Transcript Slide 1

Building a Hospitalist Program
from the ground up
Jeff Gill, MD, FAAP
Jeff Sperring, MD, FAAP
Pediatric Hospital Medicine
August 2007
Disclosure
• Neither I nor any member of my immediate family has
a financial relationship or interest with any proprietary
entity producing health care goods
or 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
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…
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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, highvolume 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).
WHAT Story #1 - continued
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
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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.
WHAT Story #3 - continued
• 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.
WHAT Story #3 - continued
• “You want me to admit a 9 month-old newonset DKA…with no PICU, no
Endocrinology support, no insulin drip
policy, no diabetic teaching available?”
“Well Dr. Surething always did that.”
WHAT Story #3 - continued
• “You want me to round on all your Csection 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”
HOW
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Staff & Leadership
Funding
Pitch (Justification)
Psychology & Culture evaluation – “mine
sweeping”
Operations (schedule, administrative support)
Selling your product and setting limits
Securing your future
How: Staff & Leadership
• Given your “What” list, how many docs will
you need?
Consider which number dominates
How: Staff & Leadership
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
How: Staff & Leadership
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
How: Staff & Leadership
• 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)
How: Staff & Leadership
• 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.
How: Staff & Leadership
• Be Careful! This is a classic trap.
Productivity ◄───────►Responsiveness
…you can maximize one or the other, but
not both. Don’t over-promise.
How: Staff & Leadership
• 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.
How: Staff & Leadership
Here comes the math section. Refill your
caffeinated beverage now.
How: Staff & Leadership
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
How: Staff & Leadership
Program A – continued
24 hours/day x 365 days per year = 8760
hours of coverage
FTE = 2080 hours/doc
Need: 4.2 docs
How: Staff & Leadership
Program A – continued
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)
How: Staff & Leadership
Program A – continued
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)
How: Staff & Leadership
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.
How: Staff & Leadership
Program B – continued
Based 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.
How: Staff & Leadership
Program B – continued
• Determine a reasonable standard in your
community for encounters/Hospitalist per
day or per hour.
Example: 1 encounter/doc/hour
…
How: Staff & Leadership
Program B – continued
• Determine how many days/year your docs
will work (for example, 1960 hours/year is
82 24-hour shifts/year)
How: Staff & Leadership
• Program B – continued
30 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: Staff & Leadership
Program B – continued
• How many encounters are there in a year?
42 encounters/day x 365 days/year =
15,330 encounters/year
How: Staff & Leadership
Program B – continued
• 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
How: Staff & Leadership
Program B – continued
15,330 encounters/year divided by
1968 encounters/doc/year
= 7.8 docs.
How: Staff & Leadership
Program B – continued
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 24hour clock.
How: Staff & Leadership
Program B – continued
• 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.
How: Staff & Leadership
Program B – continued
• 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.
How: Staff & Leadership
Program B – continued
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.
How: Staff & Leadership
Program B – continued
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.
How: Staff & Leadership
Program B – continued
17,885 hours per year divided by
1960 hours/doc/year =
9.1 docs
(instead of the 7.8 originally calculated)
How: Staff & Leadership
Who’s in charge?
• Independent Hospitalist-only director
• Pediatric Department leadership
• 3rd Party staffing company
• Pediatric subspecialist (PICU doc?)
• Non-pediatrician
• …?
How: Staff & Leadership
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.
How: Staff & Leadership
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.
How: Staff & Leadership
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.
HOW
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Staff & Leadership
Funding
Pitch (Justification)
Psychology & Culture evaluation – “mine
sweeping”
Operations (schedule, administrative support)
Selling your product and setting limits
Securing 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
General Guidelines (continued):
Always ask for more than you expect to get.
(sigh)
How: Funding
General Guidelines (continued):
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
General Guidelines (continued):
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)
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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…”
Selling your product and setting limits
“…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
Selling your product and setting limits
Whatever style of service you’ve decided on,
recognize that you’ll need to sell it, live it,
& stand behind it…
Selling your product and setting limits
…and you’ll also need to make sure you
don’t get over-stretched or set up to fail.
Selling your product and setting limits
“Under-promise and over-deliver.”
--Tom Peters’ formula for success.
Selling your product and setting limits
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?
Securing your future
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!
Securing your future
“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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