Hospitalists have gone from rarities to dominating inpatient care in the past 25 years. Currently, there are approximately 50,000 hospitalists in the United States. The term “hospitalist” was first coined by Dr. Robert Wachter and Dr. Lee Goldman in their 1996 article in the New England Journal of Medicine. The young specialty was quick to show financial benefits to hospitals with studies showing improved hospital length of stay and lower costs per admission in patients cared for by hospitalists. Currently there are 3 common hospitalist practice models:
- Hospital-employed physicians
- Physicians who are part of local primary care or multi-specialty group practices
- Physicians employed by regional or national hospitalist companies that contract with numerous hospitals
There are advantages and disadvantages for each of these 3 models and the optimal model will be different for different hospitals. Periodically, hospitals will choose to change to a different hospitalist model or change to a different physician group within a given model. Managing this transition can pose unique challenges to the hospital.
Timing the decision
The decision to change hospitalist models or change to a different hospitalist group requires long-term planning, and should ideally be made 12-18 months before the intended transition date; the larger the hospital, the more time you will need. A small hospital that only needs a few hospitalists can change groups fairly quickly. But if the hospital is looking at changing coverage of a large number of inpatient beds, then the sheer number of new doctors that have to be recruited and hired takes a lot of advanced preparation. For example, to cover 100 beds, the hospital will need somewhere between 20-30 hospitalists, depending on patient acuity and other factors. Because of the high-demand for hospitalists, it can take many months to recruit this large of a number of doctors – there are not many unemployed hospitalists reading the help-wanted classified ads in the newspaper each morning.
Many new hospitalists will be recruited from internal medicine residency programs. Residency programs run on a July through June cycle so residency graduates will be available in July/August each year. These physicians generally start interviewing for hospitalist jobs about 1 year in advance and most residents from the better programs will have signed contracts by October or November of their senior year of residency. If a hospital waits until December to recruit and interview new graduates, there will be very few uncommitted residents left.
When do you let the doctors know?
The initial planning for a hospitalist transition is usually done privately with only a small number of hospital leaders aware of the plan to change to a different hospitalist group or model. This is necessary because as soon as the current hospitalists know that their employment contracts are going to be terminated, they will start looking for a new job. When to make the upcoming transition public depends on the employment contracts that the doctors have. Most physicians will have a 60, 90, or 120 “without cause” termination clause in their contracts. This means that they have to give 60, 90, or 120 days notice if they intend to leave. The day that you tell the doctors that their employment contracts are going to be terminated is the day that they will begin looking for another job.
You want all of your doctors to stay at the hospital until the date of the upcoming hospitalist transition. If you tell them about the transition 180 days before the date and the doctors have a 90 day without cause termination clause in their employment contracts, then you are going to find yourself with no hospitalists in the final weeks or months before the transition. However, you do want to be fair to the physicians who have been providing care to the patients at your hospital – you might want to hire them again in the future plus it is just the right thing to do. It generally takes at least a month for a hospitalist to find and sign a contract for a new job so a good rule of thumb is to let the current doctors know 30 days more than whatever their without cause termination period is in their contracts. So, if they have a 90 day without cause termination clause, let them know that their contracts will be terminated 120 days in advance.
Have a contingency staffing plan
As soon as the contract termination becomes public knowledge, it will be nearly impossible for the existing hospitalist group to hire new physicians – doctors looking for permanent employment do not want to sign up to work for two or three months. Inevitably, there will be some hospitalists in the current group that were planning on leaving, get sick, get called up for military reserve duty, or go on maternity/paternity leave in the months before the transition. So you have to have a reserve of short-term physicians who can fill in the vacancies until the new hospitalist group starts.
The easiest solution is to hire locum tenens physicians. These can sometimes be local physicians that the hospital can contract with individually to provide short-term hospitalist coverage but more often, these physicians come through a locum tenens company that maintains a pool of doctors who are available for short-term employment. It is important to plan early with the locum tenens physicians so that you can get them through your hospital’s credentialing process well in advance of when you will need them. If the hospital’s credentials office takes 3 months to complete credentials for new physicians, then you need to identify and get started on credentialing those locum tenens physicians shortly after announcing the hospitalist transition decision. Even if you have to pay a retainer to the locum tenens company, it can be worth it so that you do not find yourself with patients but no doctors to take care of them just before the transition date.
Create a transition workgroup
Key leaders from the hospital, the existing hospitalist group, and the new hospitalist group need to meet regularly. Because there can be animosity between the two hospitalist groups, it may be necessary for the hospital leaders to do most meetings with the hospitalist groups individually. Initially, the workgroup should meet monthly and then in the final 2 months of the hospitalist contract, the meetings should be weekly. These meetings may only take 10 – 15 minutes but it is important to put them on everyone’s calendar to ensure a safe and efficient transition. Specific issues to cover include:
- How will test results that come back after the transition be handled? This will usually require some way of routing electronic medical record “inbaskets” to the new hospitalists.
- Who will sign verbal orders after the transition date? Verbal orders have a habit of showing up in the electronic medical record a day or two after the physician actually gave the verbal order. There needs to be a process in place for getting those orders signed. The same goes for signing discharge summaries, H&Ps, and operative notes.
- How will death certificates be managed? If a patient dies a couple of days before the transition date, the funeral home will likely send the death certificate over to the hospital after the transition date. A mechanism for signing these in a timely fashion must be agreed upon.
- How long will the current hospitalists have access to the electronic medical record? The doctors may only need to have access for a couple of weeks to sign verbal orders. However, their billing office may need access for several months to manage late bills and provide documentation of services to insurance companies.
- Managing patient hand-offs. Ideally, the transition hour should be at the end of a day shift rather than the end of a night shift. The hospitalists who have been managing the patients during the daytime are generally in the best position to answer questions about their care than the night coverage hospitalists. This can result in a smoother transition.
- What about trainee evaluations? If the current hospitalists have medical students or residents, then work with the appropriate education office to ensure that there is a mechanism for end-of-the-rotation evaluations to be completed after the current hospitalists have left. Trainees are notorious for completing their notes late so there needs to be a mechanism for co-signing these notes after the transition date.
- Get an equipment inventory. After a period of time, is can be easy to forget whether the hospitalist group or the hospital purchased computers, furniture, phones, journal subscriptions, printers, and fax machines. Make sure everyone knows what stuff stays and what stuff goes.
Meet with the nurses and other physicians
Change can be alarming for doctors and nurses who have been accustomed to one group of hospitalists and one pattern of practice. There must be a mechanism for the hospital to clearly articulate the reasons for the change and reassure the staff that there will not be a reduction in the level of medical care provided by the new hospitalist group. Surgeons who have relied on the hospitalists for inpatient consultative co-management need to be engaged. The emergency department physicians need to be aware of any change in the admitting process with the new hospitalist group. Consultants need to be confident that the new hospitalist group will not reduce the number of consults that they order.
The things you didn’t think about
Different hospitalist groups practice medicine differently and one cannot be simply substituted for another. Consideration need to be made about:
- Who manages cardiopulmonary arrests? Stroke alerts? RRTs (rapid response team alerts)? Not all hospitalists have experience managing these situations and may require additional training prior to starting coverage.
- Who manages bedside procedures such as central venous catheters, lumbar punctures, and intubations? Increasingly, internal medicine residents are not being routinely trained in these procedures. Endotracheal intubation is a particular problem – fewer and fewer hospitalists perform them and so you will need to decide if anesthesiologists, emergency medicine physicians, or respiratory therapists will become responsible for airway management if the old hospitalists performed these but the new hospitalists do not.
- How will physicians be contacted? Maybe the existing hospitalists prefer to use pagers but the new hospitalists use their cell phones or an app in the electronic medical record. Be sure that it is clear how nurses and other physicians contact the specific hospitalist managing any given patient.
- Clean up the electronic medical record. Don’t leave an option for a consult or admission to be placed to the old hospitalist group once the new hospitalist group takes over. That order for a consult will not go anywhere and patient care could suffer.
Your quality metrics will take a hit
During the last month of the old hospitalist group, the doctors will be less motivated to help the hospital with things that matter to the hospital. Anticipate that the inpatient length of stay will go up, hour of discharge will be later in the day, patient satisfaction will go down, and quality events will increase. This will be particularly true if the hospital has to rely on a lot of locum tenens hospitalists in the last weeks before the transition. It is very similar to college students getting “senioritis” in the months just before graduation. You can partly preserve performance on these various quality metrics by developing a bonus plan to pay the physicians for their performance in the last couple of months of their contract.
When a hospital changes to a different hospitalist group or model, the current hospitalists are going to feel betrayed and devalued. The end of their employment at the hospital means the end of friendships with nurses, other physicians, and hospital staff. It may mean that they have to sell their houses and move to a new community. It may mean that they will be out of work for a few months while seeking a new job. It likely means an end to a job that they really liked and were passionate about.
These physicians need to be treated as the professionals that they are. Meet with them regularly. Volunteer to provide job references. Provide them access to continuing medical education such as hospital grand rounds for a few months. And most importantly, explain to them that it was a business decision and not because they are bad doctors. Who knows, you might want to hire that physician or hospitalist group again in the future.
There will often be non-compete clauses in their employment contracts so the hospital or new hospitalist group may not be able to hire them. For those hospitalists who are superstars, it may be worth trying to negotiate a buy-out for the non-compete contracts. It costs a surprisingly large sum of money to hire a new hospitalist when you consider paying for a search firm as well as interviewing, credentialing, and orienting the new hospitalist. You may have to pay moving expenses or medical school loan repayments. When all of these are considered, it may be cheaper to pay a $25,000 or $50,000 buy-out for a current hospitalist than to hire a new hospitalist.
Managing change is one of the main things that hospital leaders do and it can be time-intensive as well as emotionally draining. But by planning in advance and giving attention to detail, changing from one hospitalist model or group to another can happen smoothly and offer new opportunities for the hospital.
November 7, 2020