Surgical Hospitalist Model Enhances Access to Surgical Consultations, Increases Physician Perceptions of Quality at Academic Medical Center

Problem Addressed

• Long wait times and disrupted schedules: Daytime consultations disrupted the elective procedures and clinics of the on-call surgeons. As a result, patients in the ED or acute care ward might wait hours until the on-call surgeon was available to evaluate them, while those awaiting elective procedures and office visits sometimes faced delays and cancelations.
• Poor match between on-call surgeon skills and patient needs: The diversity of emergency surgical conditions left many surgeons uncomfortable caring for diseases and conditions outside of their usual practice.
• Disrupted continuity of care: The 24-hour structure of the on-call schedule and separate campuses disrupted continuity of care, particularly for those patients treated by surgeons at the remote site who needed subsequent care in the ED or acute care wards at the main hospital. Surgical house staff provided the only continuity of care, but even this was constrained by their inability to work more than 80 hours a week (as mandated by the Accreditation Council for Graduate Medical Education).  
• Multifaceted reasons for lack of on-call coverage: There are a number of reasons for the lack of on-call surgical coverage, including the absence of incentives for surgeons to take call (the only benefit for surgeons at University of California, San Francisco was the revenue generated from the few consultations that actually result in a surgical procedure), declining reimbursement for surgical services, rising malpractice premiums, the migration of surgeons from the hospital to ambulatory surgery centers, a shrinking supply of surgeons, an unwillingness among many surgeons to disrupt their elective surgical cases, and growing subspecialization among surgeons, leaving many reluctant to take call for unfamiliar general surgical cases.

Description of the Innovative Activity

• Rotating surgeons: During the first year, three full-time board-certified general surgeons staffed the service on a rotating weekly basis. (The program, now in its third year, currently has four hospitalist surgeons.) During the on-call period, the surgeon schedules no elective clinics or procedures that might disrupt or conflict with acute surgical care. After the on-call period, responsibility for care is handed off to the next on-call surgeon.
• Response time goals: The program has established a goal of a 30-minute maximum response time for consultations (by either a resident or the on-call surgeon) on weekdays and 45 minutes on weekends. Performance against this standard is routinely measured.
• Surgical backup: A backup surgeon is always available, typically one of the other hospitalists.
• Referral of complex patients: Patients requiring complex surgical intervention can be referred by the team to a senior surgeon after initial assessment.
• Postdischarge followup: Patients receive follow up care at a surgical clinic, which is staffed by hospitalists who are not on call.
• Call coverage reimbursement: The University of California, San Francisco Medical Center reimburses the Department of Surgery and the surgical hospitalist for call coverage of the ED and acute care inpatient wards for a period of 1 continuous week rather than the more typical 24-hour call period.
• Per diem payment: The same per diem payment that was historically paid by the hospital to the department for on-call coverage is paid to the hospitalist team.
• Revamped billing and documentation: University of California, San Francisco revamped its documentation and billing procedures to ensure that all services and procedures are documented and billed to the appropriate third-party payers.

References/Related Articles

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Results

• Faster response time: The time to consult, which is defined as the time from the initial telephone consultation to bedside evaluation, averaged 16 minutes, with 80 percent of consults occurring within 30 minutes and 85 percent within 45 minutes. Wait time for patients undergoing appendectomy in a 6-month period before and after the start of the program decreased by 50 percent.
• Provider perception of better care: A survey found that ED physicians believe the program has resulted in shorter ED length of stay (LOS), improved patient satisfaction, improved professionalism and resident supervision, and better overall quality of care.
• Increased consults and better documentation/billing, leading to enhanced revenues: The program has proven popular with physicians in the ED and inpatient wards, as there has been a 190-percent increase in the number of requested consults and a 415-percent increase in consult revenues.² In addition, better documentation and billing processes led to a 24-fold increase in procedure revenues. The additional revenues more than offset the cost of the program.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Leadership support: The leaders of the Department of Surgery served as strong supporters and champions of the program from the onset.
• Inviting surgeon participation: All general surgeons at University of California, San Francisco were invited to participate in the pilot testing of the program. A core group of three surgeons agreed to provide on-call coverage, with the remaining surgeons (roughly 20 individuals) agreeing to be available to provide specialized expertise on a consult basis as appropriate.
• Overcoming surgeon resistance: While most surgeons supported the program, there were some initial concerns among a few surgeons that there may not be a sufficient volume of consults to justify creation of the model. These concerns diminished after implementation, as volume levels exceeded expectations. Over time, almost all faculty members came to recognize the substantial benefits of this model of care.

Resources Used and Skills Needed

• Staffing: In addition to the four surgeons who provide on-call coverage, the program requires 1.5 full-time equivalents (FTEs) to support the on-call surgeons.
• Costs: The main incremental costs for the program are salaries for the 1.5 support FTEs. The total per diem payments made to the on-call surgeons did not change as a result of this program.

Funding Sources

University of California, San Francisco

Tools and Other Resources

Getting Started with This Innovation

• Generate institutional support by demonstrating the potential value of the program, including incremental revenue generation, reduced waiting times for patients, and improved quality.
• Carefully evaluate the potential financial implications of the program. Although University of California, San Francisco generated adequate revenues to more than cover program costs, this may not be the case for other programs that adopt this model. In particular, the level of additional hospital or department support necessary (beyond the payment of per diem professional fees) cannot be determined from the University of California, San Francisco experience, and will vary from institution to institution.

Sustaining This Innovation

• Recognize that LOS and costs may rise if the program results in an influx of complex patients who are referred from other locations.
• Pay careful attention to scheduling to reduce the potential for burnout and to ensure that surgeons share the burden of providing coverage on national holidays and during major professional conferences. The addition of the fourth on-call surgeon at University of California, San Francisco significantly reduced scheduling issues and concerns.

Additional Considerations and Lessons

• Having surgeons provide on-call coverage continuously for a week (rather than the traditional model of 1 day at a time) unexpectedly gave them the opportunity to identify and help address systemic problems that they previously would not have noticed, thus leading to improvements in the quality of care.
• After instituting a new call system for physicians and nurses, the rotation for coverage is kept constantly moving, reducing patient wait time by 35 percent.

Use By Other Organizations

• This innovation has been adapted for use in a community hospital by the Everett Clinic in Everett, Washington.⁵
• 3-28-09 Revision: As was witnessed with the early experience of the medical hospitalist field, different variations of both models have emerged in medical centers across the country. As of March 2009, there are more than 30 surgery hospitalist programs across the country, and it is anticipated that there will be approximately 300 within the next 3 years.⁶