The Hospitalist as Bed Czar: Indispensability, But At What Cost?

In last week’s Annals of Internal Medicine, Eric Howell and colleagues describe an innovative experiment in which the hospitalists at Johns Hopkins Bayview became the institution’s bed czars. It worked.

So should my program and yours take this one on? If you looked up “Thankless Task” in the dictionary, you might see “Active Bed Manager.” So how did they do this?  And why?

Hopkins Bayview is a 335-bed teaching hospital affiliated with Johns Hopkins. The Chief of Medicine, David Hellmann, is an old friend and a gem, a graceful and eloquent man who is constantly looking for improvement opportunities. Under his guidance, several years ago the hospitalist group, led by Howell, agreed to become the medical center’s “Active Bed Managers” for medical patients. The ED sees 54,000 patients a year, and admits about one-quarter of them, three-quarters of these to Medicine.

One hospitalist at a time serves on the ABM service, in 12-hour shifts. During this shift, the hospitalist has no other responsibilities, freeing him or her up to act as a full-time air traffic controller for all medical patients. This involves keeping up to speed on the bed status of all medical, step-down, and intensive care units, “prediversion” round in the ICU, evaluating (by phone or in person) all new admissions, expediting ED-to-floor transfers, and sundry other tasks.

After a few years of doing this during the days, in 2006 they began providing ABM around the clock, 365 days a year. When all hell breaks loose, the ABM hospitalist notifies the “Bed Manager” – Eric or another senior hospitalist leader – who has the authority to activate resources or knock heads to free up beds or expedite transfers.

The results were truly impressive. ED length of stay for admitted patients fell by 98 minutes (458 minutes in control period to 360 minutes after the intervention), a tremendous improvement, particularly when multiplied by 10,000 patients a year. The time that the ED was on full divert – which costs the hospital both money and good will (and probably costs a few lives as well, as patients are shunted to less appropriate or more far flung hospitals) – went down by a staggering 87% (from 31% to 4% of the time)!

I spoke to Howell last week to find out more, since I was reasonably sure that I – and my fellow hospitalist leaders around the country – would receive “why don’t you do this?” calls from our CMOs within minutes of the publication of these results. “I watched for years as the hospital tried to improve throughput and stay off ambulance diversion,” he told me. “Nothing worked, but we knew that we could help fix this. After a while, we decided that it was worth trying.”

A short fiscal primer for those of you who don’t traffic in DRGs and bed-days-per-thousand: Hospitals that run full spend staggering amounts of money on efforts to improve throughput. They hire consultants (which never works, but their PowerPoint presentations are pretty to look at), they tweak admission criteria, they shop eBay to buy second-hand electronic tote boards discarded by the Hyatt. These interventions rarely make a significant dent, because to make a real impact you need someone to make scores of tough, contentious decisions in real-time, preferably someone with the negotiation skills of Richard Holbrooke.

Most hospital ultimately throw up their hands and solve the problem of throughput by – you guessed it – building more beds, at a cost these days of 1-2 million dollars per bed, depending on whether you have to meet earthquake standards (the cost is even higher for ICU beds). But hospitals can’t afford to leave their bed shortage problem unsolved – not just because they need to dis-impact the ED, but more importantly (for the bottom line) because they need to free up beds upstairs for elective surgeries. Canceling such surgeries because of bed shortages is intensely expensive and demoralizing to the C-suite folks. Plus it makes the surgeons very unhappy, a bad job retention strategy for most COOs.

I wanted to know how the ABM intervention had affected Howell’s hospitalists’ relationships – with the ED, the nurses, and the residents. He told me this:

“All relationships got better. The ED loves us – the ED chief sits in medical board meetings and asks for more hospitalists. The ICUs like us, maybe love us, because we got rid of ambulance diversion. The nursing supervisor loves us, because we help them enforce stuff, or can override policy if needed (when common sense dictates). The residents? First they were reluctant, now they love it.  But it does put the hospitalist in the middle of resolving conflicts between two house officers, house officers and the ED, sometimes house officers and the nurses…”

This intervention can’t be done on the cheap: having dedicated hospitalists on this service 24-7-365 (not performing billable activities) would likely require about 4-6 FTEs-worth of hospitalists, or close to a million dollars a year (Eric and I didn’t get into the precise numbers at Hopkins Bayview, but the math is pretty straightforward). And, in order to motivate Eric’s group to do this, the hospital anted up some additional salary support for both rank-and-file hospitalists (who saw an increase in academic “protected” time) and for leadership positions. The latter was particularly important, since the junior hospitalists were instructed to bump issues to a senior hospitalist leader (the “Bed Manager”) when the disputes got too difficult or new resources were required. At first, this was just Eric and one colleague who were always on call for this purpose; by the end, four leaders were sharing this difficult but crucial role.

Finally, I asked Eric – given what must have been Too-Numerous-To-Count political challenges – whether he was glad he did it. I also asked how he’d rank this intervention against alternative uses of the same dollars (such as surgical co-management or proceduralist services), most of which would cause less loss of hair and gastric mucosa. He responded this way:

“Yes, I am glad I did it. It put my group on the map at Johns Hopkins. Before hospitalists were largely considered “non-essential” by other faculty. Now they see us as equals, because we fixed something that they could not… for years. Also the hospital LOVES us; the president introduces me as the man who runs the entire hospital (not true but flattering)…”

I’m going to give this intervention a very high degree of difficulty – in the Hospitalist Olympics, I’d rank it as a reverse one-and-a-half somersault with three-and-a-half twists, with a good chance for a Belly Flop if it isn’t skillfully executed. In other words, Active Bed Management is not for the faint of heart, nor something to take on if you have staffing challenges elsewhere.

In part because of that, although you might get a warm and fuzzy feeling about improving throughput and decreasing diversion for your hospital, there is no way a group should take on this role simply to have its costs recouped. If you do ABM and see Eric’s results, you have created several millions of dollars of value for the average hospital (and many hundreds of thousands for the surgeons), and some of this needs to be allocated to the hospitalist program itself, in the form of more protected time, higher salaries, or other items on its wish list.

But my premise from the moment this field began was that hospitalists – because of their near-universal dependence on outside (usually medical center) support – had to constantly be looking for opportunities to add value. Particularly in tough economic times, the opposite of being Indispensable is being Dispensable. That’s not a good thing to be right now.

I haven’t told my group this (or perhaps I just did) but, assuming we have sufficient staffing, I think we should begin looking at ABM in the not-so-distant future, probably starting with a daytime service to see whether it is do-able before taking on the much more challenging task of nighttime coverage.

The American Hospital Association just released its 2008 estimates, and the number of hospitalists is now pegged at 27,000, which makes the field larger than cardiology or emergency medicine – the largest non-primary care field in Internal Medicine, and the fastest growing field in the history of medicine. This is staggering (next time, please remind me to trademark a term when I coin it), and owes to the fact that when most docs are running in the other direction, hospitalists step up to the plate and fix problems that need fixin’.

So a shout out to Eric Howell and the Hopkins Bayview crew for adding one more arrow to the hospitalist Quiver of Indispensability.

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