The Secret to Building a Successful Hospitalist Program

Ken Simone, DO, FHM, is a board-certified family physician and the founder and president ofHospitalist and Practice Solutions, a consulting company that develops, restructures, and redesigns hospitalist programs.

His book, Hospitalist Recruitment and Retention: Building a Hospital Medicine Program, is designed to guide administrators, clinical directors, medical staff leaders, and practice managers through the recruitment and retention process by analyzing current trends in hospitalist medicine and exploring factors that contribute to the challenges associated with recruitment and retention.

For several years now, it’s practically been a requirement to use the phrase “the fastest-growing medical specialty” when talking about hospital medicine. Is there still that sense of being “the next big thing” in healthcare within the profession?

Yes and no. Hospital medicine has arrived but in terms of its impact it still is the “next big thing”. In my opinion, there are many exciting changes on the horizon in which hospitalists are poised to embrace. For example, there is much to be accomplished in the areas of patient safety, the delivery of quality medical care, and cost containment. These areas require proficiency in both coding and chart documentation, the creation of and adherence to evidence-based quality guidelines, and the development of both clinical and operational systems. For example, these physicians are on the IT (Information Technology) front line helping to develop communication systems which support continuity of care, patient safety, and improved patient outcomes. Hospitalists will also continue to expand beyond direct clinical care. They will play a prominent role in both policy making and healthcare reform. They will add to their numbers in the c-suite. Hospitalists will continue to perform cutting edge clinical research. Hospitalists will also be charged with providing the majority of inpatient training to Family Medicine and Internal Medicine residents.

What is the current state of the hospitalist market in terms of supply and demand for hospitalists?

The hospitalist market is far from saturated. The challenge will be to answer “where do these hospitalists come from”? In my opinion, these new hospitalists will emerge from several diverse pools, including Family Medicine and Internal Medicine residencies. Family medicine physicians will play a significant role by filling the gap in the demand. These physicians have traditionally provided substantial medical care within the hospital and are positioned to fulfill this need. Additionally, Physician Assistants and Nurse Practitioners (eg, mid-levels) will play a role in filling this gap. If trained properly, these mid-levels will compliment the predicated physician supply shortage. I also believe that a significant number of primary care physicians will continually leave private practice as a result of the endless paperwork, regulatory changes, and financial pressures and therefore provide another pool of hospitalists.

Hospitalist tracks within traditional residency programs (in internal medicine, family medicine, and pediatrics) and fellowship programs (physician) are being created throughout the country, offering additional training to those interested in starting a career in hospital medicine.

What are the key challenges in building and maintaining a thriving program for private hospitalist practices?

Private hospitalist practices will be challenged with providing all of the services that are demanded from both their communities and sponsoring hospitals while containing costs. These practices typically do not have the financial resources available as do hospitalist management companies or hospital employed programs (although there are some large private multispecialty hospitalist groups who do have the resources). Private hospitalist practices must be adept at appropriately staffing their programs through both the development and implementation of a short and long-term recruitment and retention plan. This should minimize hospitalist turnover, resulting in practice stability thus, meeting the demands of the medical community. These practices must work collaboratively with hospital administration and exemplify community value through the delivery of quality and cost effective medical care. It is through this attention to fiscal responsibility that these practices will garner both institutional financial and operational support.

How do those differ from the challenges faced by hospital-owned programs?

Hospital-owned practices employ their physicians and typically supply financial, operational, and IT support for their hospitalist practice. This is immensely important because most hospitalist practices do not cover the cost of their salaries and benefits, and thus require financial support (subsidy). Hospitalist practices have difficulty covering their costs because of a variety of factors. Payer mix, participation in non-reimbursable services, and providing services during relatively unproductive hours (eg, night call) all contribute to this phenomenon. Therefore, programs which are financially integrated within their sponsoring institution are accommodated for this disparity. While hospital employed practices must justify this subsidy, hospital administrators are usually more critical during negotiations with private hospitalist groups. Finally, the employed model implies loyalty and aligned goals (real or imagined) with the sponsoring institution, whereas, hospital administrators may view independent hospitalist groups as having conflicting interests.

What I have presented may not always be the case. If a private group has effective leadership it will be proactive during the start-up phases of the program. This will align its goals and objectives with the sponsoring hospital, developing a mutually beneficial working relationship. In many instances, my hospitalist management consultative services are requested either by the hospitalist group or sponsoring institution to provide guidance through this crucial period.

In the book, you stress the need to identify and attract “the right people” and ensure that candidates’ vision and values match those of the program, institution, and community. What are some concrete steps recruiters can take to do this?

The recruiter should screen each candidate and discuss the practice opportunity in detail. This includes discussion of practice specifics including hospital size, geographic location (and demographics), patient demographics, cultural and spiritual interests, practice size, practice scope (including teaching and/or research opportunities, skills required, etc), practice ownership, work schedule, call obligations, leadership opportunities, etc. Recruiter should also query the candidate regarding his or her practice, professional, geographic, cultural, and spiritual needs.

Recruiters can perform a focused recruitment effort. This may include a targeted search in similar geographic areas (eg, rural, suburban, or urban), hospital size (eg, major medical center, teaching program, community hospital, critical access hospital, etc), patient demographics, etc. They may also tap into their physician (or midlevel) network for referrals. Recruiters should also perform a preliminary reference screen of the candidate regarding compatibility with the practice opportunity specifics.

What are the dangers of hiring poorly matched candidates?

There are many dangers. Recruitment efforts are very costly and time consuming. Some sources estimate that recruitment efforts can approach $100,000 when all is said and done. This includes direct costs as well as lost productivity by clinical and administrative individuals during the recruitment process. If the recruitment effort results in a poor match the new hire may leave or be terminated and the recruitment costs will grow exponentially.

Mismatched candidates/hires can have a negative effect on program morale as well as performance (financial and clinical). This may contribute to practice instability and hasten turnover of other providers therefore further compounding the problem. Lack of candidate retention will also result in a continued program workforce shortfall.

Do hospital programs pay enough attention to physician support and retention?

In my consultative experience recruitment and retention is the Achilles heel for most hospitalist programs. Although some programs excel with regard to physician support and retention many programs fall short. Programs fall short for a variety of reasons. Its leaders may not prioritize recruitment and retention because they lack an appreciation for the consequences of failed efforts. Other programs may create an ineffective plan while others have a sound process in place but lack the appropriate resources or staff. Suffice to say programs that pay particular attention to the recruitment process and have a retention plan in place tend to be more successful at hiring and retaining hospitalist candidates (eg, they identify candidates whose goals, values, and vision are aligned with those of the practice).

What are the most important characteristics of a successful retention plan?

A successful retention plan addresses a number of core issues. The plan should include a comprehensive orientation program that is informational and educational in nature. The orientation may also include job shadowing on the hospital wards for a set number of days. The retention plan should also include formal “check-in” by the hospitalist leader (eg, clinical director) at predetermined times such as three- and six-months post hire, as well as informal “check-in” by peers and the program administrator. This allows program leaders to identify potential problems and proactively attempt to head them off. Additionally, it allows the new hospitalist to provide feedback about his/her experience. The plan should also attempt to integrate the new hire into the practice and community. This can be accomplished by assigning a “buddy” or mentor based on a number of characteristics (ie, similar age, ethnical background, hobbies, family circumstances, etc). A concerted effort should be made to integrate the spouse/significant other, and family within the community. Surveys indicate that community fit for the spouse/significant other and family is an important factor influencing physician retention. A mentor (which can be the same individual as the “buddy”) should be assigned for inexperienced hospitalists. The mentor can serve as an advisor and teacher during the first year of hire. There are many other strategies that may be employed depending on the circumstances and practice resources.

What effects do high turnover volume and other retention problems have on a practice?

High turnover volume negatively impacts both the clinical and financial performance of the practice including clinical outcomes, resource utilization, cost effectiveness of the program and hospitalist efficiency. In addition, an understaffed program may lower program capacity and provider availability further impacting practice finances. Diminished hospitalist availability can create throughput problems within the hospital and cause a bottleneck within the emergency department (leading to an increase in patient wait times, patient diversion to competing hospitals, etc). High turnover negatively impacts hospitalist morale and job satisfaction and typically leads to further turnover. This will result in recruitment difficulties because most candidates view frequent turnover as a red flag. High turnover may also affect patient, referring provider, specialist, and nursing satisfaction with the program. Finally, retention problems can negatively affect PCP and specialist recruitment into the community.

You talk about the importance of the “culture” of the practice a lot in your book, noting that it plays a significant role in retention and recruitment. How do you define that term, and how does it factor in retention and recruitment?

Practice “culture” refers to the values and motivating factors of the providers within a practice. For example some practices value quality of life (eg, work-life balance), others may be driven by hard work and money (eg, the entrepreneurial spirit), while others may be committed to quality of care and patient safety. In many ways, practice culture defines the job opportunity-workplace environment. Successful practices are in touch with their culture. Each provider embraces and commits to it.

Practice culture is very important to the recruitment and retention process. Recruiting practices must identify their “culture” (the mission, vision, objectives, and values of the program) and aggressively seek like-minded candidates. This process starts from the very first contact with the candidate. The program leaders should portray practice culture with every candidate encounter from the initial contact through the site visit). If the leaders fall short in clearly communicating the practice culture this may lead to a hiring mismatch. This may translate into job dissatisfaction, behavioral problems, disruptive practice partners, and poor retention rates.

According to a 2006 retention survey by the American Medical Group Association and Cejka Search, 51% of physicians who left their jobs did so because of poor cultural fit.

If you could give one piece of advice to administrators who are looking to start a hospitalist program what would it be?

Plan, plan, and then plan. Specifically, develop both a business and strategic plan (short and long-term) before program start-up. As part of this process, administrators (and physician leaders) should clearly identify all of the factors that lead to the development of a hospitalist program and share it with all stakeholders. This will help define the programs’ mission, vision, objectives, and values. The administrators and physician leaders should involve key parties in the process and elicit feedback prior to program creation. This process allows stakeholders to have “ownership” and buy-in with the hospitalist program. Their support is crucial to the programs’ success.

What are the most common errors or mistakes made by startup programs?

Much goes into the start-up of a hospitalist program with the potential for many pitfalls. Some programs either underestimate or fail to appreciate the amount of funding and subsidy required to run a fully mature hospitalist program. This becomes problematic from both a clinical and financial perspective. I’ll illustrate this point with the following example: if resources aren’t allocated for transitions of care such as the patient discharge (from the hospital) this may result in unexpected readmissions (a negative clinical outcome). This unexpected (and often unnecessary) readmission can result in consumption of costly and non-reimbursable services expensing the hospital thousands of dollars per occurrence. This example also illustrates (1) the failure to develop both clinical and operational systems and (2) the lack of collaboration between the hospitalist program and hospital to create delivery care systems (which is another common oversight).

In many instances programs don’t accurately staff the practice at start-up or project staffing needs 6-12-months down the road. Typically, these programs underestimate the demand for and popularity of their services. When a program is understaffed it can lead to hospitalist burnout, poor clinical outcomes, overutilization of resources (and thus poor financial performance), and physician turnover. Furthermore, referring-provider satisfaction may be negatively impacted due to lack of hospitalist accessibility and/or poor clinical outcomes (and poor communication). Inadequate staffing may ultimately undermine the viability of the program. As a counterpoint, overstaffing may lead to financial difficulties within the practice. It may also create a false sense of workload expectations for the hospitalists. When the census grows and becomes more appropriate the providers may complain that they’re overworked and understaffed.

Lack of hospitalist practice leadership is an error made by many start-up programs. Some practices fail to designate a leader (eg, clinical director) prior to program start-up. In other instances the practice may hire an ineffective leader. Finally, a leader may be appointed but the administrative team fails to empower this individual. In any of these examples lack of program leadership may undermine hospitalist provider effectiveness, overall program success, and hospitalist relationships with key stakeholders. In my experience the hospital and medical community suffer when there is a leadership void within the hospitalist program. In these situations the program may not realize their full potential.

Lack of development of a recruitment and retention program is another common pitfall of start-up practices. Its leaders may be preoccupied with other operational and clinical tasks (and fail to prioritize an ongoing recruitment plan).

Failure to educate and consensus build with the key stakeholders prior to program start-up is another common error. I have discussed the merits of involving the stakeholders in your previous question.

Some programs fail to align the hospitalist programs’ vision and objectives with the institutions’ which may cause several problems downstream. This can be avoided by developing collaborative tools and strategies such as the creation of a hospitalist policy and procedure manual and holding joint meetings periodically. There are many additional tools and tactics that I recommend to my clients during the start-up phase of the program.

In the book, you say that administrators who want to run a successful hospitalist program need to understand the demographic changes occurring in the medical field. How is the physician workforce changing and what effect does this have on recruitment?

According to recent data from the American Medical Association, 67% of practicing physicians are over the age of 42 (the mature and boomer generations), 18% are 61 years of age or older, 49% are between 42 and 60 years of age, and 88% are male. Approximately 33% of practicing physicians are between 27 and 41 years of age (GenX sector), and 42% are female. Furthermore, 54% of new medical school graduates born after 1980 are female (Millennials). What this tells us is that the there are more females entering the workforce and that Generation X physicians will dominate the field in years to come.

Female physicians spend fewer hours per year providing patient care, are less likely to practice in rural areas, and tend to retire slightly earlier than do their male counterparts. Many females want to raise a family and are attracted to practice opportunities which allow for part-time work and/or job sharing. In order to appeal to this particular subset of candidates it will be helpful to pay particular attention to the scheduling model and present job sharing opportunities (if it exists in the program). The program may even consider creating a job sharing position for the right candidate.

The characteristics of GenX individuals are as follows: they appreciate organizations that provide strong orientation and mentoring programs, and they are self-reliant. While the GenX place high value on relationships, they question authority and distrust institutions. They are less loyal to employers than previous generations and change jobs frequently. GenX are entrepreneurial and value work-life balance and job flexibility. They do not believe paying dues is relevant and they are cynical. Having an appreciation for the values of the GenX group may help the recruiter/program leaders relate to these candidates. These individuals may desire job opportunities that offer career advancement. They may be particularly attracted to programs offering leadership mentoring. These candidates will also be interested in opportunities with flexible scheduling.

Keep in mind that attention to the candidate’s particular profile should continue in the retention phase.

Aside from compensation, what are the most important practice-related factors that impact physician recruitment and retention?

There are several practice-related factors that affect recruitment and retention. The day-to-day work schedule (schedule model) and call responsibilities are major factors. Programs which offer little to no call (shifts greater than 12 hours) have a recruitment advantage over programs that utilize the “traditional” model where the physician may work for 24-to-36 consecutive hours due to night call responsibilities. Programs offering block scheduling where the hospitalist works for several consecutive days followed by several days off are currently very popular. Programs that allow for a generous amount of time off each year also have recruitment and retention advantage.

Day-to-day workload expectations factor prominently into recruitment and retention. Workload is typically defined as the number of patients cared for by each provider per day, as well as the number of admissions, discharges, and consultations completed. Workload also takes into consideration administrative and other nonclinical duties. Practices that have a reasonable workload for each hospitalist have a significant retention advantage.

The hospitalist program scope of service is another factor that impacts physician recruitment and retention. Candidates look closely at the practices’ clinical responsibilities based on their interests and skill level. For example, they may be interested to know if your group provides ICU care, whether the physicians perform procedures, or whether there are teaching and/or research opportunities.

Programs that have an effective Clinical Director have a recruitment and retention advantage over programs with a leadership void. This factor cannot be under emphasized. Practices which lack effective leadership can become operationally dysfunctional (eg, internal). They may also experience behavioral and clinical difficulties. These practices may also suffer external difficulties with key stakeholders such as hospital administrators, the Nursing and/or Emergency department, primary care physicians, specialists, and patients to name a few.

Another practice-related factor is the support the hospitalist program receives from both its referring providers and specialty network. While it is important for hospitalist programs to have a large primary care referral base (eg, job security) it may be more important that the hospitalist-PCP relationship be collaborative and collegial. In my experience, hospitalists have higher job satisfaction and retention rates in medical communities that have a close working relationship between the hospitalist and referring providers. These communities also do a better job maintaining continuity of care because of the open lines of communication. The specialty network within a community may play a particularly important role to the candidate. For instance, many hospitalists prefer back-up specialist support in all fields of medicine and surgery. The presence of specialists alone does not ensure this. This specialist-hospitalist relationship must be both collaborative and collegial. In some communities there are struggles between the hospitalists and the specialists for a wide variety of reasons. This can create a stressful work environment. Having said all of this, some hospitalists search for job opportunities in communities with little specialist support (typically rural areas) because they enjoy the challenge that accompanies providing the majority of medical care for the patient.

Other practice-related factors include the availability of advanced technological resources including the availability of the electronic medical record.

Let’s look at this from a potential hospitalist recruit’s perspective: what should he or she look for when evaluating whether a program is a good fit?

The candidate should consider a number of factors during the job search. He or she should look for compatibility with the practice as it relates to mission, values, vision, and objectives. The candidate should also perform an historical assessment of program stability, the rate of physician turnover, and the overall satisfaction of the hospitalists. The candidate will also want to assess practice leadership and the relationship the program enjoys with key stakeholders such as hospital administration, the Nursing Department, the Emergency Department, PCPs, specialists, etc. During the site visit when the candidate meets the hospitalists within the practice he or she should gauge compatibility and like mindedness. For example: What drives these doctors and is it compatible with my values? Are these hospitalists motivated and driven by money? Quality of life considerations?

What questions should hospitalist recruits ask during the interviews?

The following are questions the candidate may consider:

• Why are you recruiting for this position?
• Can you provide historical background from the start-up of the program to the present?
• What are the short-and-long-term plans for the practice?
• Are there leadership opportunities available to me in the future?
• What is the hospitalist programs’ relationship with hospital administration? Is administration supportive of the program?
• What is the hospitalist programs’ relationship with the Nursing Department? Emergency Department? Medical staff? Referring providers? Specialists?
• What is the schedule model utilized by the program? What are the call responsibilities?
• What is the practices’ scope of service?
• What are the workload expectations (the candidate should be careful with this question because he or she may appear to be overly concerned with workload and viewed negatively or reluctantly).
• What are the contractual obligations?
• How many hospitalists are in the practice? How long have they been with the practice (eg, retention rate)?
• Do you utilize Physician Assistants and/or Nurse Practitioners?
• What subspecialties are available within the community? Are the specialists supportive? Do they provide appropriate back-up?
• What are the skill levels of the nurses? What is their retention rate?
• What is the programs’ source of referrals? How supportive are the referring providers?
• What is the practices’ payer mix?
• Are there opportunities to teach? To perform research?
• Are there opportunities for shareholder status (if the opportunity resides with a private entity)?
• What are your patient satisfaction scores?

Your mention in the book that hospitalists must have the “entrepreneurial spirit." What do you mean by that? Why do doctors (and hospitalists specifically) have to immerse themselves in the business side of things? Why can’t they “just be doctors” anymore?

Hospitalists are at the center of healthcare reform. They must challenge themselves to go where physicians have never gone before. They are uniquely positioned to develop innovative systems that satisfy a multitude of institutional healthcare demands. Hospitalists will lead the development of new clinical, operational, and technological systems. These systems will create financial opportunity for not only the individual hospitalist but for his/her practice, the sponsoring institution, and the healthcare delivery system. Accountable Care Organizations (ACOs) and the Patient Centered Medical Home (PCMH) are two such systems in which the hospitalist interface is crucial.

In this age of healthcare reform physicians will no longer be able to “just practice medicine”. All physicians will be responsible for practicing quality, efficient, cost effective medical care. They will need to consider economical as well as clinical factors with every patient encounter. In the future I believe there will be a performance data base for every physician that will be shared with consumers on the internet. The physicians (and practices) who fail to meet established standards will suffer financially (eg, pay for performance, do not pay, and value-based purchasing initiatives). Hospitals associated with these physicians and practices will also suffer financially.

All physicians must embrace the changes that lie ahead.

What are the hallmarks of an effective hospitalist program leader?

A successful hospitalist leader is formed from his or her leadership roles throughout his or her career. These experiences helped the individual to develop an effective leadership style and hone his or her leadership skills. Specifically, an effective leader is an excellent communicator, motivator and consensus builder. He or she leads by example and appropriately represents and advocates for the practice. This leader is a teacher, trainer, and time manager. He or she is adept at change management and delegation. The leader identifies problem areas within the program as well as opportunities for growth. He or she will champion the development of new and effective systems, processes, and service lines.

In addition to possessing both excellent organizational and management skills an effective program leader has exceptional business acumen. This individual is adept at budget development, managed care and contracting. He or she effectively leads the program in collaborative processes within the healthcare network.

How have the leadership responsibilities of hospitalists changed as the profession has grown?

Hospitalist responsibilities have grown rapidly over the last decade in response to the growth and evolution of the hospitalist movement. The expectations of both the C-suite and other key stakeholders within the healthcare system are much greater. Whereas in the past hospitalists “just” had to provide direct patient care, they now are expected to be medical staff leaders, committee chairmen, developers of evidence-based care pathways, and participants in systems development that address throughput, patient safety, communication, etc. Hospitalists are also expected to deliver quality care at a low cost. These added responsibilities reflect the confidence stakeholders have in their hospitalists. This confidence has been earned as a result of both past performance and the skill sets these physicians bring to the table.

In addition to these responsibilities, hospitalists are now assuming both leadership and executive positions. For example, these positions include Chief Executive Officer (CEO), Chief Operating Officer (COO), Chief Medical Officer (CMO), and Vice President of Medical Affairs (VPMA) of hospitals. Hospitalists are also leaders within patient safety organizations and national organizations that address quality care.

What’s the difference between “leadership” and “management?”

Leadership involves establishing clear vision and communicating this vision to others within the organization. Leaders provide both the information and knowledge necessary to realize this vision while balancing the conflicting interests of their stakeholders. Leaders educe change, advancement, and growth by establishing direction. They motivate, inspire and empowering those around them. They have excellent communication skills. Leaders are strategic planners, consensus and coalition builders, and they focus organizational vision.

Management is the organization and coordination of the activities of an enterprise in accordance with established policies and in achievement of clearly defined objectives. Management comprises the interlocking functions of formulating corporate policy and organizing, planning, and directing the organizations resources to achieve the policy objectives. Managers create order, structure and stability. They plan, budget, organize and control for activities such as resource allocation, recruitment, and performance improvement. Managers set timelines, establish agendas, and develop incentives.

Why is understanding this distinction important for a successful hospitalist program?

There are myriad administrative, operational, and clinical responsibilities within any hospitalist program. These responsibilities must be delegated to the most appropriate individual or individuals within the practice. Many of these duties will require management skills while others will require effective leadership. A hospitalist program will enhance its chances for success by identifying a clinical director who either possesses both management and leadership skills or has the potential to develop them. For example, the clinical director may be responsible for running meetings, developing policies, creating work schedules, and monitoring provider performance. He or she may also be responsible for developing and implementing strategic initiatives, building consensus among staff (and/or other stakeholders), and motivating and empowering physicians. The hospitalist practice must have both strong leadership and effective management to realize its mission, vision, goals, and objectives.

How big a factor does health information technology play in hospitalist recruitment and retention? Are younger physicians attracted to more “wired” practices?

There is no doubt that “wired” practices have a recruitment advantage especially for younger physicians who are familiar with these technologies. Practices that utilize an EMR, iPhone, Blackberry, iPad, etc. will attract more candidates. These applications (when user friendly) improve the provider’s efficiency as well as support communication and continuity of care. In many instances the hospitalist can perform “prep” rounds before they set foot in a hospital.

What’s next for hospital medicine? What are the key milestones for the profession that will change the business and practice environment in the next five years or so?

I envision that hospitalists will embrace and proactively lead healthcare reform. The specialty will continue to grow in size and develop leaders who are adept at managing change. Hospitalists will develop quality initiatives through innovative research and the utilization of information technology. They will be the voice for the delivery of quality care and patient safety.

Hospitalists will be the providers of cost effective, compassionate care. They will also be the logical choice as future CEOs and CMOs of hospitals and medical institutions. This is a cumulative reflection of professional experience and expertise. One of their greatest challenges will be the meaningful integration of both the Patient Centered Medical Home (PCMH) and Accountable Care Organization (ACO) with their outpatient counterparts. Hospitalists will become preeminent providers of medical care once they reconcile prudent management of limited healthcare resources with quality clinical outcomes. They must be the institutional leaders preparing for the recovery audit contractor program (RAC). This leadership involves scrupulous attention to chart documentation and coding. It also includes attention to bundling payments, pay-4-performance, and value based purchasing.

In the future, it is reasonable to expect that the hospitalist movement will expand to other specialty fields and niches. We are already seeing movement in this direction with the emergence of Surgicalists, procedurists, observationalists, etc. In my opinion, hospitalists will provide close to 95% of the medical care delivered within the hospital with the exception of actual surgery or cardiac catherization (for example).