According to the Society of Hospital Medicine (SHM), the number of hospitalists has increased from approximately 5,000 hospitaists in 2005 to more than 30,000 hospitalists in 2010. Despite this explosive growth and the fact that the majority of hospitals now have hospitalist programs, not all of them have been successful in establishing a thriving organization with staying power. The need for financial support of hospitalist programs and overextension of services coupled with recruitment issues, turnover, and leave of absences may lead to excessive workloads and possibly burnout. The overall annual turnover percentage of hospitalists is high, approximately 22% nationwide, despite opportunities to improve retention of physicians within a practice (SHM data). None of these issues are unique to Hospital Medicine and have been experienced by other geographically localized specialties including emergency medicine and critical care.

Patients and their families continue to express confusion about the role of hospitalists in their care and may misconstrue the term “hospitalists” for “hospice.” Too often, hospitalists assume patients understand their presence at the bedside and neglect to take the time to explain their role as the internal medicine physician or family medicine physician responsible for patient care, assuming responsibility for everything from admission to discharge, including making patient rounds and ordering all needed tests and procedures. This failure in communication may leave patients and families feeling that their primary care provider has abandoned them, which may erode the patient-hospitalist and patient-primary care provider relationship.

This chapter will explore the specific components essential to building, growing, and managing a thriving hospitalist practice with staying power.

It is important to have a strategic plan for the practice around growth and the types of hospitals and programs best aligned with agreed upon goals and objectives. For example, strategic planning may require not aligning with all groups requesting support of the hospitalist team. If a group does not fit your strategic profile or geography, it may be best to decline the opportunity to manage a program. Depending on the goals of the practice, certain approaches may not promote patient satisfaction or continuity of care goals, as for example, when a hospital simply wants your team to cover admissions during the “off hours” that residents are not covering and then transfer patients to residents or surgeons during “peak hours.” Obstacles of geographic distance requiring a day of travel of the core management team present an additional burden that make it best to pass up the opportunity without key management team members in place. Therefore, each hospitalist group should critically evaluate whether the growth into a new hospital makes sense based on the values and goals of the organization.

Before starting a practice it is critical to determine what factors predict the success or failure of strategic plans and those that the group defines as the business and financial motivators that impact on the decision to build, expand, and manage a hospitalist service.

In order to build a hospitalist practice, hospital leaders should:

• Define the clients, need for the program, the scope of services, and the type of employment model.
  
• Articulate the mission, vision, values, and key value drivers of the practice.
  
• Determine the size of the program needed and the cost of the program.
  
• Set the compensation model.

After a program is up and running, successful practices may be faced with unprecedented growth. Hospital leaders will need to:

• Set expectations and priorities for growth.
  
• Define key stakeholders.
  
• Plan for growth.
  
• Assess the evolving needs of the service, such as using midlevel providers and the pros and cons of caps on services.
  
• Determine the skills in a hospitalist practice and the need for additional physician training.
  
• Reassess the compensation model as the needs of the service change.

From the building stage forward, there is a constant need for outstanding management to ensure a hospitalist practice thrives by using the steps provided in the following tables: (Tables 26-1, 26-2, and 26-3)

• Define the right leadership and structure.
  
• Create an ownership mentality.
  
• Setting up the right processes.
  
• Tracking and reporting actionable data.
  
• Promoting outreach to the physician community and facilitating transitions of care.

Building a hospitalist practice starts with defining the clients and the need for a hospitalist program. In many community hospitals, a hospitalist program is created to care for the unassigned patient population. But even the definition of an unassigned patient is subject to much interpretation. For example, at many hospitals in the Puget Sound region of Washington State, an unassigned patient is any patient showing up in the emergency department (ED) and requiring admission who does not have a primary care doctor that admits patients at the hospital. In contrast, in Orlando, Florida, an unassigned patient is only defined as a patient who has no primary care doctor. In Orlando, if a patient has a primary care provider but that doctor does not have admitting privileges, it is standard practice to call the primary care provider to identify who will care for the patient in the hospital.

In addition to covering the unassigned patient population, many hospitalist services cover those primary care providers (PCPs) who do not want the responsibility of admitting their own patients. There are two main forms of coverage relationships: coverage arrangements for 24 hours per day, 7 days per week; and coverage which is more like a house staff model in which the hospitalist admits the patients but then turns the care back over to the PCP the next day. These latter models continue to decline in numbers because of difficulty with recruitment of high quality doctors motivated to build a meaningful career with a resident-type model.

Hospitalist programs may also be created to manage medical specialty and surgical patients, usually after establishment of the initial hospitalist program.

It is essential to determine which patients the hospitalist group will manage, the scope of services, and whether additional training for some of the program members will be required. According to SHM, 78% of practicing hospitalists are trained in general internal medicine, and another 4% in an internal medicine subspecialty, most commonly pulmonary or critical care medicine. About 3% of hospitalists are trained in family practice; about 8% in pediatrics; and 2% in med-peds. The remaining 5% are nonphysician providers, usually nurse practitioners and physician assistants. If the medical patients are the first priority regardless of their demographic, leaders then need to consider severity of illness.

In most community hospitals today, hospitalists manage ICU patients in large part due to the shortage of critical care physicians (less than 5,000 in the U.S.). In general, the larger the hospital the less ICU medicine a hospitalist performs. Many hospitals have mandatory ICU consults after a set number of days or hours in the ICU or they provide specific guidelines on managing ventilated patients. The most popular model may be a hybrid arrangement in which access to a critical care physician occurs during the day and for emergencies but in-house at night. In such cases the hospitalist commonly does the work around admissions and daily visits with a consult and a follow-up visit by the pulmonary critical care physicians.

With the labor shortage being even more severe for critical care, hybrid models, along with the advent of telemedicine, are likely to take on even more ICU coverage responsibilities in the future. In general, leapfrog compliance guidelines drive a dedicated intensivist model, typically mandated in regional and tertiary hospitals.