building a hospitalist program from the ground up jeff gill, md, faap jeff sperring, md, faap...

Building a Hospitalist Programfrom the ground up

Jeff Gill, MD, FAAPJeff Sperring, MD, FAAP

Pediatric Hospital MedicineAugust 2007

Disclosure

• Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goodsor services related to the content of this CME activity.

• My content will not include discussion/reference of any commercial products or services.

• I do not intend to discuss an unapproved/investigative use of commercial products/devices.

Resources

Society of Hospital Medicine

www.hospitalmedicine.org

Resource Center Practice Resources Establishing a Hospitalist Program

http://www.hospitalmedicine.org/

Resources

AAP Section on Hospital Medicine

http://www.aap.org/sections/hospcare

Ground Rules

Jargon-Free Zone

Basics

Practical Tips

Ground Rules

Interrupt any time for questions

Don’t let something go by that doesn’t make sense

Hit us with your experience!

Disclaimers

• Why California is “special”• References to a particular flavor of service

(e.g. “24/7”) are not meant to imply that it is superior

• When you’ve seen one Hospitalist program, you’ve seen one.” (Jack Percelay)

• We will assume that at least a few folks in the room might be unfamiliar with any given concept presented

Start-ups are tricky…

• Why

• What

• Who

• How

• When

• …and Then What?

WHY?

• Why on Earth would you want a Hospitalist program?

• Why on Earth wouldn’t you want a Hospitalist program?

WHY?

• Understanding the spectrum of interests is critical to determining preparatory steps.

Sample Answers to “Why?”

• Our competing hospital has a program…

• We need someone to cover all the uninsured patients

• So someone can cover our patients during nights and weekends (we’ll do the rest)

• Our LOS is too high—a program would lower the LOS, and save us money

A “why” Story

A nice community hospital “NCH” is considering a Hospitalist Program.

Many Pediatricians on staff at NCH also practice at another medical center “AMC” 15 miles away. The AMC has a 24/7 in-house Team which handles the bulk of admits. The community Pediatricians enjoy the lifestyle benefits, and have a favorable financial arrangement at AMC.

A “why” Story

“Why? Because we want the same deal here.”

“why” Story - continued

But…

The AMC has >30 Pediatric Beds, high-volume ED, level III NICU, and good subspecialty support.

NCH has 4 Pediatric beds, a slow level II nursery, and slow ED.

“why” story Moral

Sometimes the “why” is part fantasy. You’ll need some objective data to help you design the program you need, and to help support the pitch.

Why? To Fix it.

Often, hospitals consider a Hospitalist Program when there are problems to be fixed.

What problems do you need to fix?

Fix-it List

• Local PCP’s overwhelmed by rising outpatient volumes…not enough time to care for hospital patients.

• Community hospital service eroded by rising referrals to tertiary centers

• Nobody to care for uninsured patients

Whose Idea is this Anyway?

• The “Fix it” list is intimately associated with the party (or parties) that bring up the idea of a Hospitalist Program in the first place.

Take Home – WHY

Make sure you have a clear idea of why they want a Hospitalist Program, and who “they” are.

WHAT

• What services need to be provided?

WHAT

• A small Pediatric Unit with nearby tertiary support may readily be managed with daytime docs and home call.

• vs…

WHAT Story #1

A mid-sized urban hospital (MUH) shares services with its larger “sister hospital” (LSH) across the street.

MUH has no Pediatric services, but has a very busy L&D service and NICU.

WHAT Story #1 - continued

For various reasons, the MUH decides to replace their Nurse Anesthetist Team with a 24/7 in-house Hospitalist group, whose sole duties are to attend deliveries, and stabilize sick newborns (with good neonatology back-up).


But there’s nothing else for the Hospitalists to do.

WHAT Story #2

• Nice Community Hospital (NCH) has moved forward with their plans for a Program. Since there are only 4 Pediatric beds, they get creative.

We’ve got to get our money’s worth!

WHAT Story #2

• Hospital Administration & the Pediatric Department decides that the Hospitalist on duty can…

WHAT Story #2

• care for inpatients on the ward

• attend all newborn deliveries

• cover the NICU patients

• serve as a “pop-off” to the ED when it’s busy

• staff a new after-hours urgent care clinic…

WHAT Story #2

…and since they’re up all night anyway, they can handle all the after-hours advice calls for all of the Pediatricians on staff.

WHAT Story #3

• Big Community Medical Center (BCMC) had a dwindling Pediatric service…but there was one Pediatrician on staff, Dr. Surething, who would do anything for anyone—no questions asked.


• A Hospitalist Program was implemented… and for the first few months, the bewildered Hospitalist Team had to say “NO” far more often than they anticipated.


• “You want me to admit a 9 month-old new-onset DKA…with no PICU, no Endocrinology support, no insulin drip policy, no diabetic teaching available?”

“Well Dr. Surething always did that.”


• “You want me to round on all your C-section newborns only on day #3 of their 4-day stay because you can’t bill for that day?”

“Well Dr. Surething always did that.”

WHAT Moral

• Have a clear understanding of what the duties of the Hospitalist will be—and what they won’t.

• Know the history & culture—things work differently in different centers. If you didn’t work there before, you might not know something that’s done differently from what you’re used to.

WHAT Moral

• What kind of service do you want to offer?– Obsequious scut monkey– Pirate (now it’s MY patient and I’ll do whatever

I want—har har har!)

WHAT Moral

• What kind of service do you want to offer?– Well-defined but limited services, few changes

anticipated– Open-ended, less-defined, adapt on-the-fly– Specialized list of services, but willing to grow

over time in a controlled manner

WHO?

• Who will staff your Team?

WHO?

• The role of Extenders is a separate topic with MUCH merit…but won’t be discussed here.

WHO?

• Team of dedicated Hospitalists

• Core Team of Hospitalists sharing call or other duties with community physicians

• Collaboration by community physicians with a single director

• Other models…

WHO?

• Every model has its own set of advantages and disadvantages…

HOW?

So this is the part you’ve been waiting for?

HOW

Now that you’ve got “Why” and “What” you can start on “HOW”

HOWHOW

• Staff & LeadershipStaff & Leadership

• FundingFunding

• Pitch (Justification)Pitch (Justification)

• Psychology & Culture evaluation – “mine Psychology & Culture evaluation – “mine sweeping”sweeping”

• Operations (schedule, administrative Operations (schedule, administrative support)support)

• Selling your product and setting limitsSelling your product and setting limits

• Securing your futureSecuring your future

How: Staff & Leadership

• Given your “What” list, how many docs will you need?

Consider which number dominates


If the key to “Why” is too many patients, start by basing your staffing on patient load.

Determine a reasonable standard for patient load in your setting. – Encounters– RVU’s


If the key to “Why” is the need for an available doctor, start by basing your staffing on hours of coverage.

Determine a “Full-Time Equivalent”

- A “Management FTE,” 2080 hours

- Total in-house hours + call per doc

- Other standards


• If your doc needs to be readily available but not “awake” until needed, adjust your FTE.– On-site duty + home call (compensated or

not)– On-site duty + in-house “call” (Gill’s light-bulb

test)– On-site duty 24/7 (Administration’s

comparison group)


• If the What & Why require that a doc’s response time is short, and/or that multiple services need to be covered simultaneously, then it is less likely that a single doc on duty can cover all services.

• consider hours of coverage per day need to ensure required response time.


• Be Careful! This is a classic trap.

Productivity ◄───────►Responsiveness

…you can maximize one or the other, but not both. Don’t over-promise.


• Be Careful! This is a classic trap.

# of Patients ◄────►Speed of response

…you can maximize one or the other, but not both. Don’t over-promise.


Here comes the math section. Refill your caffeinated beverage now.


Sample calculation: Program A

• All services can be covered by one doc

• Local community standard is 24-hour shifts in-house

• FTE is 2080 hours

• Patient volume is low


Program A – continued

24 hours/day x 365 days per year = 8760 hours of coverage

FTE = 2080 hours/doc

Need: 4.2 docs



Not so fast!!

• If you have a face-to-face handoff daily, then 2 docs are present at one time– Add 1 hour per day (30 min per doc)

• Don’t forget vacation and CME! – Subtract 80 – 120 hours from FTE (equivalent

to 2 – 3 weeks vacation)



Revised Calculation:

25 hours/day x 365 days per year = 9125 hours of coverage

Productive hours = 1960/doc

Need: 4.7 docs(vs. 4.2 in original calculation)


Sample calculation: Program B

The Pediatricians on staff decide they want the Hospitalists to do all care.

Administration has recently opened an OBS Unit, which has gone unused.

The ED docs feel they have insufficient Pediatric support for consults.


Program B – continuedBased on historical data, you estimate about

30 encounters per day on the Peds unit.The OBS unit has 4 beds, and there is

sufficient volume in ED that could fill these beds most of the time (~6 encounters/day)

ED sees 10,000 patients, (about 3,000 kids) per year…and you have no idea how often you’d be consulted.


Program B – continued

• Determine a reasonable standard in your community for encounters/Hospitalist per day or per hour.

Example: 1 encounter/doc/hour

…



• Determine how many days/year your docs will work (for example, 1960 hours/year is 82 24-hour shifts/year)


• Program B – continued30 encounters on floor +6 encounters/day on OBS +6 consults/day in ED (guess!)= 42 encounters/day

For this example, assume need is the same 7 days per week



• How many encounters are there in a year?

42 encounters/day x 365 days/year =

15,330 encounters/year



• How many encounters can your doc crank out in a year?

1 encounter/doc/hour x 24 hours/shift x 82 shifts/year

= 1968 encounters/doc/year



15,330 encounters/year divided by

1968 encounters/doc/year

= 7.8 docs.



Not so fast!!

• Patients do not arrive one at a time, on the hour. A “reasonable standard” of 1 patient per hour may not match the reality of the flow of work to be done, considering a 24-hour clock.



• Consider the “response time” question. If the expectation is for floor patients to be seen (and discharged!) in a timely fashion (typically AM), and for OBS patients to be evaluated/re-evaluated frequently, then some adjustments may be needed.



• Consider instead, how many docs will it take to get the actual work done in the time frame of interest (7a – 4p? 8a – 8p?), and how much volume of work there is to do at night, weekend, other potentially slow times.



You estimate that the ward work will take 2 docs daily to complete in a reasonable time frame; OBS could be run by one doc, who might be able to pop down to the ED a few times a day. Nights involve floor calls and ED admits, but can be handled well by one doc.



Recalculation:

2 docs/12-hour day shift (floor) +

1 doc/12-hour day shift (OBS + ED) +

1 doc for 13 hour night shift (don’t forget the hand-off!) =

49 hours of coverage/day or 17,885 hours per year.



17,885 hours per year divided by

1960 hours/doc/year =

9.1 docs

(instead of the 7.8 originally calculated)


Who’s in charge?

• Independent Hospitalist-only director

• Pediatric Department leadership

• 3rd Party staffing company

• Pediatric subspecialist (PICU doc?)

• Non-pediatrician

• …?


Who’s in charge?

Regardless of the model you use for leadership, ensure that you avoid setting up a director who has responsibility but no authority.


Who’s in charge?

Leaders must be accountable to the client (hospital), and to the docs/group. Be careful to separate accountability and interest. Avoid conflicts of interest.


Who’s in charge?

Leaders must be intimately familiar with all aspects of the work of the docs/group. If the leader does not have this familiarity from direct personal experience, then the leader must be supported by others who do.

HOWHOW

• Staff & LeadershipStaff & Leadership

• FundingFunding

• Pitch (Justification)Pitch (Justification)

• Psychology & Culture evaluation – “mine Psychology & Culture evaluation – “mine sweeping”sweeping”

• Operations (schedule, administrative Operations (schedule, administrative support)support)

• Selling your product and setting limitsSelling your product and setting limits

• Securing your futureSecuring your future

How: Funding

General Guidelines:

• It is very unusual to run a Pediatric Hospitalist Program without institutional support of some kind. (Congrats to the exceptions…you know who you are.)

• It may be almost impossible to start-up a program without support.

How: Funding

General Guidelines (continued):

In business, you don’t get what you deserve, you get what you negotiate.

How: Funding


Always ask for more than you expect to get.

(sigh)

How: Funding


A “rough, ballpark estimate just to use as a starting point…” will be used as your final figure, if subsequent estimates are higher than your initial figure.

How: Funding


Create a “pro-forma budget”

How: Funding

A “pro-forma budget”…

(Business-ese for “reasonable guesses about the future expenses of a business that hasn’t been started yet”, more or less)

Pitch (Justification)

• What are you going to do?

• How are you going to do it?

• Why is it going to be worth it?

• Why should it be you instead of someone else?

Psychology & Culture evaluation – “mine sweeping”

• Understand your medical staff and administration.

Example: one of the most consistent Medical Staff concerns around start-ups is…

Medical Staff Concerns

• “I’m the Captain of this Ship, and I don’t need any Pirates interfering with my patients.”

After I heard this, I had to change my company logo. Here’s the old one:

Psychology & Culture evaluation – “mine sweeping”

“Culture eats strategy for lunch every day of the week.”

--Andy Grove, former Chairman of Intel Corp.

Operations (schedule, administrative support)

• The world’s greatest Pediatricians can’t do their best if they don’t have someone to run the home office…well.

• Find good help and pay for good resources.

Selling your product and setting limits

“In the 21st Century, if you’re in medicine, you’re in business…”


“…and if you’re in business, you’re in sales.”

--Jeff Gill

“What” reprise

• What kind of service do you want to offer?– Well-defined but limited services, few changes

anticipated– Open-ended, less-defined, adapt on-the-fly– Specialized list of services, but willing to grow

over time in a controlled manner


Whatever style of service you’ve decided on, recognize that you’ll need to sell it, live it, & stand behind it…


…and you’ll also need to make sure you don’t get over-stretched or set up to fail.


“Under-promise and over-deliver.”--Tom Peters’ formula for success.


Better yet, set yourself up so you can say “yes” more than you have to say, “no.”

Securing your future

Now that you’ve got your program up and running, how do you keep it?


It is exceedingly difficult to demonstrate the difference in clinical performance between a great group and a pretty good group.

(Outcomes, productivity, professional fee revenue, utilization, etc.)

Be a great group clinically, but ALSO be great at being…a great group!


“The best way to ensure your job security, or the security of your company in the marketplace, is to find ways to make yourself indispensable.”

--George Comstock

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building a hospitalist program from the ground up jeff gill, md, faap jeff sperring, md, faap...

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