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Building a Hospitalist Program from the ground up

Building a Hospitalist Program from the ground up. Jeff Gill, MD, FAAP Jeff Sperring, MD, FAAP Pediatric Hospital Medicine August 2007. Disclosure.

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Building a Hospitalist Program from the ground up

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  1. Building a Hospitalist Programfrom the ground up Jeff Gill, MD, FAAP Jeff Sperring, MD, FAAP Pediatric Hospital Medicine August 2007

  2. 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.

  3. Resources Society of Hospital Medicine www.hospitalmedicine.org Resource Center Practice Resources  Establishing a Hospitalist Program

  4. Resources AAP Section on Hospital Medicine http://www.aap.org/sections/hospcare

  5. Ground Rules Jargon-Free Zone Basics Practical Tips

  6. Ground Rules Interrupt any time for questions Don’t let something go by that doesn’t make sense Hit us with your experience!

  7. 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

  8. Start-ups are tricky… • Why • What • Who • How • When • …and Then What?

  9. WHY? • Why on Earth would you want a Hospitalist program? • Why on Earth wouldn’t you want a Hospitalist program?

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

  11. 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

  12. 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.

  13. A “why” Story “Why? Because we want the same deal here.”

  14. “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.

  15. “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.

  16. Why? To Fix it. Often, hospitals consider a Hospitalist Program when there are problems to be fixed. What problems do you need to fix?

  17. 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

  18. 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.

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

  20. WHAT • What services need to be provided?

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

  22. 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.

  23. 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).

  24. WHAT Story #1 - continued But there’s nothing else for the Hospitalists to do.

  25. 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!

  26. WHAT Story #2 • Hospital Administration & the Pediatric Department decides that the Hospitalist on duty can…

  27. 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…

  28. 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.

  29. 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.

  30. 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.

  31. WHAT Story #3 - continued • “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.”

  32. WHAT Story #3 - continued • “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.”

  33. 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.

  34. 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!)

  35. 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

  36. WHO? • Who will staff your Team?

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

  38. 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…

  39. WHO? • Every model has its own set of advantages and disadvantages…

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

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

  42. HOW • Staff & Leadership • Funding • Pitch (Justification) • Psychology & Culture evaluation – “mine sweeping” • Operations (schedule, administrative support) • Selling your product and setting limits • Securing your future

  43. How: Staff & Leadership • Given your “What” list, how many docs will you need? Consider which number dominates

  44. 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

  45. 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

  46. 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)

  47. 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.

  48. 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.

  49. 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.

  50. How: Staff & Leadership Here comes the math section. Refill your caffeinated beverage now.

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