Make your hospitalist program a key component of physician-hospital alignment

As more physicians move into ambulatory settings, hospitalists are taking their place and providing hospital-based services. Although this shift is great for physicians who would rather focus their practices in the ambulatory setting for financial and quality of life issues, they shouldn’t simply walk out the front door of the hospital and never give it a second thought.

A common mistake is for ambulatory-based physicians and medical staff leaders let management alone work things out with the current or prospective hospitalist service. Doing so leads to a major disconnect between the hospitalist service and the remainder of the medical staff that takes years (if ever) to remedy. The problem is that once a hospitalist service is established and its contractual relationship with the hospital is finalized, it often takes several contractual cycles for alignment issues to be corrected through contractual modification involving compensation, bonus structures, and incentives around performance and productivity metrics.

A better approach is to create a task force or steering committee made up of members of the hospitalist service, management, formal and informal medical staff leaders, and board members. The focus of this group should be to assure that the hospitalist program services not only its external customers (e.g. patients) but also its internal customers (e.g. physicians and hospital staff/management). This will help the hospitalist program support the medical staff’s and hospital’s over arching goals.

Issues that the steering committee should discuss include:

• Co-management v. handoffs: When a patient is admitted to the hospital, does the hospitalist take over the care of the patient, or is that patient to be co-managed by attending physicians? What is the role of the primary or consulting physician in writing orders or making decisions?
• Defined consultations: When a hospitalist seeks a consultation, is there a clear way to communicate the role of the consultant? For example, should the consultant provide his or her opinion only? Write orders in the patient’s chart? Co-manage the patient? Arrange for a transfer of care? Are clinical questions clearly articulated and communicated verbally so that the purpose of the consultation is clearly understood by all parties? Will the hospitalist service provide consultations in the ED, after hours for inpatients, or on weekends, holidays, or evenings when a regular attending physician is unavailable? Will any patients be turned over to the attending staff during regular hours on weekdays? 
• Communication: Should formal communication between the hospitalist and attending physician occur when the patient is admitted? When there is a change in the patient’s clinical status? When the patient is transferred or discharged?  Should this communication be in the form of a phone call or a note in the chart? These are not trivial decisions. The number one cause of sentinel events is failure to communicate in a timely and effective manner; thus communication has an enormous effect on the patient’s clinical outcomes and satisfaction.
• Role of the primary consultant: What is the primary physician’s or consultant’s role in multi-disciplinary rounds? Should he or she participate daily? Only at admission, discharge, or transfer? When a patient’s clinical status changes?
• ED/ICU call coverage: Physicians’ lack of interest in providing call coverage in the face of declining reimbursement is a key symptom in the mal-alignment between medical staffs and hospitals. The hospitalist service has a key role to play because it is often available 24/7 to provide stabilizing care to patients in the ED and ICU. This issue is so important that the hospital should address it directly in any contract negotiation. If the hospitalist program takes ED/ICU call, this responsibility should also be included in contractual terms so that the hospitalist service (or its contracting entity) and the hospital clearly understand call coverage expectations. The medical staff, hospitalist service, and hospital management should discuss coverage issues together, because some clinical services (e.g. cardiology, gastroenterology, vascular surgery) may want to continue to take call for revenue generating opportunities. The medical staff, hospitalist service, and hospital management may want to develop a quid pro quo that allows hospitalists to interpret and bill for ancillary services, such as EKG interpretation or utilization management consultations. Allowing the hospitalist service to interpret and bill for ancillary services may provide needed revenue for subsidized services, such as call. 
• Pre-and post-operative care: Having hospitalists perform pre- and post-operative care enables surgeons to focus on performing procedures and being immediately available for surgical patients. This is not a trivial decision; many surgeons want to maintain relationships with their patients but may not always be available to do so. Also, patients and their families have a low tolerance for delays when a loved one is in pain and need a physician to be immediately available—they don’t want to wait for a surgeon to finish his or her next surgery. Surgical services, medical staff leadership, the hospitalist service, and management must determine the specific role hospitalists play when providing support for surgical services in both the pre- and post- operative settings.
• Procedures: The Cedars Sinai Hospital’s hospitalist service in Los Angeles leverages hospitalists to perform common procedures such as peripherally inserted central catheters, central venous pressure lines, or arterial line placement. The hospital found that if the same individuals perform the same procedures in the same way in large numbers, they become remarkably proficient with few complications. Again, this is not a trivial decision—many surgeons and intensivists make a significant proportion of their income from performing these procedures; thus, the steering committee should vet this issue thoroughly. 
• Palliative care: Many hospitalists now specialize in palliative treatment for patients admitted to an inpatient palliative or hospice unit. This is an essential part of the continuum of care and is becoming increasingly accepted as a rational and humane approach to caring for patients at the end of life. Whether to include palliative care as a part of the hospitalist program’s scope of service should be a decision made by the medical staff, management, and board in conjunction with the hospitalist providers.
• Observation services and units: The use of observation units may facilitate the more efficient care of inpatients waiting to be admitted or sent home, patients with less acute conditions, and patients awaiting transfer or discharge to another facility or another level of care. In addition, the government’s financial integrity program has asked hospitalists to provide the right level of service for the right Medicare severity-adjusted DRG. Hospitalists may play a key role in managing these individuals in a cost effective manner through the use of treatment protocols and care plans. Hospitalists’ involvement in such programs and units should be yet another discussion point when deciding on their scope of service at your healthcare organization.
• OPPE, FPPE, standardized bundles, and clinical pathways: Just who is going to do all of this stuff? This is the question I am often asked when busy ambulatory-based physicians learn about the Joint Commission’s requirements pertaining to ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE). They have a similar reaction to the Institute for Healthcare Improvement’s (IHI) “standardize to excellence” philosophy  to create standardized pathways and bundles around high-volume or high-risk DRGs. A physician who sees 30-40 patients per day in his or her office has little time to donate to proctoring or sitting on clinical pathway committees; thus, physicians are increasingly looking to hospitalists to take a leadership role in both the development and implementation of such programs. Management, in its need to meet accreditation and regulatory requirements, is increasingly including such responsibilities as part of hospitalists’ scope of service obligation, and like the issues addressed above, this should be clearly stated in a contractual agreement.
• Seat on MEC: Due to the importance of the hospitalist service and the many needed functions it provides, many medical staffs are creating an ex-officio seat on the medical executive committee for a representative or leader of the hospitalist service to provide input and directly respond to issues as they arise.

A myriad of issues are often inadvertently neglected, ignored, or not addressed formally as a part of a hospitalist service’s contractual agreement with the hospital. Creating a clear vision of a hospitalist program’s scope of service is not something that should be done unilaterally by management. Rather, it should be the result of a collaborative interdisciplinary discussion between formal and informal medical staff leaders, management, and the board. 

Alignment only comes when the needs of the hospitalist program, the medical staff, the hospital staff, the hospital, and the community are met. This is something that will not occur by chance but by thoughtful and careful planning.

Jon Burroughs, MD, MBA, FACPE, CMSL is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Marblehead, MA.