Tuesday, March 31, 2015

Medical Staff Development Plan - Why It's Essential to a Hospice's Growth

Resourceful (and strategic) use of physicians in hospices and palliative care programs has proven to accelerate the success of creating Accountable Palliative Care Organizations (APCOs) in some of our nation's communities (we'll explore several of these success stories in future posts). And while building an APCO is a test of endurance, will, and collaboration, the process of developing an APCO is stalled more frequently by the slow, fitful, and fragmented process of acquiring the palliative medicine "intellectual capital" requisite to an APCO. A Medical Staff Development Plan (MSDP) will serve as a management guide for the alignment of the physician staffing plan with the Hospice strategic plan.

The MSDP will allow a hospice to:
  • identify the opportunities and risks of the current medical staff complement relative to the development of a community APCO ;
  • define a reasonable range of investment required to meet recruitment needs; and
  • demonstrate the strategic and proactive thinking of hospice/palliative service senior leadership to the community, its hospitals, and other key stakeholders.

The MSDP comprises five sections:

  1. Community Assessment of palliative care practices - identifies improvement opportunities and provides competitive intelligence about peer and neighboring programs,
  2. Three-Year Staffing Plan - translates community needs into physician staffing requirements and associated financial commitments, 
  3. Responsibility Chart and Professional Performance Profile–these tools enable leadership to systematically identify decisions and activities that must be accomplished and to pinpoint the functions (positions) that will take on roles relevant to those results, 
  4. Compensation Plan –recommends physician compensation models to produce desired physician behavior and translates administrative, supervisory and teaching (AS&T) activities for physicians into fair and reasonable compensation ranges, 
  5. Recruitment Plan - the articulation of "community hospice and palliative care" practice opportunities that attract talent and fill competency gaps.

Securing executive/Board support for building a HPM staff is easier when it's the result of a well-thought out, comprehensive and strategic plan that pegs recruitment to milestones.

Building Blocks of a High-Performing Hospice Medical Staff

I'm asked from time to time what makes for a better- performing hospice medical staff. I'm unsure that there is a straightforward answer. The strategy of hospices building medical staffs is a recent and uncommon practice. Uncommon because the median daily census (in 2010) of U.S. hospices was just over 50, and more than three-quarters of hospices admitted fewer than 500 patients annually. Hardly sufficient scale to employ a single full-time physician, let alone a medical staff of five or more. By one rule of thumb oft cited for physician staffing levels (1 FTE per 100 ADC), only 18% of the U.S. hospices would consider employing a full-time HPM physician.
Those who have closely followed other health care sectors, such as home health and infusion therapy, are quick to point out that consolidation swept rapidly through these sectors once reimbursement was tightened or reformed, and sub-scale agencies found that size did indeed matter. Will hospices follow a similar pattern? I wouldn't want to wager a hospice's existence against it. So the hospices of the future will likely be larger. And with size comes the need for a medical staff structure that enables access and quality.

The structure may vary from hospice to hospice, but most will arrive at the right structure by careful and thoughtful building of the medical staff. Here follows, from our study, the eight building blocks.

  • Create full-time “blended” practice opportunities that attract and retain HPM physicians
  • Develop bench strength to account for volume fluctuations, departures, back-up coverage
  • Amass “intellectual capital” for an infrastructure that supports an effective and efficient medical staff
  • Deploy hybrid compensation models to align physician and hospice incentives, and reassess at least annually
  • Maintain relentless focus on capturing information on physician activity to provide timely and constructive feedback and aid performance management
  • Clearly articulate expectations among medical staff practitioners, medical leadership, and hospice management
  • Create virtual organizational structure to extend influence of medical staff into greater community to reduce fragmentation of late-life care
  • Foster an unswerving commitment to performance improvement to minimize inappropriate practice variation, reduce regulatory risk, and win the confidence of referring sources.

We'll examine, over the coming months, each of these building blocks with a little more precision. As always, your comments are invited.

Wednesday, March 11, 2015

The Evolving Role of Hospice and Palliative Medicine Leadership

As hospices and palliative care services evolve into accountable palliative care organizations with greater scope and influence over late-life care within their communities, a "new" physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the "chief community palliative care officer".

These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:

-build and sustain relationships that evolve into community-wide palliative care networks

-disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance

-inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics

-envision and stimulate a change process that coalesces the community around new models of late-life care

Daunting challenges, to be sure.  As hospice executives and HPM physicians (and nurse practitioners) come to grips with  rules around eligibility and face-to-face recertification requirements, we would all do well to remain mindful of the strategic leadership objectives that will ultimately determine how successful we are in transforming late-life care in the US. We've seen the importance of HPM leadership in exemplar communities across America (some of which have featured in this blog) -  assembling the right mix of intellectual capital, at the right time (what we refer to as bellwether practices) becomes one of the must-have competencies of late-life care organizations.