospitalist about his work, his involvement in SHM leadership, and how administrators can work with HM to improve the healthcare delivery.
Question: How would you characterize your role?
Answer: I work closely with the medical director of the hospitalist group to support physician practice operations for employed hospitalist physicians.
Q: What do you like most about your job as an administrator?
A: I serve professionals who make a difference in people’s lives, and I work with a specialty that is making a difference in how healthcare is being delivered in the country. Additionally, I work for a health system that has the mission to improve the health of the people in the communities we serve.
Q: What motivated you to join—and lead—SHM’s Administrators Task Force?
A: I have been a member of both MGMA (Medical Group Management Association) and SHM for many years, and I have seen SHM mature in the sense of meeting needs of nonclinicians who are looking for an avenue to network and seek answers to our common issues. I remember going to annual meetings, looking for familiar faces, and seeking out peers among the stream of physicians attending the event. Several of us saw the need for an avenue, especially at the annual meetings, for administrators to huddle and brainstorm.
As nonphysician administrators, we send a powerful message about our commitment to the specialty of hospital medicine by becoming a member of the society, and we do need to remember that this is a community unique to our needs as hospital medicine practice administrators.
Q: How is the task force moving HM forward?
A: The Administrators Task Force (ATF) is helping to develop initiatives and programs that promote and define the role of nonphysician practice administrators in hospital medicine. The ATF is charged with facilitating and enhancing the integration of administrators into the society. We strive to strengthen the society’s ability to fulfill its mission by developing and using the talents of current and future administrative leaders.
Q: How is the ATF helping hospitals improve patient care?
A: I believe it is by strengthening the role of the society. ATF has reached out to administrators nationwide to build awareness of the value of SHM resources, and we advised on the practice management [curriculum] for HM10. Plus, we have created the Web-based Practice Administrators’ Roundtable Series. These quarterly events provide an opportunity to discuss issues of common concern and share best practices around various topics. Following a brief formal presentation, participants are encouraged to take part in the discussion.
We all know that SHM offers a remarkable avenue for clinical knowledge, and we are helping to build an avenue for nonclinicians.
Q: Are there ways for other hospitalists and administrators to get involved with SHM?
A: First, visit the Practice Management Institute Web page at www.hospitalmedicine.org. It has information about the Practice Administrators’ Roundtable Series and resources on staffing and scheduling, career satisfaction, and coding and documentation.
Second, come to HM11, SHM’s annual meeting. We will be hosting a special-interest forum specifically designed for administrators. TH
Brendon Shank is vice president of communications for SHM.
Ajay Kharbanda, MBA, CMPE, is regional director of Arlington-based Texas Health Resources, a nonprofit healthcare system that serves 16 counties in North and Central Texas with 4,100 beds at 24 acute-care and short-stay hospitals. Kharbanda, chair of SHM’s Administrators Task Force, chatted with The Hospitalist about his work, his involvement in SHM leadership, and how administrators can work with HM to improve the healthcare delivery.
Question: How would you characterize your role?
Answer: I work closely with the medical director of the hospitalist group to support physician practice operations for employed hospitalist physicians.
Q: What do you like most about your job as an administrator?
A: I serve professionals who make a difference in people’s lives, and I work with a specialty that is making a difference in how healthcare is being delivered in the country. Additionally, I work for a health system that has the mission to improve the health of the people in the communities we serve.
Q: What motivated you to join—and lead—SHM’s Administrators Task Force?
A: I have been a member of both MGMA (Medical Group Management Association) and SHM for many years, and I have seen SHM mature in the sense of meeting needs of nonclinicians who are looking for an avenue to network and seek answers to our common issues. I remember going to annual meetings, looking for familiar faces, and seeking out peers among the stream of physicians attending the event. Several of us saw the need for an avenue, especially at the annual meetings, for administrators to huddle and brainstorm.
As nonphysician administrators, we send a powerful message about our commitment to the specialty of hospital medicine by becoming a member of the society, and we do need to remember that this is a community unique to our needs as hospital medicine practice administrators.
Q: How is the task force moving HM forward?
A: The Administrators Task Force (ATF) is helping to develop initiatives and programs that promote and define the role of nonphysician practice administrators in hospital medicine. The ATF is charged with facilitating and enhancing the integration of administrators into the society. We strive to strengthen the society’s ability to fulfill its mission by developing and using the talents of current and future administrative leaders.
Q: How is the ATF helping hospitals improve patient care?
A: I believe it is by strengthening the role of the society. ATF has reached out to administrators nationwide to build awareness of the value of SHM resources, and we advised on the practice management [curriculum] for HM10. Plus, we have created the Web-based Practice Administrators’ Roundtable Series. These quarterly events provide an opportunity to discuss issues of common concern and share best practices around various topics. Following a brief formal presentation, participants are encouraged to take part in the discussion.
We all know that SHM offers a remarkable avenue for clinical knowledge, and we are helping to build an avenue for nonclinicians.
Q: Are there ways for other hospitalists and administrators to get involved with SHM?
A: First, visit the Practice Management Institute Web page at www.hospitalmedicine.org. It has information about the Practice Administrators’ Roundtable Series and resources on staffing and scheduling, career satisfaction, and coding and documentation.
Second, come to HM11, SHM’s annual meeting. We will be hosting a special-interest forum specifically designed for administrators. TH
Brendon Shank is vice president of communications for SHM.
Ajay Kharbanda, MBA, CMPE, is regional director of Arlington-based Texas Health Resources, a nonprofit healthcare system that serves 16 counties in North and Central Texas with 4,100 beds at 24 acute-care and short-stay hospitals. Kharbanda, chair of SHM’s Administrators Task Force, chatted with The Hospitalist about his work, his involvement in SHM leadership, and how administrators can work with HM to improve the healthcare delivery.
Question: How would you characterize your role?
Answer: I work closely with the medical director of the hospitalist group to support physician practice operations for employed hospitalist physicians.
Q: What do you like most about your job as an administrator?
A: I serve professionals who make a difference in people’s lives, and I work with a specialty that is making a difference in how healthcare is being delivered in the country. Additionally, I work for a health system that has the mission to improve the health of the people in the communities we serve.
Q: What motivated you to join—and lead—SHM’s Administrators Task Force?
A: I have been a member of both MGMA (Medical Group Management Association) and SHM for many years, and I have seen SHM mature in the sense of meeting needs of nonclinicians who are looking for an avenue to network and seek answers to our common issues. I remember going to annual meetings, looking for familiar faces, and seeking out peers among the stream of physicians attending the event. Several of us saw the need for an avenue, especially at the annual meetings, for administrators to huddle and brainstorm.
As nonphysician administrators, we send a powerful message about our commitment to the specialty of hospital medicine by becoming a member of the society, and we do need to remember that this is a community unique to our needs as hospital medicine practice administrators.
Q: How is the task force moving HM forward?
A: The Administrators Task Force (ATF) is helping to develop initiatives and programs that promote and define the role of nonphysician practice administrators in hospital medicine. The ATF is charged with facilitating and enhancing the integration of administrators into the society. We strive to strengthen the society’s ability to fulfill its mission by developing and using the talents of current and future administrative leaders.
Q: How is the ATF helping hospitals improve patient care?
A: I believe it is by strengthening the role of the society. ATF has reached out to administrators nationwide to build awareness of the value of SHM resources, and we advised on the practice management [curriculum] for HM10. Plus, we have created the Web-based Practice Administrators’ Roundtable Series. These quarterly events provide an opportunity to discuss issues of common concern and share best practices around various topics. Following a brief formal presentation, participants are encouraged to take part in the discussion.
We all know that SHM offers a remarkable avenue for clinical knowledge, and we are helping to build an avenue for nonclinicians.
Q: Are there ways for other hospitalists and administrators to get involved with SHM?
A: First, visit the Practice Management Institute Web page at www.hospitalmedicine.org. It has information about the Practice Administrators’ Roundtable Series and resources on staffing and scheduling, career satisfaction, and coding and documentation.
Second, come to HM11, SHM’s annual meeting. We will be hosting a special-interest forum specifically designed for administrators. TH
Brendon Shank is vice president of communications for SHM.
CPT 2011 Update
In the past, observation services typically did not exceed 24 hours or two calendar days. However, changes in healthcare policy coupled with the impetus to reduce wasteful spending have spurred an atmosphere of scrutiny over hospital admissions. Sometimes there are discrepancies between a hospital’s utilization review committee and a payor’s utilization review committee in determining the appropriateness of healthcare services and supplies, in accordance with each party’s definition of medical necessity. This situation has caused an increase in both the number and cost of observation stays.
In response, subsequent observation-care codes (99224-99226) were developed and published in the 2011 edition of Current Procedural Terminology (CPT).1
Codes and Their Uses
CPT outlines three subsequent observation care codes:
- 99224: Subsequent observation care, per day, for the evaluation and management (E/M) of a patient, which requires at least two of these three key components: problem-focused interval history; problem-focused examination; and medical decision-making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.
- 99225: Subsequent observation care, per day, for the E/M of a patient, which requires at least two of these three key components: expanded problem focused interval history; expanded problem focused examination; and medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.
- 99226: Subsequent observation care, per day, for the E/M of a patient, which requires at least two of these three key components: detailed interval history; detailed examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.
Subsequent observation-care codes replicate the key components and time requirements established for subsequent hospital care services (99231-99233). However, the relative value units (RVUs) of physician work associated with subsequent observation care are not weighted equally (see Table 1, below). Subsequent observation care is a less-intense service, and therefore is valued at a lesser rate.
The attending of record writes the orders to admit the patient to observation (OBS); indicates the reason for the stay; outlines the plan of care; and manages the patient during the stay. Specialists typically are called onto an OBS case for their opinion/advice (i.e. consultants) but do not function as the attending of record.
According to CPT 2011, subsequent OBS care codes can be reported by both the attending physician of record and specialists who provide medically necessary, nonoverlapping care to patients on any day other than the admission or discharge day (see Table 2, above). At press time, CMS and private payors had not provided written clarification on the use of subsequent observation-care codes. Therefore, it is imperative to monitor payments, denials, and policy clarifications providing further billing instruction.
On the Horizon
Prior reporting guidelines required the reporting of subsequent observation-care days with established outpatient codes (99212-99215). Some member plans insisted on referrals for all outpatient visits regardless nature of the service. Without the mandated referral for established patient visits performed in the observation setting, physician services were denied for coverage.
The creation of subsequent observation codes might play a role in decreasing these denials. Be sure to review the private payors’ fee schedules for inclusion of 99224-99226 codes. If missing, contact the payor or include it as an agenda item during your contract negotiations.
For more information on observation care services, check out “Observation Care” in the July 2010 issue of The Hospitalist. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is faculty for SHM’s inpatient coding course.
References
- Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology: Professional Edition. Chicago: American Medical Association Press; 2011.
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2011.
In the past, observation services typically did not exceed 24 hours or two calendar days. However, changes in healthcare policy coupled with the impetus to reduce wasteful spending have spurred an atmosphere of scrutiny over hospital admissions. Sometimes there are discrepancies between a hospital’s utilization review committee and a payor’s utilization review committee in determining the appropriateness of healthcare services and supplies, in accordance with each party’s definition of medical necessity. This situation has caused an increase in both the number and cost of observation stays.
In response, subsequent observation-care codes (99224-99226) were developed and published in the 2011 edition of Current Procedural Terminology (CPT).1
Codes and Their Uses
CPT outlines three subsequent observation care codes:
- 99224: Subsequent observation care, per day, for the evaluation and management (E/M) of a patient, which requires at least two of these three key components: problem-focused interval history; problem-focused examination; and medical decision-making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.
- 99225: Subsequent observation care, per day, for the E/M of a patient, which requires at least two of these three key components: expanded problem focused interval history; expanded problem focused examination; and medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.
- 99226: Subsequent observation care, per day, for the E/M of a patient, which requires at least two of these three key components: detailed interval history; detailed examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.
Subsequent observation-care codes replicate the key components and time requirements established for subsequent hospital care services (99231-99233). However, the relative value units (RVUs) of physician work associated with subsequent observation care are not weighted equally (see Table 1, below). Subsequent observation care is a less-intense service, and therefore is valued at a lesser rate.
The attending of record writes the orders to admit the patient to observation (OBS); indicates the reason for the stay; outlines the plan of care; and manages the patient during the stay. Specialists typically are called onto an OBS case for their opinion/advice (i.e. consultants) but do not function as the attending of record.
According to CPT 2011, subsequent OBS care codes can be reported by both the attending physician of record and specialists who provide medically necessary, nonoverlapping care to patients on any day other than the admission or discharge day (see Table 2, above). At press time, CMS and private payors had not provided written clarification on the use of subsequent observation-care codes. Therefore, it is imperative to monitor payments, denials, and policy clarifications providing further billing instruction.
On the Horizon
Prior reporting guidelines required the reporting of subsequent observation-care days with established outpatient codes (99212-99215). Some member plans insisted on referrals for all outpatient visits regardless nature of the service. Without the mandated referral for established patient visits performed in the observation setting, physician services were denied for coverage.
The creation of subsequent observation codes might play a role in decreasing these denials. Be sure to review the private payors’ fee schedules for inclusion of 99224-99226 codes. If missing, contact the payor or include it as an agenda item during your contract negotiations.
For more information on observation care services, check out “Observation Care” in the July 2010 issue of The Hospitalist. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is faculty for SHM’s inpatient coding course.
References
- Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology: Professional Edition. Chicago: American Medical Association Press; 2011.
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2011.
In the past, observation services typically did not exceed 24 hours or two calendar days. However, changes in healthcare policy coupled with the impetus to reduce wasteful spending have spurred an atmosphere of scrutiny over hospital admissions. Sometimes there are discrepancies between a hospital’s utilization review committee and a payor’s utilization review committee in determining the appropriateness of healthcare services and supplies, in accordance with each party’s definition of medical necessity. This situation has caused an increase in both the number and cost of observation stays.
In response, subsequent observation-care codes (99224-99226) were developed and published in the 2011 edition of Current Procedural Terminology (CPT).1
Codes and Their Uses
CPT outlines three subsequent observation care codes:
- 99224: Subsequent observation care, per day, for the evaluation and management (E/M) of a patient, which requires at least two of these three key components: problem-focused interval history; problem-focused examination; and medical decision-making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.
- 99225: Subsequent observation care, per day, for the E/M of a patient, which requires at least two of these three key components: expanded problem focused interval history; expanded problem focused examination; and medical decision-making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.
- 99226: Subsequent observation care, per day, for the E/M of a patient, which requires at least two of these three key components: detailed interval history; detailed examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.
Subsequent observation-care codes replicate the key components and time requirements established for subsequent hospital care services (99231-99233). However, the relative value units (RVUs) of physician work associated with subsequent observation care are not weighted equally (see Table 1, below). Subsequent observation care is a less-intense service, and therefore is valued at a lesser rate.
The attending of record writes the orders to admit the patient to observation (OBS); indicates the reason for the stay; outlines the plan of care; and manages the patient during the stay. Specialists typically are called onto an OBS case for their opinion/advice (i.e. consultants) but do not function as the attending of record.
According to CPT 2011, subsequent OBS care codes can be reported by both the attending physician of record and specialists who provide medically necessary, nonoverlapping care to patients on any day other than the admission or discharge day (see Table 2, above). At press time, CMS and private payors had not provided written clarification on the use of subsequent observation-care codes. Therefore, it is imperative to monitor payments, denials, and policy clarifications providing further billing instruction.
On the Horizon
Prior reporting guidelines required the reporting of subsequent observation-care days with established outpatient codes (99212-99215). Some member plans insisted on referrals for all outpatient visits regardless nature of the service. Without the mandated referral for established patient visits performed in the observation setting, physician services were denied for coverage.
The creation of subsequent observation codes might play a role in decreasing these denials. Be sure to review the private payors’ fee schedules for inclusion of 99224-99226 codes. If missing, contact the payor or include it as an agenda item during your contract negotiations.
For more information on observation care services, check out “Observation Care” in the July 2010 issue of The Hospitalist. TH
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She also is faculty for SHM’s inpatient coding course.
References
- Abraham M, Ahlman J, Boudreau A, Connelly J, Evans D. Current Procedural Terminology: Professional Edition. Chicago: American Medical Association Press; 2011.
- Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual: Chapter 12, Section 30.6.8. Available at: www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Accessed Jan. 16, 2011.
Flexibility Is King
Michael Radzienda, MD, FHM, once worked in a hospitalist program in which physicians were scheduled 30 days straight on clinical duty and 30 days off clinical duty. Although it sounds harsh by today’s standards, that job was so satisfying, he says, the schedule never felt like a burden. Conversely, he’s seen hospitalists work five days on and five days off, and the job was treacherous.
His point: Work schedules are just one influential piece of the job satisfaction pie.
“Satisfaction has more to do with work relationships and opportunities for growth,” says Dr. Radzienda, chief of hospital medicine and director of hospital medicine service at Medical College of Wisconsin/Froedtert Memorial Lutheran General Hospital in Milwaukee.
Shift-based staffing has become the norm, as more than 70% of hospitalist groups use a shift-based staffing model, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.1 That figure is up 40% from SHM’s 2005-2006 survey. Conversely, the number of HM groups employing call-based and hybrid (some shift, some call) coverage is declining—2.8% of groups employ call-based schedules, and 26.9% use a hybrid schedule. Those figures have dropped significantly from the 2005-2006 report, from 25% and 35%, respectively.
If you are going to make HM a career, you’ll need time to be with your family and pursue other interests, Dr. Radzienda says. As HM groups turn to more shift-based models, in which hospitalists work a set number of predetermined shifts and have no call responsibility, the challenge is setting a schedule that balances productivity and quality time off.
Fixed = Inflexible
The most popular way to schedule is through blocks of five days on/five days off (5/5) or seven days on/seven days off (7/7), in which hospitalists work 12 or 14 hours at a time, says Troy Ahlstrom, MD, FHM, a member of SHM’s Practice Analysis Committee and CFO of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City, Mich. Many HM groups employ this model because it’s easy to schedule and is attractive to residents who want a fixed schedule. But from a career satisfaction standpoint, the 5/5 and 7/7 schedule models present their own issues.
Fairness is the first potential pitfall. If all of the physicians in a group work the same schedule, they all have to log the same number of shifts and receive the same compensation. This leaves little to no wiggle room for hospitalists who want to make more money by picking up more shifts or those who want to work fewer shifts, Dr. Ahlstrom says. “People have different income goals,” he adds.
Second, physicians have to see the same number of patients throughout the day. This doesn’t take into consideration the reality that some hospitalists naturally work faster than others, thereby forcing the slower-paced doctors to keep up with an imposed patient load. “Invariably, no matter what you do, people are different,” Dr. Ahlstrom says.
Another consideration is that when physicians are working 12 to 14 hours a day, essentially they have no time for activities other than work and sleep, which doesn’t match the realities of life. Inevitably, things in personal lives crop up, which leads to swapping shifts that the group scheduler doesn’t know about or overloading the scheduler with shift-change requests, Dr. Ahlstrom explains.
Additionally, 7/7 schedules and their ilk squeeze a year’s worth of work into a compressed time frame, which can lead to intense stress and burnout, says John Nelson, MD, FACP, MHM, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., SHM co-founder, and practice management columnist for The Hospitalist. “Maximizing the number of days off is not the holy grail,” he says. “If you choose to shut your life down on days that you work, that is going to be toxic.”
Flexibility Equates to Fairness
Dr. Nelson has long advocated a flexible shift schedule that accommodates individual preferences by giving physicians in the group autonomy in deciding how much or how little they want to work. While the group as a whole has to get all the work done, the flexibility comes from one physician taking more shifts as another takes less.
Dr. Radzienda tries to create teams within his group by pairing hospitalists with similar scheduling preferences. For example, he might have a pair working 5/5 and another working 14/14. “Up front, it takes a lot of work, but once you template it out, it becomes a good strategy,” he says.
He also strives to build robust backup plans and jeopardy models (see “Surge Protection,” September 2010, p. 43) into the schedule for short-notice callouts, as you never know when a hospitalist will need to miss a day or two because of illness or a family emergency. “Psychologically, it helps to know that you don’t have to be a hero if you’re ill or emotionally strained,” Dr. Radzienda says.
Dr. Ahlstrom agrees that a flex-schedule strategy has a positive impact on hospitalists’ career satisfaction and longevity. He suggests hospitalists be allowed to specify how many patients they want to see and be compensated according to their workload through built-in bonuses for physicians who work more. Dr. Nelson suggests paying hospitalists per relative value unit (RVU) of work. “I think hospitalists would like it and find it liberating to be paid on production,” he says.
An added bonus to flexible work hours and patient load, according to Dr. Ahlstrom, is that pay difference “will lead to a far more collegial atmosphere, because physicians know they are getting compensated fairly for the amount of work done.”
Another advantage of a flexible schedule is hospitalists knowing they have the option of ramping up or scaling back the number of shifts they work, Dr. Ahlstrom says—for example, a physician who wants to reduce shifts in order to coach his daughter’s softball team or have Friday nights off to watch her son play high school football.
“You prevent burnout by allowing people to change their work schedule depending on what’s going on in their life,” Dr. Ahlstrom says. TH
Lisa Ryan is a freelance writer based in New Jersey.
Michael Radzienda, MD, FHM, once worked in a hospitalist program in which physicians were scheduled 30 days straight on clinical duty and 30 days off clinical duty. Although it sounds harsh by today’s standards, that job was so satisfying, he says, the schedule never felt like a burden. Conversely, he’s seen hospitalists work five days on and five days off, and the job was treacherous.
His point: Work schedules are just one influential piece of the job satisfaction pie.
“Satisfaction has more to do with work relationships and opportunities for growth,” says Dr. Radzienda, chief of hospital medicine and director of hospital medicine service at Medical College of Wisconsin/Froedtert Memorial Lutheran General Hospital in Milwaukee.
Shift-based staffing has become the norm, as more than 70% of hospitalist groups use a shift-based staffing model, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.1 That figure is up 40% from SHM’s 2005-2006 survey. Conversely, the number of HM groups employing call-based and hybrid (some shift, some call) coverage is declining—2.8% of groups employ call-based schedules, and 26.9% use a hybrid schedule. Those figures have dropped significantly from the 2005-2006 report, from 25% and 35%, respectively.
If you are going to make HM a career, you’ll need time to be with your family and pursue other interests, Dr. Radzienda says. As HM groups turn to more shift-based models, in which hospitalists work a set number of predetermined shifts and have no call responsibility, the challenge is setting a schedule that balances productivity and quality time off.
Fixed = Inflexible
The most popular way to schedule is through blocks of five days on/five days off (5/5) or seven days on/seven days off (7/7), in which hospitalists work 12 or 14 hours at a time, says Troy Ahlstrom, MD, FHM, a member of SHM’s Practice Analysis Committee and CFO of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City, Mich. Many HM groups employ this model because it’s easy to schedule and is attractive to residents who want a fixed schedule. But from a career satisfaction standpoint, the 5/5 and 7/7 schedule models present their own issues.
Fairness is the first potential pitfall. If all of the physicians in a group work the same schedule, they all have to log the same number of shifts and receive the same compensation. This leaves little to no wiggle room for hospitalists who want to make more money by picking up more shifts or those who want to work fewer shifts, Dr. Ahlstrom says. “People have different income goals,” he adds.
Second, physicians have to see the same number of patients throughout the day. This doesn’t take into consideration the reality that some hospitalists naturally work faster than others, thereby forcing the slower-paced doctors to keep up with an imposed patient load. “Invariably, no matter what you do, people are different,” Dr. Ahlstrom says.
Another consideration is that when physicians are working 12 to 14 hours a day, essentially they have no time for activities other than work and sleep, which doesn’t match the realities of life. Inevitably, things in personal lives crop up, which leads to swapping shifts that the group scheduler doesn’t know about or overloading the scheduler with shift-change requests, Dr. Ahlstrom explains.
Additionally, 7/7 schedules and their ilk squeeze a year’s worth of work into a compressed time frame, which can lead to intense stress and burnout, says John Nelson, MD, FACP, MHM, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., SHM co-founder, and practice management columnist for The Hospitalist. “Maximizing the number of days off is not the holy grail,” he says. “If you choose to shut your life down on days that you work, that is going to be toxic.”
Flexibility Equates to Fairness
Dr. Nelson has long advocated a flexible shift schedule that accommodates individual preferences by giving physicians in the group autonomy in deciding how much or how little they want to work. While the group as a whole has to get all the work done, the flexibility comes from one physician taking more shifts as another takes less.
Dr. Radzienda tries to create teams within his group by pairing hospitalists with similar scheduling preferences. For example, he might have a pair working 5/5 and another working 14/14. “Up front, it takes a lot of work, but once you template it out, it becomes a good strategy,” he says.
He also strives to build robust backup plans and jeopardy models (see “Surge Protection,” September 2010, p. 43) into the schedule for short-notice callouts, as you never know when a hospitalist will need to miss a day or two because of illness or a family emergency. “Psychologically, it helps to know that you don’t have to be a hero if you’re ill or emotionally strained,” Dr. Radzienda says.
Dr. Ahlstrom agrees that a flex-schedule strategy has a positive impact on hospitalists’ career satisfaction and longevity. He suggests hospitalists be allowed to specify how many patients they want to see and be compensated according to their workload through built-in bonuses for physicians who work more. Dr. Nelson suggests paying hospitalists per relative value unit (RVU) of work. “I think hospitalists would like it and find it liberating to be paid on production,” he says.
An added bonus to flexible work hours and patient load, according to Dr. Ahlstrom, is that pay difference “will lead to a far more collegial atmosphere, because physicians know they are getting compensated fairly for the amount of work done.”
Another advantage of a flexible schedule is hospitalists knowing they have the option of ramping up or scaling back the number of shifts they work, Dr. Ahlstrom says—for example, a physician who wants to reduce shifts in order to coach his daughter’s softball team or have Friday nights off to watch her son play high school football.
“You prevent burnout by allowing people to change their work schedule depending on what’s going on in their life,” Dr. Ahlstrom says. TH
Lisa Ryan is a freelance writer based in New Jersey.
Michael Radzienda, MD, FHM, once worked in a hospitalist program in which physicians were scheduled 30 days straight on clinical duty and 30 days off clinical duty. Although it sounds harsh by today’s standards, that job was so satisfying, he says, the schedule never felt like a burden. Conversely, he’s seen hospitalists work five days on and five days off, and the job was treacherous.
His point: Work schedules are just one influential piece of the job satisfaction pie.
“Satisfaction has more to do with work relationships and opportunities for growth,” says Dr. Radzienda, chief of hospital medicine and director of hospital medicine service at Medical College of Wisconsin/Froedtert Memorial Lutheran General Hospital in Milwaukee.
Shift-based staffing has become the norm, as more than 70% of hospitalist groups use a shift-based staffing model, according to the State of Hospital Medicine: 2010 Report Based on 2009 Data.1 That figure is up 40% from SHM’s 2005-2006 survey. Conversely, the number of HM groups employing call-based and hybrid (some shift, some call) coverage is declining—2.8% of groups employ call-based schedules, and 26.9% use a hybrid schedule. Those figures have dropped significantly from the 2005-2006 report, from 25% and 35%, respectively.
If you are going to make HM a career, you’ll need time to be with your family and pursue other interests, Dr. Radzienda says. As HM groups turn to more shift-based models, in which hospitalists work a set number of predetermined shifts and have no call responsibility, the challenge is setting a schedule that balances productivity and quality time off.
Fixed = Inflexible
The most popular way to schedule is through blocks of five days on/five days off (5/5) or seven days on/seven days off (7/7), in which hospitalists work 12 or 14 hours at a time, says Troy Ahlstrom, MD, FHM, a member of SHM’s Practice Analysis Committee and CFO of Hospitalists of Northern Michigan, a hospitalist-owned and -managed group based in Traverse City, Mich. Many HM groups employ this model because it’s easy to schedule and is attractive to residents who want a fixed schedule. But from a career satisfaction standpoint, the 5/5 and 7/7 schedule models present their own issues.
Fairness is the first potential pitfall. If all of the physicians in a group work the same schedule, they all have to log the same number of shifts and receive the same compensation. This leaves little to no wiggle room for hospitalists who want to make more money by picking up more shifts or those who want to work fewer shifts, Dr. Ahlstrom says. “People have different income goals,” he adds.
Second, physicians have to see the same number of patients throughout the day. This doesn’t take into consideration the reality that some hospitalists naturally work faster than others, thereby forcing the slower-paced doctors to keep up with an imposed patient load. “Invariably, no matter what you do, people are different,” Dr. Ahlstrom says.
Another consideration is that when physicians are working 12 to 14 hours a day, essentially they have no time for activities other than work and sleep, which doesn’t match the realities of life. Inevitably, things in personal lives crop up, which leads to swapping shifts that the group scheduler doesn’t know about or overloading the scheduler with shift-change requests, Dr. Ahlstrom explains.
Additionally, 7/7 schedules and their ilk squeeze a year’s worth of work into a compressed time frame, which can lead to intense stress and burnout, says John Nelson, MD, FACP, MHM, director of the hospitalist practice at Overlake Hospital in Bellevue, Wash., SHM co-founder, and practice management columnist for The Hospitalist. “Maximizing the number of days off is not the holy grail,” he says. “If you choose to shut your life down on days that you work, that is going to be toxic.”
Flexibility Equates to Fairness
Dr. Nelson has long advocated a flexible shift schedule that accommodates individual preferences by giving physicians in the group autonomy in deciding how much or how little they want to work. While the group as a whole has to get all the work done, the flexibility comes from one physician taking more shifts as another takes less.
Dr. Radzienda tries to create teams within his group by pairing hospitalists with similar scheduling preferences. For example, he might have a pair working 5/5 and another working 14/14. “Up front, it takes a lot of work, but once you template it out, it becomes a good strategy,” he says.
He also strives to build robust backup plans and jeopardy models (see “Surge Protection,” September 2010, p. 43) into the schedule for short-notice callouts, as you never know when a hospitalist will need to miss a day or two because of illness or a family emergency. “Psychologically, it helps to know that you don’t have to be a hero if you’re ill or emotionally strained,” Dr. Radzienda says.
Dr. Ahlstrom agrees that a flex-schedule strategy has a positive impact on hospitalists’ career satisfaction and longevity. He suggests hospitalists be allowed to specify how many patients they want to see and be compensated according to their workload through built-in bonuses for physicians who work more. Dr. Nelson suggests paying hospitalists per relative value unit (RVU) of work. “I think hospitalists would like it and find it liberating to be paid on production,” he says.
An added bonus to flexible work hours and patient load, according to Dr. Ahlstrom, is that pay difference “will lead to a far more collegial atmosphere, because physicians know they are getting compensated fairly for the amount of work done.”
Another advantage of a flexible schedule is hospitalists knowing they have the option of ramping up or scaling back the number of shifts they work, Dr. Ahlstrom says—for example, a physician who wants to reduce shifts in order to coach his daughter’s softball team or have Friday nights off to watch her son play high school football.
“You prevent burnout by allowing people to change their work schedule depending on what’s going on in their life,” Dr. Ahlstrom says. TH
Lisa Ryan is a freelance writer based in New Jersey.