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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 Medicine University of California, San Francisco. Just in the Past Five Years.

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Robert M. Wachter, MD

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  1. 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

  2. Just in the Past Five Years • Rheumatology: TNF blockers • Neurosurgery: Gamma knife • Obstetrics: No VBAC • Geriatrics: Aging population • Pediatrics: Couple of new vaccines

  3. 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

  4. Oh yeah, and there have been a few changes in clinical hospital medicine too! Hospitalists, cont.

  5. 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.

  6. 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 With Change Comes Opportunity…

  7. 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)

  8. Some Observations on the Biggies • Quality • Safety • IT • Co-management • Residency replacement • Workforce growth

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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…”

  19. 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

  20. Managing Everybody and Everything Big-Time Comanagement Resident Duty Hours Buy-In Complete Starting Up UCSF Hospitalist Program Faculty

  21. 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: • Scope of practice • Coverage hours • Quality of people (sometimes trumps all) • Increasing challenge for all programs

  22. “He had a hat!” Everybody Wants Us!!! Now, can somebody make it stop?

  23. 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

  24. 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

  25. 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.” Remember Gretsky’s Rule “Skate to where the puck is going, not to where it is.”

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