robert m. wachter, md

Whipsawed: Can Hospitalists Thrive in the Face of

Co-Management, Non-Teaching Services, Transparency, P4P, and the

Reality of Perpetual Change?Robert M. Wachter, MD

Professor and Chief of the Division of Hospital MedicineUniversity of California, San Francisco

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.




are needed to see this picture. QuickTime™ and aTIFF (Uncompressed) decompressor




Just in the Past Five Years

Rheumatology: TNF blockers Neurosurgery: Gamma knife Obstetrics: No VBAC Geriatrics: Aging population Pediatrics: Couple of new vaccines



And Hospitalists? Quality/Value: measurement, reporting, P4P, and massive cost

pressures (think Berwick/Morrison’s talks) Patient Safety: NPSGs, marked increase in state regulatory

activity, reporting of errors, no pay for preventable adverse events

IT: Most hospitals building new systems Patient population: Morrison’s HONDAs, hospital

overcrowding ACGME Regulations: End of residents as inexhaustible cheap

labor force Workforce: Doubling (or more) of many programs

Hospitalists, cont.

Oh yeah, and there have been a few changes in

clinical hospital medicine too!

QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.

Whipsaw |ˈ(h)wipˌsô|

(noun) a saw with a narrow blade and a handle at both ends, used typically by two people.

(verb) subject to two difficult situations or opposing pressures at the same time : the army has been whipsawed by a shrinking budget and a growing pool of recruits.

(verb) compel to do something.



With Change Comes Opportunity…

Life consists not in holding good cards but in playing those you hold well. Ecclesiasticus



Opportunity is missed by most people because it is dressed in overalls and looks like work. Thomas Edison QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.

But With Opportunity Comes Change… and Challenge

No field in the history of medicine has needed to be as cognizant of context– National – Regional– Local

» C-Suite» Other docs» Nursing

The goal: benign but purposeful opportunism (BBPO)





Some Observations on the Biggies

Quality Safety IT Co-management Residency replacement Workforce growth

Quality I: Megatrends

Recognition of the power of simple transparency Appreciation of limitation of trained seal process

measures Shift toward outcome measurement…

– ICU outcomes

– Readmission rates

– Risk-adjusted hospital mortality

– Patient satisfaction

Even if payer P4P stalls out, local P4P will grow

Quality II: Implications For Us Begin to shift focus on improving broader

outcome measures– Do you know your outcomes in key areas?– How would you improve them (particularly

readmit rate and overall case-mix adjusted mortality)?

How can you make “local P4P” work for you? Even with fewer “trained seal” measures,

you’ll still need to be able to catch fish in your mouth


Patient Safety I: Megatrends

Joint Commission has run out of low-hanging fruit– High risk abbreviations vs. improving communication &

med rec

Emergence of state reporting systems – Key shift was NQF “Never Events” list

Recognition of importance of culture– So now what?

No pay for errors – a clever strategy to put skin in the game

Pt. Safety II: Implications For Us

New targets: nosocomial infections, decubs, falls– Limited evidence-base for prevention– “Present on admission” initiatives

Taking RCAs to the next level– Extraordinary transformation at UCSF: the weekly RCA

Possible that we may be ready to attack culture– Hospitalists should own this

Zero tolerance for the disruptive physician– Well, maybe a little for the rainmaker proceduralist



IT I: Megatrends

Tremendous growth in IT implementations Some consolidation in industry; big dogs

beginning to sniff around– GE, Microsoft, Google

IT-induced errors and unintended consequences a hot topic

IT isn’t just CPOE– EMRs, barcoding, Vocera, cellphones, smart pumps, e-

ICUs, telemedicine…

Emergence of IT haves and have-nots







IT II: Implications For Us Hospitalists becoming key IT go-to people The tight link between IT and the other mega-forces

– Quality measurement (including case-mix adjustment, billing)– Safety targets– Regulatory compliance

As targets change, IT will need to change with it– Readmit rates: improve care across continuum– No pay for errors: improve capture of “Present on Admission”

Another barrier to entry for outpatient-based docs The IT-induced “Dis-location” of medicine

– Where do people write their notes?– The death of radiology rounds– The flattening of healthcare

Surgical Co-Mgmt I: Megatrends

Value (quality/cost) the name of the game Surgeons not available for 8-10 hours/day

– Similar to PCPs, just different reasons

Compared w/ surgeons, hospitalists are cheap labor Few surgeons skilled in (or enjoy) management of

medical co-morbidities Training programs: duty hours led Chairs to

abandon notion of training surgeons in medicine

Surgical Co-Management II: Implications For Us

Massive growth in co-management “opportunities”– UCSF: Neurosurgery, Ortho, BMT, Complex CHF…– Once size won’t fit all (“real” hospitalists vs. PGY4s)

Inevitable tension over who pays (the “global fee”) Need thoughtful terms of engagement, inc. triage rules Much more comfortable transition in community than in

academia– Violation of our prized silos

If you don’t like it, find other work– Don’t bother trying not to own this

Great to have friends in high places


ACGME Regs: Megatrends

End of residents as cheap labor pool– Need for docs to replace much of this labor in many areas

Recognition that residents are mostly there to learn– And that they require supervision

“We have a 250-bed community hospital embedded within a 800-bed AMC”– AMCs are going to have to figure out how to function like

community hospitals

QuickTime™ and aTIFF (Uncompressed) decompressorare needed to see this picture.QuickTime™ and a

TIFF (Uncompressed) decompressorare needed to see this picture.

ACGME Regs: Implications For Us

Massive growth of non-teaching services Fundamental questions over “What is a hospitalist”?

(and particularly what is an “academic hospitalist”?)– Challenges re: job satisfaction, 2nd class citizen, promotion

Time to thoughtfully build new teams– Who are the right players, how are they trained?– What things should be localized on specialized teams (eg,

procedures)? The ultimate bargaining chip in hospital negotiations

– “We’re happy to do this, if…”

Hospitalist Growth: Megatrends

Unprecedented in the history of medicine In any field, rapid growth creates challenges

– Differentiation and specialization– How to ensure quality– How to retain (or thoughtfully evolve) culture– How to adapt management structure from “start-up” to

mature business Recruitment and retention now the dominant

themes

UCSF Hospitalist Program

0

10

20

30

40

50

60

1997 2001 2005 2008 2017

Starting Up

Buy-In Complete

Resident Duty Hours

Managing Everybody and Everything

Big-Time Comanagement

Faculty

Growth: Implications For Us Inevitable tensions re: “old timers” vs. “newbies”

– Especially if older folks successful in differentiating

– “Diastolic dysfunction”

At UCSF, 8 out of last 9 hires young women– Maternity leaves ~ the lunchtime crowd at McDonalds

Managing across multiple axes:1. Scope of practice

2. Coverage hours

3. Quality of people (sometimes trumps all)

Increasing challenge for all programs

Everybody Wants Us!!!

Now, can somebody make it stop?



“He had a hat!”

Can We Thrive While Being Whipsawed?

Takes new set of skills– Leadership, change management, team building,

saying “no”, or “yes, if…” Leadership and innovation must be everybody’s

job, not just the leader’s– The “charismatic leader” model doesn’t work once

you grow beyond a certain size– Needs to be replaced by (gasp) a BUREAUCRACY

Innovation doesn’t just happen– Training, brainstorming opportunities, retreats– Can’t just worry about today’s pt. and e-mail




Can We Thrive? Hell, Yes

Change is harsh if you can’t control/lead it– We are in staggeringly good position to do so

When it gets boring, it’s time to start looking for a new job– Why would you ever want to do anything else?

It’s not their fault that everybody wants you to do more with less– It’s yours if you let them– Key is to make them see that creating favorable conditions

is in their interest, not just yours

Remember Gretsky’s Rule

“Skate to where the puck is going, not to where it is.”



But also the Herb Brooks (coach of the “Miracle on Ice” Olympic team) caveat:

“You'd have to be a real idiot to skate to where the puck used to be. On the other

hand, if everyone skated to where the puck is going, you'd have one big train wreck.”



robert m. wachter, md

Documents