hospitalist consultant

Why do Hospitals Ask for an OBGYN Hospitalist Consulting Visit?

Hospitals and their doctors request consultants for a variety of reasons, but OBGYN hospitalist related consultations are usually more specific.

Most requests originate from a hospital that is experiencing a series of bad outcomes in labor and delivery, which has led to malpractice events, or because local ob gyn doctors are stressed out and are looking for relief.

Sometimes these obgyn doctors learn of OBGYN hospitalist solutions while they are attending continuing medical education conferences.

The main reason either hospitals, a hospitalist company, an OB hospitalist group, or local obgyn physicians start an OBGYN hospitalist program is because it makes it safer for women in labor.

However, it also has the benefit of improving the work life balance for the private OBGYN’s as well as family practitioners and midwives who do deliveries.

Imagine being on call but yet able to sign out your responsibilities for a few hours in order to attend your child’s birthday party. This is just one example where obgyn hospitalists come into the scene.

Patients benefit because there is an experienced board-certified OBGYN physically present in the hospital to respond to an emergency and be available while their private practitioner is on the way into the hospital.

Patients are seen more rapidly for evaluation and studies show that the hospital experiences a reduced cesarean section rate.

In many hospitals, the OBGYN hospitalist also sees gynecologic emergencies in the main ED with the same rapid evaluation.

So although the reasons can vary for a doctor or hospital to request a consultation with a hospitalist about designing or enhancing a hospitalist program, it usually boils down to better patient safety and overall improvements for physicians and nurses and midwives.

If you have any questions or need to request Dr Olson for a consultation please contact Rob.

obgyn hospitalists

The ABCs of OBGYN Hospitalists

OBGYN hospitalists are generally board-certified obstetrician-gynecologists who focus their practice on hospitalized women and generally do not have an outpatient office. Hospitals hire them for several reasons but the most important is for safety. Especially in obstetrics, the clinical situation can change so rapidly that unless a physician is actually in labor and delivery to respond on an emergency basis there can be a bad outcome for mother or baby or both.

Just like the rapid penetration of internal medicine hospitalists, OBGYN hospitalist programs are spreading. Although a few programs have been around for many years, in 2007 there were only approximately 15 in the United States, and currently there are over 244 with two to six new programs starting up monthly. It certainly is not standard of care yet but I’m predicting it will become standard of care within three to five years. Some people use the word Laborist, but a better term is OBGYN hospitalist for those programs in which there is responsibility not only of labor and delivery, but also of gynecologic emergencies in the main ED (Emergency Department). OB hospitalists only stay in labor and delivery and the private OBGYNs staff the main ED.

Financially speaking, almost all programs lose money. Depending on the volume, that loss can be between $1-$200,000 or up to 1 million dollars. Roughly, a program costs $1.5 million and the income it generates can bring in $500-$750,000 a year. Hospitals with 2000 deliveries or more have a lower amount of loss. It is important to look at a wider budget rather than simply profit or loss because:

  1. Bad outcomes lead to malpractice costs
  2. Hospitalists can increase the volume of high-risk pregnancies that can help to fill up the neonatal ICU, which can be a profit center for hospital
  3. Retention and recruitment of not only physicians but of the expensive-to-train labor and delivery nurses

Many hospitals help pay for the program by transforming their outpatient OB triage areas into OB emergency department (OB ED). This increases the facility fee for evaluation substantially.

Many hospitals are facing the same problems:

  1. OBGYNs do not want to take call
  2. There are unassigned patients
  3. There may be midwives and family practitioners doing deliveries without backup
  4. No one wants to accept the transfer of high-risk patients
  5. Patients wait a long time for evaluation
  6. Maternal Fetal Medicine specialists want to do an outpatient practice only and not come to the hospital
  7. No one wants to do vaginal births after cesarean section (VBACs)
  8. The cesarean section rate is too high

An OBGYN hospitalist can help with all of these issues, making the private practitioners happy by taking the call, caring for the unassigned and high-risk patients, consulting for the family practitioners and midwives, evaluating patients promptly, working collaboratively with the MFM specialist, encouraging VBAC by taking responsibility while the private practitioners stay in their office, and studies prove that having professional full-time OBGYN hospitalists reduces the C-section rate.

There are no great downsides other than the direct costs to the hospital. Initially the private practitioners are skeptical, but within a few months they become the program’s biggest fans. Patients are satisfied and studies prove this. Nurses are supported and empowered. It can become a very important competitive advantage for a hospital that has a nearby competing hospital.

 

The Impact of Hospitalists on Gynecologic Emergencies

Up to now, I have been commenting mainly on ob.gyn. hospitalists’ impact on labor and delivery, but our surveys show that the majority (64%) of ob.gyn. hospitalists also have responsibility for seeing gynecologic patients in the main emergency department as well as inpatient consultation.

Most gynecologic emergencies are as you would suspect: threatened miscarriage, ectopic pregnancy, pelvic inflammatory disease, and, to a lesser extent, torsion of benign tumors as well as the occasional malignancy, and the common vague abdominal pain syndromes. Ob.gyn. hospitalists provide the main emergency department with the type of service that they provide in labor and delivery (L&D) triage or the obstetric ED: immediate or at least rapid response, expert clinical care, and the ability to work with the team in the ED or with other team members such as surgeons in the case of major trauma involving either pregnancy or gynecologic organs. This rapid response results in increased patient satisfaction as well as a more efficient ED.

However, having an ob.gyn. hospitalist cover the ED comes at a cost, as it physically takes him or her away from covering potential emergencies in the L&D area. Some hospitals get around this problem by allowing the ob.gyn. hospitalist to only go to the ED when they’re unoccupied; or if they make a diagnosis requiring surgery, they will call the on-call gynecologic surgeon so that the ob.gyn. hospitalist is not in the operating room with a case just when they’re needed for a shoulder dystocia or prolapsed cord in L&D.

This compromise of allowing diagnosis but not surgical treatment is a good one because even though the main ED is frequently geographically separate from L&D, the ob.gyn. hospitalists can usually rapidly leave the main ED to respond, while they could not provide the same response if they were in the middle of a surgical case. Having a backup gynecologic surgeon on call also provides a mechanism for outpatient follow-up for a medically treated gynecologic emergency patient.

Well-run programs also have an obstetric physician on backup call for follow-up of unassigned outpatient obstetric patients who need to be seen after triage or obstetric ED visits. More importantly, these programs have a backup physician if the ob.gyn. hospitalist gets either too busy or too fatigued. However, our most recent ob.gyn. hospitalist.com employment survey shows that between 35% and 45% of programs do not have an adequate emergency backup system in place to cover the hospitalists (www.obgynhospitalist.com) [now obgynhospitalistconsulting.com].

Rapid and easily obtained gynecologic consultation also helps with improved patient care, diagnosis, treatment, and turnover of inpatient beds. With in-house ob.gyn. hospitalists, the days of internists, family practitioners, and traditional hospitalists having to wait until after office hours for a gynecologist to see an inpatient are over. Traditionally, that consultation would take place at 6 p.m. or 7 p.m., and then additional ordered diagnostic imaging might not take place until the next day, adding unnecessary delays in diagnosis and causing longer hospital stays than necessary.

Gynecologic responsibilities add to the body of knowledge that ob.gyn. hospitalists need to be skilled at, especially with diagnosis and medical treatment. However, requiring hospitalists to provide gynecologic coverage also emphasizes the potential challenge of how to maintain superb gynecologic surgical technique. This is difficult with low volumes of surgical cases. Once again, this problem can be eliminated if there’s a gynecologic surgeon to do the work in the operating room. This is also an area that is of particular interest to the Society of OB/GYN Hospitalists as they discuss and decide which skills and competencies hospitalists must possess and maintain.

Originally posted FEBRUARY 14, 2013 on ehospitalistnews.com

What I Learned at the Annual SOGH – Society of OB/GYN Hospitalists

What do you get when you put 83 enthusiastic ob.gyn. hospitalists, generalists, and administrators together in one big conference room in Denver? You get a lot of fun and great, relevant clinical information essential for hospitalists working all across the country today.

Even though I’ve been an ob.gyn. for 35 years and a hospitalist for the last 5, this annual clinical meeting [SOGH – Society of OB/GYN Hospitalists] taught me new business and clinical information. As our model of practice develops, we also can learn much from each other, and this annual event allows us to meet face-to-face to discuss our common problems, share workable solutions, and socialize.

Here were some of the meeting highlights for me:

Dr. Richard Porreco of Rocky Mountain Hospital for Children, Denver, reminded me to respect the condition of placenta percreta, and his expert advice on ways to deal with it was invaluable. He also reviewed peripartum intensive care and discussed the possible future roles for ob.gyn. hospitalists in leading critical care of these patients.

Dr. John Hobbins of the University of Colorado, Denver, explained the use of sonography in labor and delivery, an area that we will all need to pay attention to in the near future. Personally, I only use ultrasound in triage and to identify fetal position in labor, but he showed some of the benefits of using it to assist prior to operative delivery.

Darrell Ranum, J.D., regional vice president of patient safety for The Doctors Company in Columbus, Ohio, covered the factors that result in the delay in treatment of fetal heart rate abnormalities. His conclusion was that communication issues and the delay in the arrival of the physician can both be alleviated by having an ob.gyn. hospitalist on-site. This is something that we still need more data to prove, but his closed claims data was convincing.

Dr. Arthur Townsend spoke about the importance of hospitalist statistics. Collecting statistics is difficult, and hospitalists may not see the benefits. However, Dr. Townsend demonstrated how to make gathering statistics easier with his Web-based solution and the value in doing so, which we need to embrace to prove the difference we make as hospitalists.

Ob Hospitalist Group hosted the lunchtime lecture by Miranda Klassen on amniotic fluid embolism. Miranda, who founded the Amniotic Embolism Foundation (afesupport.org), is not only a survivor, she has made it her mission to educate physicians to identify and rapidly respond to this potentially fatal and often misdiagnosed condition. This was very worthwhile reviewing.

Dr. Stan Davis of Edina, Minn., spoke about the human factors in labor and delivery. He was able to communicate the TeamSTEPPS system in a concise and effective way that made it easier to understand and more relevant for me than all the other times I’ve been exposed to this complex subject.

Dr. John Nelson (nelsonflores.com), cofounder of the Society of Hospital Medicine (hospitalmedicine.org), spoke about starting and operating a professional society, and lessons learned from medical hospitalists so that, hopefully, we can avoid their early missteps.

Prior to the conference, 56 ob.gyns. participated in The Doctors Company’s highly specialized emergency obstetric simulation workshop. One of the highlights of this workshop was the attendance of Professor Christopher B. Lynch, who flew in from the United Kingdom to personally demonstrate his B-Lynch suture technique for the control of postpartum hemorrhage. In addition, GE sponsored a concurrent hands-on ultrasound in labor and delivery course with live models. It was a fantastic mix of learning and practicing old and new skills.

Questcare hosted a welcome reception, which gave attendees an informal chance to meet and discuss problems and solutions related to being hospitalists. This also gave general ob.gyns. who aspire to be hospitalists a chance to ask seasoned hospitalists about their experiences. This is what the annual meeting was all about: networking, talking with peers, and knowing that we are not alone out there practicing this new model of ob.gyn. medicine.
SOGH will hold its third annual clinical meeting in Denver from Sept. 19 to Sept. 21, 2013. Save the date to come and learn more about both the clinical and the business aspects of being an ob.gyn. hospitalist.

Originally posted NOVEMBER 20, 2012 on ehospitalistnews.com

More Than Just a Job – My Job as an OBGYN Hospitalist

It’s bittersweet that this will be my last column, but I appreciate the opportunity that this news organization [ehospitalistnews.com] has given to me, and it’s been an honor to share my thoughts about the new ob.gyn. hospitalist model, how it is changing our profession, and the future that lies ahead.

This is an exciting time to be in this rapidly evolving field because this is a new way of delivering health care to women by utilizing board-certified ob.gyns. who are physically present in the hospital. Their presence has led to proven increases in patient safety, a demonstrable reduction in bad outcomes, as well as decreased malpractice costs.

Additionally, programs not only lead to increased lifestyle satisfaction for hospitalists, but contribute to reducing private ob.gyns.’ stress and conflict of needing to be in the office and the labor and delivery department.Although hospital administrators have to pay the considerable gap between the costs of these programs and the amount of billing provided to the hospital by the work the physician hospitalists perform, administrators also are very satisfied. This can be seen by the veritable explosion of new hospitalist programs across the United States. When I began my career as a hospitalist in 2007, I could only find 15 programs, and now there are 200 nationally.

If I speculate and try to imagine 3-5 years in the future, I think there will be ob.gyn. hospitalists in at least 75% of all hospitals delivering 2,000 or more babies per year. That means there will be at least 102 programs employing approximately 612 (6 × 102) hospitalists.

For those of you considering this opportunity, it is a chance to reduce your work hours by moving to hourly shifts instead of days in the office and nights on call. You can have a good salary while having a life outside of medicine as well. You can hone your clinical skills by concentrating on obstetrics and perhaps emergency gynecology cases as you learn to work in teams; implement systemwide improvement; and have a greater emphasis and potential impact on patient outcomes, satisfaction, and quality.

It is a profession and not just a job. It is one of which I’m proud and love to do. I am convinced that having ob.gyn. hospitalists makes it safer for women. It is an opportunity to get in at the ground floor and help influence our profession’s newest model of care that is changing women’s inpatient care in this country right now and for many years to come.

Originally posted JUNE 20, 2013 on ehospitalistnews.com

Character Traits of an ObGyn Hospitalist

Through my experience as an ob.gyn. hospitalist, it quickly became clear which things work well and which things do not in an ob.gyn. hospitalist program.

Although internal medicine and pediatrics have been using the hospitalist model for quite some time, it is still a model in its infancy for ob.gyn. medicine. With hospitals investing significant amounts of funding to start ob.gyn. hospitalist programs, there is neither time nor money to waste on pursuing the things that don’t work. The expectation is that even though it’s a new program, it should work almost immediately.

Those who have been through the torturous process of establishing, integrating, and/or converting to any new program in any aspect of life know that this is a fairly unrealistic expectation. There are, however, some basic ingredients or attributes that I believe must be present to lessen the pain and increase an ob.gyn. hospitalist program’s chances of success.

The following are some qualities that should be considered when ob.gyn. hospitalist candidates are interviewed:

• A physician who is a seasoned professional. Finding and then hiring the right people are always challenges in any industry, but even more so for ob.gyn. hospitalist recruitment. The best candidates for ob.gyn. hospitalist jobs need to be seasoned board-certified physicians. Not only will they be involved in every true ob.gyn. emergency, but they must also be able to educate and hold their ground against other, sometimes older ob.gyns., family physicians, and midwives who may not be practicing the most up-to-date, evidence-based medicine. This is not a job for a beginner. Physicians with expert clinical skills are essential for a program’s success, as they are the first responders and must be able to deal with or assist in every situation that presents itself.

• A physician who is a team player. The team needs to be flexible and responsible. Smooth handoff rounds, conveying all necessary information, are essential. An outgoing physician needs to introduce the incoming physician to any active patients. Scheduling needs to be fair and allow call dates to be traded to fit everyone’s schedule. Obviously, team members won’t know if they will be compatible until they start working together, but hospitalists must be willing to leave their egos at the door to be “team players.”

• A doctor who is willing to serve. The private practitioner obstetrician needs to keep her own patient happy and safe, whereas ob.gyn. hospitalists need to keep all the patients and all the labor and delivery professionals (and sometimes the gynecology emergency department professionals) safe and happy. Ob.gyn. hospitalists need to go out of their way to ask nurses and physicians the question: Is there anything I can do to help?

One of the great things about being a hospitalist is that the work is so varied, but programs need hospitalists who are willing to help anyone who asks and are comfortable doing so – from the private practitioner who needs a quick ultrasound to determine position, to the OR tech who requires help moving a patient. Some physicians may think these tasks are just scut work, but they are essential to developing a safe, efficient high-reliability organization (HRO) that can avoid catastrophe in a real crisis or emergency.

• A physician who inspires trust. Hospitalists are consistently meeting patients for the first time. They won’t have developed a relationship with patients over the previous months of pregnancy, so ob.gyn. hospitalists need to be able to bond with them and their families quickly. For example, one of the tools I find to be effective when I deal with a mom who has experienced a failed home birth by a lay midwife is this simple phrase: “I know this is not what you planned, but I am so glad that you are here with us so we can take care of you.”

• A doctor who is a good communicator. Hospitalists need to be able to solve problems quickly by using tact, diplomacy, and professionalism at all times. Being involved with emergencies and bad outcomes, they need to be comfortable with debriefing the team and communicating sensitively with patients and families. Highly developed communication skills also extend to documenting the chart and liaising with an absent private practitioner, the nursing team, and the hospital’s administration.

I was one of the original ob.gyn. hospitalists at my community hospital in Bellingham, Wash. Having Dr. Chris Swain’s company, the OB Hospitalist Group, consult helped us to quickly establish a successful new program. Our team of four hospitalists is employed by St. Joseph’s Medical Center. It is a successful program that I’m proud to say encompasses these aforementioned ingredients: We smoothly integrate our scheduling and handoffs; the local obstetricians, family practitioners, and midwives trust us and appreciate our work; and we regularly foster open communication by attending the nurses’ handoff meetings as well as huddling with the anesthesiologist and nurse team leader.

Originally published SEPTEMBER 25, 2012 for ehospitalistnews.com

 

Leadership Role in Quality and Cost Control – Hospitalist Programs

When an ob.gyn. hospitalist program starts at a hospital, there is often a varying degree of distrust, resistance, and uncertainty about how hospitalists fit into the rhythm of the labor and delivery department.

In the initial stages, the ob.gyn. hospitalist may be relegated to the sidelines and just used in a limited capacity – for an emergency or for patients without a physician, for example.

In established programs, it can be the other end of the spectrum, as ob.gyn. hospitalists are looked to for oversight, leadership, and standardization, and provide these skills, often facilitating how the L&D department operates overall. They can evolve into the manager of labor and delivery rather than only providing coverage.

I was recently intrigued by an article in the New Yorker entitled, Big Med by Dr. Atul Gawande, a surgeon, writer, and public health researcher, in which he compares the operation of his local Cheesecake Factory restaurant to hospital medicine. He observes how, unlike in medicine, the Cheesecake Factory has figured out how to “deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality.” Lamenting the current state of hospital care, Dr. Gawande rightly states: “Our costs are soaring, the service is typically mediocre, and the quality is unreliable.”

Dr. Gawande also points out that doctors are paid for services, not results. Unlike a restaurant, historically medicine is not service oriented. Medicine is becoming like a chain restaurant as large corporations transform it into a Southwest Airlines approach to health care – a high-quality, low-cost product.

We need to keep working toward what the Institute for Healthcare Improvement calls the Triple Aim which seeks to improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the per capita cost of health care.

We need to demonstrate our value by continuing to emphasize our commitment to safety and quality outcomes.

It is necessary to demonstrate that our commitment to safety and quality outcomes translates into real improvement as well as real patient satisfaction. This is going to require data collection as well as new skills and competencies on our part. Not only will we have to hone our clinical skills, but we will also have to step up as leaders to work with the other members of the health care team.

How do quality and cost control occur? Is it even possible to deliver high-quality yet low-cost hospital medicine? And who is actually in charge to help make this happen?

Change in the medical world does not happen quickly; however, the adoption of ob.gyn. hospitalists is one way hospitals can immediately start addressing these issues.

Ob.gyn. hospitalists can be used in a leadership role with responsibility for a patient’s overall care, medical costs, and results. The can coordinate who cares for the patient and how, help reduce costs in malpractice by being physically present in L&D to handle emergencies or other challenging situations, oversee collaboration on standardization to deliver consistency and best practice medicine, and ensure good patient outcomes through their presence, clinical skills, and experience.

The military uses the term C4 – command, control, coordination, and communication. Adapting this for the medical environment could look something like this:

 Oversight instead of command. This can be done by facilitating how the department runs, prioritizing and assigning assets, and being the diplomat and intermediary between hospital administration and L&D.

 Leadership instead of control. This is accomplished by instituting standardization, ensuring best practices, and facilitating policy integration to enable collaboration and consensus to achieve the best possible outcomes at the lowest cost.

 Coordination. The ob.gyn. hospitalist can coordinate between patients and their family physician, midwife, or obstetrician; coordinate between the private practitioner and the ob.gyn. hospitalist; and coordinate between nurses and physicians in L&D, and the patient during follow-up.

 Communication. The ob.gyn. hospitalist can work to ensure that everyone from the L&D floor to the hospital administrators knows what is going on all of the time.

It is fascinating to watch this process occur in real time and to be part of this transformation. There are so many different variations of how ob.gyn. hospitalists are used in different programs. However, I think this gradual shift from coverage only toward oversight, leadership, coordination, and communication is inevitable. Because this transformation makes common sense and because it leads to greater patient safety with better outcomes at the same time, it reduces stress and improves working lifestyles for the private ob.gyn. as well as family physicians, midwives, and the labor and delivery nurses.

Originally published OCTOBER 24, 2012 on ehospitalistnews.com and edermatologynews.com