April 15, 2017

Meaningful Work

Having left Cleveland in July of 2000, one of the meccas of tertiary healthcare in the US, I ventured west with my wife and newborn son to join a thriving Emergency Medicine private practice of 10 physician partners in a suburb south of Seattle. I was attracted to the group based on the values they lived out daily around teamwork, the quality of care they provided and a sense of family. They took care of each other like an extended family and were proud of the care they provided. Soon after joining, despite enjoying the practice outside of an academic environment, I became frustrated with the hospital admissions process for the 10-20% of my patients who needed to stay in the hospital, as the gears of throughput came to a grinding halt. The local primary care providers (PCPs) were extremely busy, and it would take hours for them to come see their patients for admission, or I would be left to write holding orders and hope patients were seen in a timely manner. Often, I would find out that no one saw them for 14 hours from the time I saw them at 5pm until the next morning when the PCP came in to round on patients at 7 am before returning to their office to see patients in the office. I went to speak to our hospital CEO to let him know my challenges. He questioned, “What do you want to do about it?” True to Sound’s now unpublished 6th core value of getting stuff done, I replied, “Let me bring on three additional partners and cover the inpatients for the hospital.” And that is what we did. We saw our first patients in September of 2001 under the name of Sound Inpatient Physicians. PCPs were hesitant to assign care to us for their patients who needed hospitalization, so we started with patients without a PCP referral base.  From a business perspective, we were learning as we went, but the clinical part was easy. We started with an nontraditional schedule of working 7 day shifts, followed by 5 night shifts from home and then had 9 days off. We averaged about 3 or 4 admissions over 24 hours, with one physician working days and another one working nights. What the hospital quickly realized was that throughput dramatically improved. There were fewer ‘code blue’ events on our assigned patients, and documentation dramatically improved, driving up the hospital’s case mix index. In addition, they found that the PCPs we were covering for were much happier not having to come in for hospital calls on patients that were not “their own.” The very next month, we received a call from a neighboring hospital inquiring about our service. Then a third hospital called, concerned that their medical staff were thinking of leaving because they saw a better career opportunity in “the new program” that Sound Inpatient Physicians was developing down the road. The hospital leaders asked us to partner with them for the care of their hospitalized patients. We quickly started our second and third programs in January of 2002, followed by two other programs south of Seattle that following summer. Early on, we were exclusively focused on being a good medical group. Our thesis was that if we recruited and retained good people, great care would be provided, and that would set Sound Inpatient Physicians up for success. To this day, we acknowledge that none of us went into medicine to be average. What gets in the way of practicing great medicine is not where you went to medical school or where you trained, but fundamentally, it is creating the right work environment that drives great success. Communication and information systems need to be solid, workload manageable and ancillary services need to be in place to optimally serve patients. At that time and to this day, we focus on making sure providers have a work environment that supports providing the best patient care. Meaningful work to me is feeling proud of the care we give patients. I can say, without a doubt, 16 years later that this fundamental underpinning to our practice is alive and well in each of our more than 225 hospital partners nationwide. We know that 70%+ of the patients seen by hospitalists are covered by Medicare and Medicaid and providers often coordinate care activities which are uncompensated.  Professional fees do not cover the cost of all the clinicians who provide care for our patients.  This gap requires hospitals to pay the difference between what we bill to payers and the cost of employing providers; this is commonly referred to as a “subsidy” by some hospitals. We quickly realized that to build our organization and deliver a better and more sustainable career for physicians and advance practice providers, we needed to consistently deliver value to our hospital partners that justified the cost of our services. From my perspective, this falls into the categories of ‘better to be lucky than good’. By 2004, we had not only realized where we could add value for hospital partners but we made some big bets. We began to transform Sound Inpatient Physicians from not just a good medical group, but into a performance management organization. In order to recruit and retain great people and build a better career opportunity, we needed to focus on building a better work environment. In order to build a better work environment, we needed funding from hospitals. For hospital partner buy in, we need to drive value for them. As a performance management organization, we made deep Investments in our technology platform, Sound Connect, and we created a hospitalist RN role to drive reproducible results in patient care and partner satisfaction. We also created a leadership program for providers that would one day enable Sound to be known for developing great healthcare leaders, just as GE is known for developing great business management leaders.  We strive to be the healthcare organization of choice that will prepare the next generation of clinical leaders in the United States. Importantly, we rolled out a path to partnership model for our providers, allowing us to build a long-term, sustainable career path for them. We found our way forward and evolved our vision to be the unmatched leader at improving quality and lowering the cost of healthcare for patients in each of the communities we serve. Eventually, Sound Inpatient Physicians grew from working in my house (we got kicked out when my third child was born and ran out of space) to become a nationally recognized organization focused on our vision – and changed our name to Sound Physicians. But we never lost sight of patients being our greatest concern and our providers being our greatest asset.  Most of our growth comes by word-of-mouth referrals. We partner with new hospitals and providers who fundamentally believe that we deliver a better career opportunity for providers and a tremendous impact on patient and hospital outcomes in the United States. We also recognized that through our core competency of physician recruiting, we could develop a separate business to provide interim staffing for hospitals with needs for short term coverage so we started Echo Locum Tenens in 2010. Most importantly, having this team of temporary staffing recruiters in place allows us to better deliver on the role we promised to our full-time clinical colleagues around workload.  The demand for these services continues to grow for a number of specialties. By 2014, we realized that Sound Physicians had an incredible opportunity to impact quality and cost of patient care beyond the walls of the hospital. We realized that 50% of every dollar spent on healthcare occurs from the time a patient shows up in the ED through 90 days post-discharge. To be an organization of scale, and make a significant impact, Sound Physicians merged with Cogent Healthcare. We took the best practices from both thriving groups to build a better organization together. One of the benefits of the merger was the great group of intensivists within the organization (The Intensivist Group), now referred to as Sound Critical Care. We are now the largest group of intensivists in the nation focused on the same approach of driving reproducible processes to get reproducible results in the ICU. Around the same time we started a division to provide secondary case reviews and claims appeal services. We realized Sound had a number of experts already on our team who work on Utilization Review committees and could help hospitals improve their clinical documentation review processes. We call this group Sound Physician Advisory services. Our hospitalists and intensivists colleagues can work on their time off from home after completing training. We then set our sights on Medicare’s Bundled Payment Care Improvement initiative (BPCI).  As the largest provider-group participant, we realized we had a massive opportunity to invest in better outcomes for patients through improved transitions beyond the walls of the hospital. Traditionally, hospital goals are about getting patients out of the beds once they are healthy enough to leave the hospital. Little attention was paid to where they went after leaving the hospital. Certainly, no data was used to determine what post-acute care facilities had better outcomes.  As a result, hospital readmissions were frequently high. This realization launched a revolution within Sound Physicians with a focus on improving transitional care. To complete another piece of the acute episode of care path, we expanded our practice into emergency medicine, which I personally practiced for more than 15 years. Today, support services are perfectly aligned to serve our emergency department (ED) providers.  Importantly, we are now able to create a more efficient and higher quality inpatient stay for patients needing hospitalization by integrating all of our services. We are bringing our same passion building a better work environment for our providers and better performance across the acute episode of care. Our vision to be the unmatched leader at improving quality and lowering the cost of healthcare for patients in each of the communities we serve resonates with our colleagues. It is why we are here. Every time we go into a new community, I know care gets better because of the incredible quality, teamwork, innovation and service each and every one of our colleagues brings to their work with their hearts and minds each day. I am proud to be part of Sound Physicians, and more excited about our future than ever. Our team’s passion for making a meaningful difference in the lives of our patients, one at a time, is palpable both in the hospitals where we care for patients and for our business colleagues. This defines meaningful work to me. I feel very lucky and proud to be leading Sound Physicians. Thanks for reading.

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