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Service Delivery Innovation Profile

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


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Snapshot

Summary

The University of California, San Francisco Medical Center realigned its surgical team to provide increased coverage and consultations in the emergency department through use of rotating surgical "hospitalists" who take call for a week at a time (rather than the traditional 24-hour on-call shift). This program, believed to be the first large-scale implementation of a surgical hospitalist model in the United States, resulted in quicker response time for consultations and, according to physician surveys, shorter emergency department length of stay, better patient satisfaction, improved professionalism and resident supervision, and better overall quality of care.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on response times for appendectomy, post-implementation data on overall response times, before and after comparisons of usage of the consult service, and physician surveys of their perception of the program.
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Developing Organizations

University of California, San Francisco, Dept. of Surgery and Dept. of Medicine
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Use By Other Organizations

  • This innovation has been adapted for use in a community hospital by the Everett Clinic in Everett, WA.5
  • 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 surgical hospitalist programs across the country, and it is anticipated that there will be approximately 300 within the next 3 years.6
  • As of March of 2010, there are an estimated 200 surgical hospitalist programs emerging around America, inspired by the University of California, San Francisco model.
  • As of April 2011, the concept of a dedicated emergency surgeon has now been implemented in approximately 400 hospitals across the United States.7

Date First Implemented

2005

Problem Addressed

Problems of inadequate surgical on-call coverage and a general lack of access to acute surgical care in emergency departments (EDs) have reached epic proportions in the United States, leading to major consequences for critically injured and uninsured patients.1 The University of California, San Francisco experienced these problems as well. Before July 2005, on-call emergency surgical consultations at University of California, San Francisco were provided in 24-hour shifts by a diverse faculty with varied specialties who had to cover 2 campuses 3 miles apart. This system of care resulted in a number of problems:
  • 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 cancellations.
  • 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.

What They Did

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Description of the Innovative Activity

To address the crisis in access to emergency surgical care, surgical hospitalist models were designed to augment the traditional acute care surgery model. This new model is designed to be more patient-centered, humane, responsive, and readily accessible. The University of California, San Francisco Medical Center's model is believed to be the first large-scale implementation of the surgical hospitalist in the United States. The model has several key components that are described below:
  • Staffing and call schedule: As of July 2012, there are 8 core surgeons involved in the program. The call schedule involves assignment of a single weeklong daytime person Monday through Friday 6 a.m. to 6 p.m., with separate evening and weekend call surgeons. The Medical Center has witnessed variable lengths of days on call—some involve just a single day or even shorter stretch, and the key resulting challenge is to preserve continuity in care. The surgical hospitalist program also is supported by important and valuable contributions of the nurse practitioners assigned to the service.
  • 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 followup 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: The University of California, San Francisco Medical Center revamped its documentation and billing procedures to ensure that all services and procedures are documented and billed to the appropriate third-party payers.

Context of the Innovation

The surgical hospitalist program was implemented at University of California, San Francisco Medical Center, an academic health center that includes 2 campuses, a 600-bed main hospital and a second campus with a 50-bed hospital and several specialized clinics, as well as a center for comprehensive cancer care. Before this innovation was implemented, emergency general surgical care was provided by a highly diverse faculty spread across 2 campuses, each surgeon taking call on a 24-hour basis. As an academic medical center with salaried faculty, University of California, San Francisco found that there were few incentives for surgeons to be available for call.3 As a result, patients at the medical center experienced long waiting times for surgical consults along with other disruptions in continuity of care, both for patients needing consults and for elective-surgery patients being cared for by on-call surgeons. These problems led to the decision to reorganize the on-call coverage system to better meet the academic health center's mission of providing quality, safe care to patients while also teaching residents.

The surgical hospitalist model was adapted from a successful medical hospitalist model that was implemented at University of California, San Francisco in the early 1990s.4 By focusing on continuity and comprehensiveness of care, this model has improved both quality and efficiency and has been recognized nationally as an acceptable practice for providing services to medical inpatients. In addition, a quality improvement program at San Mateo General Hospital (a low-volume facility) provided some background for the surgical hospitalist model at University of California, San Francisco,1 as did the experiences of San Francisco General Hospital where physician John Maa, MD (now at University of California, San Francisco) developed some of the structural elements for the program. The surgical hospitalist program at the medical center expanded and built on these previous efforts.

Did It Work?

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Results

Preliminary findings after the first year suggest that the University of California, San Francisco surgical hospitalist program has improved response times and physician perceptions of the quality of care, while also generating new revenues that more than pay for the program.1
  • 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.
  • Anecdotal reports of improved safety and efficiency: Information provided in May 2011 indicates that by assisting emergency surgeons interoperatively with spinal exposure, control of hemorrhage, and dissection, surgical hospitalists contribute to patient safety, promote intrahospital and operating room efficiency, and ease the on-call burden for subspecialists. Allowing surgical hospitalists to perform emergency surgeries during surgical schedule "windows" created by canceled and shorter-than-expected procedures has also contributed to increased surgical suite efficiency; this prompted the hospital to dedicate one surgical suite to emergency procedures.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on response times for appendectomy, post-implementation data on overall response times, before and after comparisons of usage of the consult service, and physician surveys of their perception of the program.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • 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 3 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: Although 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 8 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.
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Funding Sources

University of California, San Francisco
Some initial financial support came internally from the University of California, San Francisco Medical Center, which awarded a stipend to the Department of Surgery. As noted, the incremental revenues generated by the program more than cover the cost on an ongoing basis.end fs

Tools and Other Resources

Wall E. Surgical hospitalism: a perspective from the community hospital. Surgery. 2007 Mar;141(3):327-9. [PubMed]

Adoption Considerations

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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 the 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.

Use By Other Organizations

  • This innovation has been adapted for use in a community hospital by the Everett Clinic in Everett, WA.5
  • 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 surgical hospitalist programs across the country, and it is anticipated that there will be approximately 300 within the next 3 years.6
  • As of March of 2010, there are an estimated 200 surgical hospitalist programs emerging around America, inspired by the University of California, San Francisco model.
  • As of April 2011, the concept of a dedicated emergency surgeon has now been implemented in approximately 400 hospitals across the United States.7

Additional Considerations

  • Having surgeons provide on-call coverage continuously for 1 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.
  • Information provided in March 2010 indicates that an unexpected benefit of the model was derived through the increased availability of the surgical hospitalist to assist surgeons from other services with intraoperative consults, to enhance both patient safety and quality of care. Many surgical specialty services came to recognize that a general surgeon was invariably available and to request assistance intraoperatively for spinal exposure, control of hemorrhage, and dissection through preoperative anatomy. This allowed extensive collaboration with specialty surgical colleagues both for revenue sharing and research endeavors. As the surgical hospitalist has become expert in the care of challenging emergency conditions, the operating room (OR) nurses have also become more comfortable working with the surgical hospitalist and are better able to prepare the equipment they will need. Whether it is by promoting earlier discharge, implementing preoperative assessment guidelines to minimize OR cancellations, promptly evaluating new consults, or assisting with discharge planning of inpatients, the surgical hospitalist seeks to enhance patient throughput in the hospital.
  • Information provided in March 2010 indicates that an unanticipated strength of the program for both men and women is the potential for increased career satisfaction derived from a greater control over work and life balance. A key principle of the program is a group-based practice model and a willingness to share in the care of patients through a team approach to perioperative care. In addition, surgeons have the opportunity to periodically rotate into (and out of) the call scheme and thereby to achieve a better level of work and life balance through a predictable schedule and greater control of their career and family time.
  • Ultimately, the surgical hospitalist program seeks to promote earlier discharge (output), implement preoperative assessment guidelines to minimize OR cancellations (throughput), and promptly evaluate new consults (input) to promote patient flow through the hospital and alleviate ED overcrowding, boarding, and ambulance diversion.
  • Information provided in July 2012 indicates that the principle of the dedicated onsite availability of an emergency surgeon has now been extended to a number of surgical services across the country, including neurosurgery, orthopedics, and otolaryngology. The dominant model remains in the private practice setting, of a junior graduate who is recruited out of general surgery residency to be available for consults in the daytime to establish their practice. A key question often asked is, what is the difference between the acute care surgery and surgical hospitalist model? From one perspective, the two fields are merging and unifying in the middle; the common key principle involves a dedicated emergency surgeon.
  • Information provided in July 2012 indicates that not all surgical hospitalist programs have succeeded nationally, and some have been the casualty of their own success. It is essential to carefully distinguish a surgeon functioning as a surgical hospitalist dedicated to the core concepts of safety and quality in emergency care from locum tenems.

More Information

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Contact the Innovator

Hobart W. Harris, MD, MPH, FACS
UCSF Department of Surgery
513 Parnassus Avenue, S-301
San Francisco, CA 94143-0104
Phone: (415) 514-3891
E-mail: harrish@surgery.ucsf.edu

Innovator Disclosures

Dr. Hobart W. Harris has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Nelson JR, Wellikson L, Wachter RM. Specialty hospitalists: analyzing an emerging phenomenon. JAMA. 2012 Apr 25;307(16):1699-700. [PubMed]

Maa J, Carter JT, Gosnell JE, et al. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007 May;205(5):704-11. [PubMed]

Maa J, Gosnell JE, Carter JT, et al. The surgical hospitalist: a new solution for emergency surgical care? Bull Am Coll Surg. 2007 Nov;92(11):8-17. [PubMed]

Maa J, Nelson J. The surgical hospitalist program management guide: tools and strategies for executives and physicians. Marblehead, MA: HCPro; 2009.

Specialist hospitalists: could they be the answer to the challenge of call panels? ED Management. 2008 Jun;20(6):61-3. [PubMed]

Lin PH. The practice of general surgery today requires growth and adaptability. Bull Am Coll Surg. 2008 Mar;93(3):4-5. [PubMed]

Footnotes

1 Maa J, Carter JT, Gosnell JE, et al. The surgical hospitalist: a new model for emergency surgical care. J Am Coll Surg. 2007 May;205(5):704-11. [PubMed]
2 Maa J, Gosnell JE, Carter JT, et al. The surgical hospitalist: a new solution for emergency surgical care? Bull Am Coll Surg. 2007 Nov;92(11):8-17. [PubMed]
3 Maa J, Gosnell JE, Gibbs VC, et al. Exporting excellence for Whipple resection to refine the Leapfrog Initiative. J Surg Res. 2007 Feb;138(2):189-97. Epub 2007 Feb 9. [PubMed]
4 Wachter RM, Goldman L. Implications of the hospitalist movement for academic departments of medicine: lessons from the UCSF experience. Am J Med. 1999 Feb;106(2):127-33. [PubMed]
5 Wall E. Surgical hospitalism: a perspective from the community hospital. Surgery. 2007 Mar;141(3):327-9. [PubMed]
6 Maa J. Personal communication, March 28, 2009.
7 Maa J. Resolving the crisis in emergency surgical care. General Surgery News. 2010 Nov;37(11):1, 32-3.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 26, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: September 25, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 22, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.