Tag Archives: hospitalist management

Remaining Idealistic During growth

When AIM was founded over nine years ago, it was created with one purpose. Namely, to provide care of the hospitalized patient that was better, faster, safer, and more cost effective than before. The approach was and still is completely different than the vast majority of hospitalist programs out there that are profit driven. Keeping volumes down to improve quality by allowing staff the time they need to excel is still a novel approach. Taking care of our staff so they have a good work-life balance gives them the energy & motivation to strive for excellence. These concepts are so simple and so successful that you would think they would be widely adopted. Yet, here we are, one of those rare programs that actually cares about every employee and remains solely focused on quality.
A physician that interviewed recently described our approach, along with our excellent benefits package, as maybe ‘too good to be true’. She & her family are lovely people and hopefully will join AIM eventually, but I think it’s sad that this recruit was actually a little unsure because of our approach being so unusual as to make it almost hard to believe. Based on what’s out there, she has every right to be skeptical since 20-25 daily encounters and frequent burnout & staff turnover seems to be the current state of hospitalist affairs, to the point where it’s become accepted as ‘normal’. Are we really so disenfranchised and settled into these ritualized routines of 20+ encounters and punishing shifts daily that AIM keeping it to 15-18 encounters a day seems unbelievable? When the average hospitalist lasts only about four years in a program before moving on as is the case now, hospitalist medicine has a problem.
In the long run, I hope that everyone moves to the quality focused format that AIM has been so successful with. In the meantime, being surrounded by overworked, unappreciated, & burned out hospitalists at so many other programs sure helps with recruiting. Once an interview candidate visits and speaks with members of our team, we usually end up adding a new provider. That’s good for AIM, but not good for hospitalist medicine as a specialty. I think hospitalist medicine has ceded control of its own growth and identity to large hospitalist management groups focused on profits and expansion over quality. That’s going to come back to haunt our profession down the road. Well, AIM will continue to stand alone in our region as a group that understands that patient care is our focus, not dollars. That will never change.

2015 Review & looking ahead to 2016: A Time of Growth

In January of 2015, AIM was managing two hospital sites and had just started a fledgling nursing home division. As of January 1, 2016, AIM consists of seven separate divisions including four hospitals, 8 nursing homes, and Palliative Care & LTAC divisions. That’s over 300% growth in 2015! Success breeds success, and our approach of keeping patient volumes under control and allowing our hospitalists time to succeed leads to some pretty impressive metrics. These include lower lengths of stay, higher case-mix index, lower costs per case, and higher patient satisfaction. All of these numbers translate into improved quality of care at lower costs, and they have a significant and direct impact on the bottom line of the hospitals that AIM serves. This, in turn, makes our group very appealing, leading to further expansion. To put it another way, we don’t just think of ourselves as working to take care of patients. We work to take care of patients better, faster, safer, and with higher patient satisfaction. We ‘AIM’ to be the best at what we do, and we take that goal very seriously as a core principle.
As a consequence of controlling volumes and allowing our staff the time they need to do a great job, we have excellent staff retention and recruiting continues to go well. There are still so many surrounding programs that choose to go short staffed, either because of the inability to recruit, or simply to try to save money at the expense of the hospitalists, who get crushed with well over 20 encounters a day on a daily basis, which is not sustainable. This quickly leads to staff dissatisfaction, which leads these providers to seek out & join AIM. I’ll never understand that model of ‘work them until they leave’. AIM keeps its doctor’s happy and with a good work-life balance. In return, they do great work, which saves hospitals considerably more money than using less staff up front. Why so many programs fail to understand that happy & satisfied hospitalists leads to higher quality & more cost effective care in the long run is beyond me.
Bundled payments and other government sponsored initiatives to improve quality and decrease costs have led AIM and other organizations to expand into other arenas across the continuum of patient care. Expansion of our nursing home services this year, along with the addition of our Long-term Acute Care (LTAC) and Palliative Care divisions are logical extensions of our inpatient programs. A large percentage of waste in the system takes place in these transitions of care areas, particularly in Skilled Nursing facilities. By taking a management role in these facilities, AIM has positioned itself to provide even more efficient, high quality, and cost effective care.
As we look to 2016, there are many exciting things on the horizon. Continued growth into other hospitals, skilled nursing facilities and LTACs is a given. Continued system & process improvements such as our move to geographic rounding with interdisciplinary bedside rounds will be starting shortly. Streamlining care and patient flow from admission to discharge will continue to improve the patient experience, and should be reflected by even better HCHAPS scores for patient satisfaction. In short, AIM continues to work to find ways to make health care better, faster, and safer. If you are a hospitalist reading this, can you say that about your program, or are you just there to take care of as many patients as you can in a shift? Is your program able to say that you’ll NEVER see 20 patients in a day? If not, stop working in a patient ‘factory’ and meet our team and see just how rewarding it is to be a part of a team dedicated to the highest quality of care and patient satisfaction while maintaining equal satisfaction for our providers. 2016 will be quite a ride…time to jump on board!

Survey says….

When Advanced Inpatient Medicine started at our Wilkes-Barre site in October of 2013, I saw a very dysfunctional facility that was essentially run by specialists and the primary care docs that consulted them frequently. There was no thought to the changing landscape from a fee for service mentality to a pay for performance one. Right before we started there, I met with the CEO & warned that if we did our job right, he would have many consultants beating down his door to complain about us. In fact, that is exactly what happened. We didn’t consult a pulmonologist for every simple pneumonia or cardiologist for every chest pain, so, as our service grew, some specialists got upset and considered us a threat to their livelihood. One went so far as to try to get us thrown out with literally fabricated stories about our performance. On the 2014 physician satisfaction survey, my fellow medical staff, especially the medical specialists, crucified us. They were very critical and talked about a lack of communication and expressed concerns about clinical quality of care. After all, as one cardiologist put it, “You can’t possibly take care of CHF without a cardiologist.” Yes, it was that bad. We had to work with the CMO & other staff to create a dashboard to show that our quality was better than the general primary care doctors, with a markedly lower length of stay with no corresponding increase in admission rates.
Fast forward a year later to the newly released annual physician satisfaction survey this week. Our group has had a tremendously large increase in our scores across the board. No longer does the medical staff seem suspicious that everything we do is part of some conspiracy to affect their livelihood. (Yes, there is always one who just won’t give up that idea!) We received much higher marks in the perception of quality of care, communication, etc. The bottom line is that we have now generally become accepted as a part of the medical staff that provides a quality role at that hospital. That is a very gratifying survey to read because it means that things are progressing right on schedule. Taking care of hospitalized patients is the easy part, and not a whole lot different from place to place. Changing a culture requires patience & the ability to communicate openly & realize that this is a gradual process. Bad habits have been allowed to fester for a generation. Yet, we are slowly putting in system & process improvements that are starting to create fundamental change. The resistant few are beginning to realize that pay for performance is coming whether they like it or not. Those that refuse to embrace it will be left without a hospital to work at. Truthfully, that’s fine with me because I believe that our hospitalist team will be able to provide excellent care of those patients.
AIM continues to grow by hiring staff that embrace the two pronged challenge of patient care and improving the system. Are you one of those looking to truly make a difference? We have added several more sites and are looking for some talented providers that have that same mindset. Time to jump on board!

A Singular Honor

Happy New Year! Today, I found out that I would be the 4th ever recipient of the Certified Leader in Hospitalist Medicine designation. To be recognized as such, one has to complete three Leadership courses and a research project. The Leadership courses that are offered through the Society of Hospitalist Medicine (SHM) have had an enormous impact on my ability to lead my program. Courses cover leadership, finance, hospital finances, conflict resolution, negotiation, and many, many more. If anyone is interested in taking a leadership role in hospitalist medicine, these courses are a must. The research project must be approved by a review board and it is a very detailed process.
My project was to show that we can perform several interventions in a rural setting to decrease readmissions for four key diagnoses: CHF, MI, COPD exacerbations, and pneumonia. I chose this for our rural site at Wayne Memorial Hospital because I couldn’t find a single study regarding readmissions that was performed in a rural site, and thought that perhaps there would be other factors that affect readmission rates here versus an urban setting. As it turns out, we used four interventions: hiring four discharge coordinators to do bedside teaching & arrange follow-ups, etc., having the pharmacist perform medication reconciliation at the bedside prior to discharge, a home health visit on the 3rd day after discharge for everyone, and follow-up phone calls from both a pharmacist & discharge coordinator. The results were better than anticipated. Readmission rates fell over 34% over the one year study period, with CHF being the main diagnosis showing the statistical significance. As it turns out, being on ten or more meds at discharge was significant, and the home health intervention was also significant. No other variable turned out to make a difference, although I suspect having the coordinators make the follow-up appointments and phone calls had a large contribution to the decrease, although it couldn’t be shown statistically. As a result, we changed our approach to discharges and continued and expanded the coordinator role long-term. The bottom line is that we showed that research studies like this can be performed in a rural setting successfully, and I am very proud of this accomplishment. For the full details & discussion, look for the report soon on the SHM web site & eventually in the hospitalist literature where we hope to publish the entire project.
Having achieved this honor solidifies my place, and, more importantly, my program’s place as a leader in hospitalist medicine. When I started this company in 2006, I approached this with the idea that we can do things differently. I wanted to make a difference and become a leader for change. I wanted to make hospitals more efficient, safer, and of higher quality. Many hospitalist programs and companies are interested in profit margins and growth. I am as interested in profit as anyone, but that is not my focus at all. I fit well with the SHM because their goals mirror my own and they don’t provide just lip service. Their goal is to train the leaders of tomorrow who will help us transition from a fee-for-service mentality to a pay for performance model. I am proud to be a part of that change and perhaps a leader of this change by my example. Advanced Inpatient Medicine has adopted this goal which reflects my philosophy. If you are interested in making a difference & not just ‘working’ as a hospitalist, then come on and jump on board and be a part of something special. We are growing & can use the help.

An overview at one year

One year at our newest site in Wilkes-Barre has come and gone and with it, a lot of changes. Starting fresh at a facility that simply hasn’t been progressive in the transition from fee-for-service to pay-for-performance has not been easy. Taking a facility where specialists run the show and transitioning to hospitalists who can manage in a more cost effective and efficient manner was initially met with resistance by many specialists. Perhaps we came on too strong initially, since, after all, this whole hospitalist thing came as a complete culture shock to them. Fortunately, we were able to show an ever increasing split between our data metrics versus the private physician community. That included length of stay, case mix index, and others. Those differences add up to millions of dollars to the hospital when extrapolated over time, and that’s why the administration has been totally supportive of trying to promote the growth of our program.
It isn’t an easy task. What do you say to the worst offenders in the hospital, the ones with the extra-long lengths of stay who waste resources and cost the hospital money? “Well doctor, we want you to give your patients to the hospitalists because we can save money and they do a better job”. Not exactly a way to endear yourself to the medical staff. Economics does speak volumes these days, though, and the hospital does indeed want us to grow because we simply do a better job of inpatient care. By better, they mean more efficient and more cost effective. When we do a better job, people get out of the hospital faster & that saves the hospital lots of money. Larger than that, I think that the higher quality issue is far more important. Hospitalists are supposed to be able to provide care that is better, as in up to date, accurate and effective care. Our group meets every month and has a journal club. We review the latest literature & keep up with the latest standards of care. We work hard to provide the highest quality of care possible and all of our staff are always encouraged to keep up with the latest news in the medical literature. That’s the ‘better’ type of care that I think about. Interesting though, most data suggest that higher quality of care is actually more cost effective as well, so being a top notch doctor usually means being a more cost effective one as well. It has been gratifying that this has been noticed and the administration has given us their full support to continue to expand.
Year two will bring a different set of challenges as we continue to grow. We want to start to put our stamp on the inpatient process and really start to transform things. We have talked about improving patient flow from the ED, geographic rounding, better handoffs, team rounds with nursing, and a host of changes that will result in better communication and better patient care. If we do that, the ‘better’ care becomes more cost-effective care, and the entire hospital benefits in addition to the patients. That’s the brass ring of being a hospitalist. We love the challenge of getting there.

Raising the bar

Getting our new site in Wilkes-Barre off the ground has been a rewarding, but intense, experience. Getting a chance to attend the annual Society of Hospitalist Medicine meeting this past week in Las Vegas has been a great way to recharge the batteries after months of hard work. As usual, inspiration was everywhere, with plenty of innovative ideas around and great people to network with. One of the big topics was the recent release of the ‘Key Principles and Characteristics of an Effective Hospitalist Medicine Program’. They were created essentially as an assessment guide for hospitals & a framework for hospitalist groups to look at ways to improve their capabilities and performance. There are ten guiding principles and 47 characteristics listed, which serve as a benchmark to self assess our program to see where we stack up as compared to the gold standard. I am happy to say that AIM stands strong. Our group embodies these standards in almost every aspect. That’s not to say that some of these principles don’t need a little more refinement, but the core structure is there. Our focus on team based care that is patient centered and focused on aligning goals with those of the hospital fits this gold standard well. Working on improving care coordination across care settings by working closely with referring providers is another key principle that AIM has embraced. Playing a leadership role in the hospital in key areas such as patient safety and quality improvement is another core value of our group that is reflected nicely in the publication. In fact, given the similarities of our mission with the new Principles and Characteristics of an Effective Hospitalist Medicine Group, this is yet another testament that AIM remains at the forefront of hospitalist care. These principles and characteristics will no doubt be tweaked over time, but AIM will continue to remain one step ahead of the curve.

As this conference concludes, it’s time to get back to work and apply some fresh ideas to our program to keep AIM a step above the rest. It’s been a great conference for learning new aspects of care, networking for fresh perspectives on ideal hospitalist care, and to verify AIM’s standing as one of the top hospitalists programs in the country. We will be reviewing these principles as a group and looking for ways to raise the bar yet again.

Whoever said change is easy wasn’t talking about hospitals!

The harsh reality of starting a new hospitalist program is that there are those in that hospital that will embrace it and those that just won’t, no matter what. People fear change, even if it is to their benefit. The old guard of specialists and surgeons at our newest site is a perfect example of how tricky new start-up programs are.

    AIM took over its latest site in October of 2013. (Which is why I haven’t had much time to blog!) It became apparent very quickly that not everyone was happy to see us. After a few weeks, we figured out why. The specialists and surgeons dominated the hospital from top to bottom, and they were completely out of control. Consultants consult multiple other consultants, surgeons count the number of consults our team writes for them versus other docs in the same specialty, and make sure that they exact every nickel out of a patient regardless of length of stay or any quality metrics. It borders on unethical. Pulmonologists argued that our hospitalists weren’t qualified to provide ventilator management, even though it was part of our credentials. They didn’t argue because of patient safety, but purely because of economics. Every aspect of this inpatient care facility was doctor driven, with no regard for input from other personnel, including, in many cases, the patient. So, here comes our new hospitalist group into the fire. We started off by creating a multidisciplinary team to increase efficiency and communication between departments. We pushed administration to support us as we fought the cardiology groups to start performing stress tests and echoes on weekends to improve the dismal length of stay at the facility. (They were contracted to do so, but it had never been enforced.) We worked with radiology to be able to obtain MRIs on weekends as well. We knew Rome wasn’t created in a day, but we have begun to make inroads. Fortunately, administration realized the cost savings potential and has been backing us soundly since day one.

      On and on it went, seemingly every few days receiving a complaint or pushback from someone who was only interested in their own bottom line. It demonstrated the sad state of affairs that is much of the fee-for-service landscape that many cling to since they know how to take full financial advantage. When I extrapolate what is going on here nationally, it is no wonder there is a health care crisis! Pay-for-performance means accountability. When we bring up national measures like the Choosing Wisely campaign, it is intended to stop waste. The amount of waste going on at this one facility alone shows the problem on a frightening scale. Absolute power corrupts absolutely, right? Well, physicians in this facility have too much power. We need to create a patient-centric, TEAM approach to health care. That is the only way to create the safest, highest-quality, and most cost-effective hospital environment. So many are still trying to cling to the ‘good ol’ days’, when doctors could seemingly do whatever they wanted. Well, our team embraces the challenge of helping to change from a fee-for-service to a pay-for-performance environment. We aren’t afraid to partner with nurses, case managers, and patient educators. In fact, we are trying to bring them into our patient care model. That’s why we’ve been successful & why AIM is growing in size and reputation. It also doesn’t hurt that this model saves hospitals enormous amounts of money in the process. That’s why we want hospitalists on our team who can work as total team players. They can take great care of a single patient at the bedside, but also help to improve the entire system and process from admission to discharge.

    Changing a hospital landscape that is so uninterested in a progressive model of team-based health care that is cost-effective and of the highest quality is an enormous challenge. AIM embraces that challenge. It is very rewarding to see the buy-in from nurses and other ancillary personnel that are now being asked their opinions on patient care. Now, all we need to do is get the physicians, especially the specialists and surgeons, to start practicing medicine like they care about something other than their own bottom line. With time, they’ll come around. Guess what? If they don’t, the train isn’t waiting for them, folks. This is the way of medicine in 2014. Guess what else? It’s a better way.

Faith restored

My faith has been restored. If you read my last blog, (go ahead, it’s right below this one, I can wait) you will understand that I was very unhappy and disappointed with many of my hospitalist brethren for some of the more outrageous demands that they were making when considering a hospitalist position within our organization, and seemingly ignoring the important aspects of the job while focused only on compensation and minimizing workload. It seemed as if the high demand on hospitalists had brought out the worst that some people had to offer. Well, I had the pleasure of interviewing a couple this past week that actually came to me because of AIM’s ideals of excellent patient care and wanting an opportunity that afforded them the chance to do the best job that they could. They asked questions about the system, the amount of patients that they would expect to see, and spent a great deal of time trying to learn our system and how we planned to operate. While we discussed salary & benefits, it wasn’t the first question they asked, and they clearly had the attitude that I look for in our employed physicians. Namely, a desire to excel and to deliver the best care that they could, and a willingness to invest time into improving the overall patient care process. Our hospitalists are expected to provide more than just excellent patient care. We expect them to provide care that is faster, safer, of higher quality, and to deliver that care in a more efficient manner. I am thrilled to find hospitalists who still believe in those ideals. I have my fingers crossed that they will join our team, since you never know what other factors may affect their decision-making process. I do know that they would be a perfect fit for our team, though. So, if these two found AIM, I know that there have to be others out there who are motivated to try to improve the status quo and go beyond ‘ordinary’ hospitalist bedside care and join a team that wants to be extraordinary. Like I said, faith restored. Now, back to recruiting since we are about to announce out next expansion site shortly.

Something is rotten with recruiting!

While excited about our newest expansion into Wilkes-Barre General Hospital, the recruiting experience as I form my new staff has been eye opening. There is such a relative shortage of hospitalists that there is almost a feeding frenzy by hospitals to offer up just about anything to entice a hospitalist to sign on the bottom line. It’s been disturbing to see competitors that have lots bigger bank accounts than this growing organization of mine throwing out large signing bonuses, relocation expenses, vacation time, and more to get docs, and that’s essentially where the market is right now. Many of those docs looking to make a quick loan repayment, however, find out quickly how life works when their new hospital makes them see 20 patients a day or finds ways to make bonuses unreachable without any recourse. There’s no way that I can compete against these deep pocketed organizations except by making sure that my message of quality and job satisfaction cuts through the dollar signs, and that is the part that really rubs me the wrong way lately.
Many young hospitalists have already taken full advantage of the market to make increasingly greedy demands because they know full well that someone out there is going to be desperate enough to give them what they want. So, over the past few weeks, I have had hospitalist recruits start conversations with comments like: How much are the bonuses? How many vacation weeks? When do I get a raise? I want full tail coverage from day one and am not doing any night call…and on and on. What ever happened to these questions: What philosophy does your group have? How will you help me advance my career and gain leadership experience? How will we do CME? How does the team get along? What effect will this job have on my lifestyle and family life? There have been no questions about quality of care or how the hospital is approaching changes in health care. These are all important questions and, in my opinion, way more important than how much you get paid for your moving van. Have hospitalists become hired guns? Have we already started to lose our way because of greed? I won’t even talk about locums docs, because they take all this to the extreme …talk about hired guns!
So, as you think about the next phase of your career and consider various hospitalist programs, look at the program, not the benefit package, as first on the list. We all have school loans, but, you know what? You are all going to pay them off no matter where you work. Therefore, wouldn’t it make more sense to work where you would have the best satisfaction, safest workload, opportunities for personal and professional growth, and overall best lifestyle? Money can’t buy happiness. As long as a group like mine is competitive with its salary & benefits, and AIM certainly is, then all of the intangibles that AIM offers should be very enticing to any hospitalist. I just hope most docs can figure that out when they rub the dollar signs out of their eyes. It’s not your fault though! Hospitals all over are throwing those dollar signs at hospitalists & many docs just can’t help themselves. Be smarter than that and don’t be fooled. When you make your checklist of plusses and minuses when choosing a program, I submit that salary should be no higher than the middle of your list. If you want it first on the list, I guarantee that you will get paid exactly what you want by somebody. Whether you get anything else out of that job besides a paycheck (headaches, frustration, and fatigue, maybe?) is another story. As the knight said to Indiana Jones…choose wisely.

Blogging from SHM 2013

Returning to the annual national Society of Hospitalist Medicine conference always manages to reinvigorate and motivate me to continue to run the best Hospitalist programs in the region. I define best as most efficient, cost effective, and with the highest quality and patient satisfaction. Yesterday, Dr. Patrick Conway spoke about the ideal Hospitalist in 2014 and beyond as part of the opening remarks on day one. We have come a long way since Dr. Robert Wachter’s little group of inpatient physicians. The common theme of the entire meeting was summarized nicely by Dr. Conway: that all hospitalists must buy in to the concept that we need to be the drivers and the leaders in health care reform, that we need to embrace and become the leaders in effective change, and it is up to us at our individual hospitals to show everyone how to be more efficient, cost effective, and maximize the patient experience. Does this sound familiar? You may have just read almost those same words in AIM’s philosophy section on this web site. AIM embraces this challenge of being the best in all these areas.
Speaker number two of the morning was Dr. David Feinberg, CEO of the UCLA health system. Dr. Feinberg’s talk is one that i hope that all hospitalists can view on the SHM web site so we can all be reminded that it all starts with the patient. His title was ‘Healing Humankind One Patient at a Time’, and he spoke of never being satisfied and getting it right ‘all the time’. He mentioned that 85 out of 100 patients at UCLA give the hospital experience the highest rating, which he said made them the ‘cream of the crap’. He wanted to get it right 100% of the time. That’s no easy task, but I echo his statements, especially regarding mentally making every patient a family member and treating them like you would your own. I have used this same analogy when teaching students, and it works well.
There is some validation when I go to meetings like this that AIM remains way ahead of the curve in terms of the excellent care we provide. Our group remains committed to the team approach, a collaboration among the doctors, nurses, social workers, ancillary personnel and anyone else involved in patient care to create a unified system that minimizes risk, improves satisfaction, and controls costs. Now that the batteries have been recharged and I am satisfied that AIM remains among the best hospitalist groups out there, it’s time to leave Washington, DC and get back to work. I can’t wait to apply some things I learned this week to make us even better.