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Inpatient Physician:

Hospitalist: New Team Member

Betty J. Noyes, RN, MA and
Sonya A Healy RN, MS
 

To coordinate care and manage costs, physicians are being added to the inpatient management team. To assist the chief nurse executive in assimilating this new team member into the patient care provider group, the authors describe the role of the hospitalist, the goals of the organization in using the new role, questions to ask and steps to take to ensure success for the whole care team and the organization.

Even after downsizing, rightsizing, quality improvement projects, information systems upgrading, and plain old budget cutting, the cost and quality of care ; may not be meeting the standards of either your healthcare facility or those of the managed care companies. Are you, as the patient care executive, still hearing these comments from patients, nurses, and physicians: "My doctor told me I could go home today but the nurse said that he hasn't written the order. What should I tell my husband?" "The evening charge nurse reported last night that Dr. Smith never called back with the antibiotic order for Mr.Jones. We tried to reach him all night." "Hospital administration keeps making changes in its policies and procedures, our practice group is up in arms, we don't have a voice but we can't possibly attend all those meetings and keep our practice going." If these are comments that you are hearing, something is still missing from the management of care. Recognizing that an important component was absent from care coordination and cost control many practice groups and clinics began to add physicians to the inpatient management team. Early efforts of Hospitalists are found at the University of California in San Francisco. Physicians specializing in hospital-based care are called Hospitalists, a term first coined by Dr. Robert M. Wachter at the University of California at San Francisco (UCSD).

What Is a Hospitalist?

Robert Wachter, MD, at UCSF, defined Hospitalists as physicians who spend a minimum of 25%-100, of their time based in a hospital setting. They serve as the physician of record after accepting referrals of hospitalized patients from primary care physicians. They return these patients to the care of the primary physicians at the time of hospital discharge. achter describes four stages that can serve as a guide to understanding the variation and evolution in models existing today: 

Stage I: Primary Care physician (PCP): Every primary care physician follows his or her own patients into the hospital. This is the traditional system that has existed for hundreds of years in the U.S.
Stage II: Physicians within a practice group rotate hospitalist responsibilities. Members take turns providing care for groups of hospitalized patients. Rotation schedules may last weeks or months. When any of the group's patients are admitted to the hospital for care is provided by the designated hospitalist(s). Typically, the medical group reimburses these physicians itself, although other funding sources may be developed. .
Stage III: Either the medical group practice or the acute care facility hires dedicated Hospitalists. The primary care physician may choose to refer his or her patients to the hospitalist or not. Usually incentives are offered to use the hospitalist. In this stage, some organizations consider using Hospitalists that are provided and managed by outsourcing companies. These companies recruit and provide organizations with credentialed Hospitalists.
Stage IV: On admission to the acute care facility, all patients are "handed-off" to the hospitalist. Either the medical practice group or the acute care facility can provide the hospitalist.

Benefits Derived from the Hospitalist Model

Early data show that the hospitalist model has benefits for all participants-physicians, nurses and other care providers, the hospital and payers, and most importantly, the patient (Fig. 1). As the benefits of Hospitalists have become known, the use of this model is expanding. They are being integrated into the organization of medical staff departments such as internal medicine, family practice, pediatrics, and even surgical services.

     

Benefits to the Patient: Clear and timely explanations about care Rapid access to solve patient needs 24-hours/day Rapid response to emergencies Continued access to other specialists as needed Reduction in the length of stay Decrease utilization of resources Enhanced coordination with other participants of an integrated delivery model Reduced risk of untoward events

New Strategies

Imagine how wonderful it would be if there existed a model of acute care delivery in which all care providers worked as a team and clinical pathways and practice guidelines were jointly developed, applied, and monitored by a care team committed to results outcomes? In this model of care, physicians take a proactive role in redesigning cost-effective systems to support care and are accountable for budgetary compliance? Also, rather than 40 physicians coming in and out of the patient unit, only a few, selected for their clinical, admini.5trative and teamwork abilities, are caring for his or her group of patients and available to the nursing staff, patients and family 24 hours a day. The physician responsible for the patient's care throughout his or her stay would admit that patient directly from the ER. Another aspect of this model means that systems are put into place based on the needs of the patient, not the convenience of the department. This means that it. a diagnostic study were ordered, it would be performed when the physician required it, not when the department opened the following day and the physician would be available to read it immediately. Medical records and other pertinent information would be available through organized information systems. Some of these ideals can be achieved with the addition of the hospitalist to the inpatient care team.

Planning for the New Team Member: Goals and Actions

Planning involves:

• Visioning: What should the model look like and how should it function to be successfully

• Designing: What systems and process design will be necessary to make it function success- fully for each of the stakeholders?

• Ground Rules: W11at are the rules that will de- fine the measurement of success, the roles and responsibility of each of the participants?

• Patient aggregation: Would aggregating patients in clusters facilitate systems, process communication, and outcomes?

• Work Simplification: What processes need to be simplified and clarified to all stakeholders to enhance workflow?

• Communication Plans: What methods and with what frequency will each of the stake- holders be best informed?

• Education and Team Building: Defining the new roles and responsibilities, discussing and understanding performance expectations.

• Monitoring: What data sets will be used to measure outcomes? Which national bench- marks apply?

Goals

The general goals of organizations considering implementing hospitalist programs include:

• Improved outcomes of care

• Lower risk of malpractice incidents

• Reduced cost of patient care for the acute care facility

• Better research and teaching for medical staff education

• Improved operational efficiency throughout the hospital

• Improved patient satisfaction

• Satisfied medical staff with enhanced revenue

Action

Questions and strategies for the Patient Care Executive to consider are:

• What is the "content of care" the hospitalist provides?

• What can the organization do to maximize the effectiveness of that "content" of care?

• How are we going to measure the results of that content?

• What system changes are required and how can we be prepared to do what it takes to achieve them and prove the results?

As with any change to a system, the introduction of the hospitalist to the patient care' team requires redefinition of the team functions, roles, and responsibilities. The care team delivery model must share ownership and accountability with the hospitalist. When adding any new player, team building and involvement of all stakeholders is critical to success. Goals must be identified, integrated, and implemented. The care team must take responsibility for the commitment to collaborative decision making and shared treatment planning. Communication among all members should be valued and teamwork rewarded in new and different ways. The team can be accountable for outcomes both clinical and financial with no passing of the buck. Competency requirements are now team-wide. All are responsible For maintaining and improving clinical expertise: Goals must be measured and monitored. In the planning for shared goals, it is important to identify the fears and apprehension of the stakeholders. There are issues that should be addressed and careful planning and foresight can avoid failure from the doctor's perspective, unacceptable outcomes might be:

• Overworked Hospitalists. The employing organization will require a single hospitalist to see too many patients and work too many hours;

• Communication is fault)' and cumbersome, with increased dissatisfaction among the stakeholders patients, physicians, and agencies;

• Patient satisfaction decreases because the family perceives a lack in care, knowledge, or clinical skill of the family physician;

• Referring physician satisfaction decreases be- cause they feel they have "lost the case" and their credibility as an expert is lost;

• Physicians fear that the revenue generated by seeing patients in the hospital will be lost to them and their office practice will not be able to sustain appropriate income;

• Referral patterns to subspecialists are lost be- cause the hospitalist will "do it all" and not refer to subspecialists, causing them to lose revenue.

  From an operations perspective it would be unacceptable if:

• Nursing is not prepared with the essentials of team building and clarification of roles and responsibilities before the hospitalist is added to the team;

• Operating systems go unchanged and costs rise. For example, when the hospitalist orders a service for a patient and it is not available, the s)'stem is gamed and STAT replaces routines causing costs and frustration to rise within the departments;

• Communication plans fail; blame and finger pointing occur;

• Nurses feel overworked because their functions have not been identified clearly;

• Continuity is disrupted. Referrals are lost and agencies do not understand clearly who to call for what information;

• Costs are not reduced;

• Quality declines because Credentialing and monitoring of the hospitalist have not been defined and monitored.

Careful planning, measurement of outcomes, and redesign improvements can avert these pitfalls. In organizations that have patient satisfaction studies, it was found that scores vary depending on when questions were asked. For example, if a patient were to, be asked, "would you be willing to see a different MD when admitted to the hospital?" versus "when you were in the hospital were you pleased with the prompt response and access you and your family had to an MD?" It has been found that patients and families much prefer access and expertise when the crisis of hospitalization occurs. Of course, even though the hospitalist is the physician of record, the patient's "family" doctor can visit the patient. The close collaboration of all parties is essential to the establishment of a successful hospitalist program. Outcomes will be determined by the hospital, the practice group, the managed care organization, medical staff and nursing, so clear definitions and mutual goal setting is critical.

Conclusion

The authors believe that Hospitalists will become the major providers of inpatient care in the U.S. These models have existed successfully throughout Western Europe for man)' decades. Studies art: needed to show the true outcomes and impact of this model. As a major clinical voice in organizations, patient care executives should embrace this opportunity. Hospitalists cannot be airdropped into the organization and be effective. Many CEOs and physician leaders believe they can. It does provide much hope for the missing links in the chain of efforts to enhance outcomes at reasonable costs. Design and implementation are essential and at times difficult. Information systems are critical aides in communication and data access Legal aspects must be dealt with and difficult medical staff politics must be addressed objectively. Some physicians will need education and mentoring in the efficient use of their time and integration with existing employees and hospital procedures. Procedures may need to be changed to meet new demand schedules. Practice does make perfect. Expert physicians in acute care will add quality. Efficiency does make money and improve care. There is no time to reinvent the wheel. Objective consultants and colleagues who have learned through trial and error can be of invaluable assistance in the establishment of a hospitalist model for your organization.

References:

1. Wachter RM, "Hospitalists fan winds, of change, and inpatient care won't be the same" Managed Health Care 1998;8(1)36-39

2. Noyes BJ. "Hospitalists: Recommendations for successful integration." Reengineering the Hospital. 1998;5(3):6-9 JONA . Vol. 29, No 2 . February 1999