It Takes a Village

In 2008, St. Mary’s Health Center in St. Louis, MO, and IPC Hospitalist Co., a North Hollywood, CA-based national physician group practice that provides in-hospital medical care, teamed up to establish a 20-bed medical unit. In two years, the hospitalist unit has achieved significant improvements in quality metrics. Here, Philip Vaidyan, MD, Director of Hospital Medicine in the Department of Internal Medicine and Practice Group Leader of the IPC Hospitalist team at St. Mary’s, discusses the unit’s experience so far.

How is the hospitalist unit at St. Mary’s structured?

We meet every morning at 9am with the nurse practitioner to do the handoffs. Our model works this way: a hospitalist, when he or she is on call, is on call with three nurse practitioners, so during the course of 24 hours, that hospitalist has probably accumulated

anywhere from 25-30 patients. And by 9:30 am the next morning, those patients will be redistributed among eight hospitalists. So, on any given day after the morning meeting, everybody knows how many patients they are going to see, and it’s consistent; nobody is going to be seeing 30 patients one day and 10 the next.

The meeting is also attended by the unit-based case manager and social worker, along with the team leader of nursing, so everyone is on the same page as far as which patients are being discharged that day, and what needs to happen with those patients.

We also have twice-a-week multidisciplinary meetings where half of us do walking rounds. The meetings are led by the hospitalist, so this multidisciplinary team consists of the hospitalist, charge nurse, physical therapist, nutritionist, care manager, social worker, home health coordinator, wound care nurse, and unit-based pharmacist.

How important is it to have buy-in from the entire staff?

It’s absolutely critical. Having all of us together, working toward the same goal, putting the patient at the center, is what makes it work. The whole teamwork method actually helps transform peoples’ approach to patients.

The hospitalist unit at St. Mary’s utilizes an academic-hybrid model. What is meant by this?

With the academic-hybrid model, the hospital and the department of medicine have a vested interest in making sure that the hospitalists who are hired here are resident-friendly and have the capacity and the competency to teach. That’s why part of their time is sponsored by the department of medicine, and the clinical part of their time is sponsored by the IPC. It has actually been a collaboration between IPC and the department of medicine at St. Mary’s Health Center to come up with a program in which hospitalists are actively involved in the inpatient teaching of the medical residents, improving hospital systems of care and patient care.

What are some of the challenges you’ve faced?

We have a 32-bed unit, and there are patients of other primary care doctors and a few other hospitalists who also wait in the ER. There may be one or two beds open at any given time, and if it opens in our hospitalist unit, we’re going to get the priority. Initially, we weren’t able to achieve 100% capacity in our unit. We had patients from other physicians who had to be seen, so we were only able to achieve 80-85%. The hospital administration actually wrote out a memo to the mid-level managers and bed-control nurses, and now we’re able to achieve almost 100%.

The other challenge is that in our unit, we’ll have eight hospitalists spend an hour with a nurse practitioner every morning, so that’s eight physician hours. You can argue that in that time, we could have seen three patients, and we’re not getting any additional revenue. But now, people know that having this team meeting every morning, 365 days a year, helps to build team camaraderie. Those meetings are very important, not only for patient safety and handing off information, but also for interfacing with the social worker and case manager.

What results has the hospitalist unit seen in terms of readmissions and length of stay?

Our goal has always been to build a strong, team-based approach to healthcare. And the outcomes we focus on are readmission rate, length of stay, and patient satisfaction, based on HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) score. We have a sister unit that is not run by hospitalists, so that was the comparison. We started at about the same place back in June 2008, and nearly two years later, St. Mary’s has shown a significant reduction in 30-day readmission rates, and our length of stay actually is trending down. Patient satisfaction went up by about 25-30%, which is the top box on the HCAHPS data, compared to the other unit, which remained pretty much the same over the last two years.

Are there any plans in place to expand?

That is the next phase; the hospital administration wants us to expand, but we have a 32-bed unit and we’re expending a lot of resources from the physician side. So when we expand, the challenge is going to be what happens with our morning handoff meeting—whether we have to divide into two teams. But we’re actually thinking about having physician champions in other units and possibly setting up a telemetry hospitalist unit in the next six months.

If we could expand and get the kinds of results that we got in our unit, it would be awesome. But we have to make some decisions, like how the physician champions should be reimbursed—those are the kinds of things we need to sit down with the administration and discuss to come up with a plan.

What advice would you offer to other organizations in terms of establishing a hospitalist unit?

Many institutions spend a lot of money on a hospitalist program, and if you look at those programs, how many of them are engaged with the hospital to help improve the systems of care? I don’t think it’s too many, and most of this money is going to actually subsidize the schedule, where many physicians work on a one-week-on, one-week-off basis. It’s a half-time job, and they get subsidized for a full-time job. Maybe hospitalists in new programs should be seeing 13-15 patients and not 20 patients, so that they’ll have adequate time to participate in multidisciplinary meetings and quality improvement programs.

Our program has really evolved over the past five years. When we started it, we had about 30 patients, and now we manage about 120. We provide the primary in-patient teachers for the residency program, and we are the go-to guys for the hospital system improvement programs. We’re a small community teaching hospital, and through this program, we’re able to make a difference for our patients.