Hospitalists taking on quality initiatives
UCSF docs each gravitate to specific issues
The position of hospitalist, only in existence for about five years, has evolved into a respected "new breed" of physician that has grown considerably in that short period of time. Not only have hospitalists (physicians whose primary professional focus is the care of general medical patients in a hospital) grown in number, but also in the diversity of roles they assume. While some spend all of their hours at the hospital, others devote a considerable amount of time in academia. And a significant number have become quality leaders for their institutions.
"It is a relatively new concept for many hospitals to have a cadre of physicians who see part of their role being the care and stewardship of the institution — to help make the hospital system better," says Robert M. Wachter, MD, associate chair of the department of medicine at the University of California at San Francisco (UCSF) and chief of medical service at UCSF Medical Center. "We believe an effective hospitalist group should be excellent in care but should also see themselves as really good citizens of the institution. So the institution has a group of physicians functioning as leaders in quality, efficiency, and resources management issues that cut across all departmental lines, which they have not had in other physicians," he says.
In academia, some hospitalists spend most of their time taking care of patients, while others do patient care for two or three months of the year and spend the rest of their time on QI and patient safety issues, Wachter explains. "Almost everyone here has tried to take ownership of one issue," he notes. The entire group, as well as the hospital, benefit he says, because "they are very good collaborators."
Health care institutions benefit from the presence of hospitalists in a variety of ways, Wachter says. "One benefit to the hospitals is that they have individuals on staff whose focus on patient safety is a natural outgrowth of their role as hospitalists," he explains. "It’s very natural for them to take on the system’s focus. We work well with quality managers, nurses, pharmacists, and upper-level managers." In essence, that’s the nature of the field, he says. "As part of their role, hospitalists coordinate many specialists and case managers. Being a quality leader comes very naturally."
In addition, Wachter’s own research indicates that simply having hospitalists on staff will improve quality. In a recent article in the Journal of the American Medical Association, he and a co-author conducted a review of the current literature on hospitalists and demonstrated that hospitalists can help lower costs and reduce lengths of stay.1
"Our original premise was that the hospitalist model should markedly improve efficiency without harming quality and patient satisfaction; that turns out to be very well supported by the literature," he says. "Under the most conservative interpretation, it markedly and significantly improves efficiency of care without harm to patients, and it hints that it will actually improve quality."
As for decreased lengths of stay, there may be a few mechanisms at work, Wachter says. "One is practice makes perfect’ — the more you do something the better, and the faster, you become at it," he explains. "A given patient may look the same to most doctors, but to the hospitalist, something might just not smell’ right, and extra tests could be ordered."
Another piece is availability. "If my job has me in this building from 8 a.m. to 6 or 7 at night, there is a whole lot I can accomplish toward the goal of getting the patient through promptly and safely that I could not have done otherwise," he explains. "I can see a patient at 8, the lab comes back at 11 and requires action, and that action takes place at 11:15. A doctor who only spends part of the day in the hospital cannot do that."
Finally, by their constant presence, hospitalists build up a "favor bank," he says. "When we work in the same building with the same people all the time, we just get to know them very well," he observes. "So we are able to say, Mary, it would be great if you could do this MRI today — I’m really worried about this guy.’ If you have a solid relationship with case managers and others, you can do that. And to the extent that those relationships drive the system, the hospitalist just has an easier time than the primary care physician."
Reference
1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002; 287:487-494.
For more information, contact: Robert M. Wachter, MD, Department of Medicine, University of California, San Francisco, P.O. Box 0120, San Francisco, CA 94143-0120. Telephone: (415) 476-5632.
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