Question

Plateau University Hospital is a large academic medical center in a major urban area. In order to survive in a competitive and economically challenging geographic market, Plateau built upon a strategy of inpatient volume growth. Each time the volume group, it increased capacity through savings in reduced length of stay (LOS). This allowed the hospital to meet its ambitious budgetary goals and realize the desired growth and profit targets.

To accomplish this, Plateau has made some dramatic strides in efficiency over the past five years. However, executives feel that much of the low-hanging fruit has been picked and further progress and additional opportunities for length of stay reductions will require greater creativity. When looking at further opportunities to reduce length of stay while maintaining their mission to deliver high-quality patient care, Plateau leadership is exploring the idea of building upon their small hospitalist group. Currently, there is a four-person hospitalist group, which manages the inpatients of a small proportion of the hospital-owned office group practices. These hospitalist have a reduced length of stay compared to other doctors and are perceived to deliver high-quality and accessible care. Is there more opportunity here?

Plateau leadership has begun to read about the growth in hospitalist programs across the country and has heard about their potential to improve efficiency and quality of inpatient care. On the other hand, they also have heard that these programs have potential problems with hiring and retention as many doctors see them as temporary “burnout jobs” for recent graduates. The current crop of four doctors seems to fit this profile. Before hospitalist have been working a lot of weekends and route is low. While they are running their own program, they reportedly have insufficient support or leadership.

To take on the challenge of building a hospitalist group, the hospital hires and energetic but inexperienced physician leader. Dr. Angel Young is ambitious, and he realizes he got the job largely because others may not have wanted the position. However, he sees this as a real turnaround opportunity. After the first few meetings with the hospitalist group, young realizes he has an uphill battle. In spite of the negatives associated with their current situation, the four hospitalist are still resistant to change and appear resistant to Young’s new authority.

Young immerses himself in the job and tries to experience the hospitalist role as the four practitioners do. He is a hands on leader who studied the workflow and processes in which his group operated. He also networks with leaders at other hospitals enjoins national hospitalist groups to develop a better understanding of the landscape for this growing specialty. He knows that in order to be successful, he needs support from both the hospital administration above and from the four hospitalist below. After a few months, he is able to list the challenges and opportunities associated with building a successful hospitalist program.

Challenges

• Low morale-“ignored,” “overworked,” “underpaid”

• Difficult personalities-“us versus the world” culture

• Resistance to change • Revolving door of leaders-“why trust this one?”

• Reputation as “burnout job”

• Lack of administrative structure-no organized schedule, no moonlighting (coverage) pool for nights and weekends

• Loosely supervised and inefficient-no real boss, no metrics, little accountability

• Rapid growth-no strategic plan to recruit and retain hospitalists providers Opportunities

• Harness institutional need for hospitalist services

• Provide attention to hospitalist/gain trust

• Job redesign-make it sustainable with possibility for upward mobility

• Create room for career development-add academic opportunities, research support

• Create administrative structure-take-out of hands of frontline physicians

• Process improvement-remove irritants in the system

• Create proper incentives-bonus plan with quality and efficiency measures

• Utilize information technology capabilities-improve workflow and provide data to drive productivity

• Expansion-infused new people and attitudes

With support from Plateau administration, young begins to tackle these challenges and initiate the change campaign. However, young does not move too quickly and impulsively with respect to change. He knows he needs a few “short-term wins” to begin the cultural change process and build support from both the group and his bosses. Developing a fair bonus plan with proper incentives is an effective early step that garners significant support. In addition, monthly hospitalist lectures are added to the hospitals lecture schedule. This conveys a concern for career development and provides a venue for education and teambuilding among the hospitalist.

Equally important among Young’s early steps is quickly building a moonlighting pool. This effort wrestles away a large chip of informal power that the hospitalist previously wielded. Through a new call system and some strategic process improvements, the hospitalist are also able to be more efficient and productive. The number of admissions per FTE increases and the length of stay for the hospitalist patients improves. These positive results attract additional support from hospital administration to help energize the initial push and withstand any resistance around the change efforts.

While the first six months are rough and not without tension and resistance, the initiative seems headed in the right direction. Young works with his hospitalist group to ensure that they maintain their initial momentum by communicating about goals and accomplishments, encouraging teamwork, in creating a strategic vision for the hospitalist service at Plateau University Hospital.

Case Questions

1. What are the challenges a new leader faces when trying to implement change?

2. How can Dr. Young best approach this difficult group of doctors?

3. What are the key elements in building a successful hospitalist program, and how can Plateau build a sustainable model that will be attractive enough to recruit and retain positions?

4. What kinds of data and metrics might a hospitalist leader need to run his group and track progress and success?

5. What is senior leadership looking for from Dr. Young and his group, and how can they best deliver on these expectations in order to ensure ongoing support and resources for their program?

Answer 1

1, Challenges a new leader faces:
- Low morale-ignored,overworked,underpaid
-Difficult personalities -'us versus the world' culture
-Resistance to change resolving door of leaders -"why trust this one"?
-Reputation to burn out job
-Lack of administrative structure -no organized schedule,no moon lighting(coverage) poor for nights and weekends..
-Loosely supervised and ineffecient,no real boss,no metrics,little accountablity.
-Rapid growth-no strategic plan to recruit and retain hospitalists providers oppurtunities
-Harness institutional need for hospitalist service
-Provide attention to hospitalist/gain trust
-Job redesign-make it sustainable with possibility for upward mobility
-create room for career development
-Add academic opportunity,research support
-Create administrative structure-take-out of hands of frontline physicians
-process improvement -remove irritants in the system
-create proper incentives-bonus plan with quality and efficiently measures
-Utilize information technology capabilities -improve work flow and provide data to drive productivity
-Expansion-infused new people and attitudes
2, Dr,young best approach this difficult group of doctors with the support from plateau administration,young begins to trackle thses challenges and initiate the change campaign..but young does not move quickly and impulsively with respect to change..He knows he needs a few short-term wins to begin the cultural change process and build support from both the group and his bosses..
3, Key elements to build a successful hospitalist program is developing a fair bonus plan with proper incentives is an effective early step that garners significant support and also monthly hospitalist lectures and needed to the hospitals lecture schedule..This conveys a concern for career development and provides a venue for education and teambuilding among the hospitalists.. Quickly building a moon lighting pool..this effort wrestles away a large chip of informal power that the hospitalist previously wielded..Through a new call system and some strategic process improvement it can makes hospitals more efficient and productive..the number of admissions per FTE increases and the length of stay for the hospitalists patients improves..
5, Senior leadership looking for from Dr.young and his group is loosely supervised and inefficient-no real boss,no metrics,little accountability,need from hospitalist leader to run his group and track progress and success..Young works with his hospitalist group to ensure that they maintain their initial momentum by communicating about goals and accomplishments,encouraging teamwork,in creating a strategic vision for the hospitalist service..these all the way they can deliver best support and rsources at plateau university hospital ..