Multisite directors tackle management and logistical challenges

Expanding health systems offer new career path for hospitalists.


The rapid pace of consolidation in the health care industry is helping to carve out a new career path for hospitalists: the multisite director. As health networks expand, there's a growing need for skilled leaders who understand both the clinical and administrative challenges of managing a large system.

“Now that hospital medicine has been around for 15 to 20 years, the leaders that started out as site-based directors are maturing and able to take on larger leadership roles,” said Scott Rissmiller, MD, who started 16 years ago with Carolinas Hospitalist Group as medical director of Carolinas Medical Center in Charlotte, N.C., and has since been promoted to president and chief medical director overseeing 23 acute care facilities. “The hospitalist leader is the natural choice to head up services and standardize best care across multiple facilities.”

Photo by Thinkstock
Photo by Thinkstock

According to reports from Norwalk, Ct.-based Irving Levin Associates, which tracks health care mergers and acquisitions, overall deal volume in the health care services sector was 18% higher in 2014 compared with 2013, with deals involving hospitals rising by 14%. The Affordable Care Act is a major force driving the activity, the company noted, pushing smaller hospitals to align with larger groups in order to achieve economies of scale.

That growth has created opportunities for hospitalists like Darren Thomas, MD, ACP Member, who was hired 10 years ago as 1 of 4 hospitalists at St. John Medical Center in Tulsa, Okla., and later moved up to his current position as director of hospitalist services for St. John Health System. He now oversees 68 physicians at 4 community hospitals and 1 long-term acute care facility.

One of the challenges is maintaining a part-time clinical role despite considerable administrative demands, he said.

“There's always an inherent tension with being a hospitalist in a leadership role because there can be a perception that we don't understand the real-life challenges of clinicians,” said Dr. Thomas. “But it's impossible to do full-time clinical work while leading a large group.”

How it works

A multisite director, or chief hospitalist, typically oversees site or program directors at each of the hospitals in a health care system. Partnering with those local leaders is integral to success as an overall director, according to Dr. Thomas.

“One of the things I negotiated for when I accepted this job was having adequate associate directors to help me oversee this large group,” he said. “I work with 5 hospitalist associate directors whose jobs are about 25% administrative.”

Site director responsibilities are divided by geography, specialty, and patient volume, he said. Three directors based at the main center in Tulsa oversee the ICU, the general medicine unit, and the night admission team, respectively. In the community hospitals he oversees, 3 are managed by the same director, while another hospitalist is in charge of a fourth community hospital in a more remote location.

These directors lead weekly or monthly meetings to discuss site issues, which Dr. Thomas attends as needed and as his schedule allows. He spends several hours a week on the road traveling between sites, especially when hospitals are recruiting new hires, and he communicates regularly with his directors via teleconferences.

Some systems have more than 1 layer of multisite directors. At Carolinas Hospitalist Group, for example, site directors report to 4 regional directors who then report to Dr. Rissmiller.

At 12-hospital Alina Health, based in Minneapolis, Minn., each site has both a lead and associate lead hospitalist who supervises quality assurance and human resource issues, said David Beddow, MD, regional medical director for Alina Health Hospitalist Service. Dr. Beddow directly supervises hospitalist programs at 6 of Alina's hospitals and acts as a resource for the others.

“Each site I supervise has a monthly meeting and they are scheduled so that I can get to every site every month,” said Dr. Beddow. “One of my primary goals is to understand what's going on at each site, and in order to do that you really have to be there.”

Typically, all hospitals in a system operate under the same compensation structure, productivity expectations, and quality metrics, while local leaders control daily operations. For example, local directors usually control their own scheduling because they are most familiar with their site's unique staffing needs.

“If a smaller site has only 2 docs rounding and 4 to 5 [full-time equivalents], it's important to keep those physicians happy in order to maintain a steady workforce,” said Dr. Beddow. “As long as it's reasonable and it doesn't run afoul of any patient care issues, we let each site schedule shifts as they see best for them.”

The idea is to set common standards and goals but give local leaders some leeway as to how they are achieved. “We believe our individual groups should have autonomy but with accountability,” said Dennis Deruelle, MD, national medical director for acute care at IPC Healthcare, a national acute hospitalist and post-acute provider organization based in North Hollywood, Calif.

Advantages and challenges

There are many solid reasons to embrace a multisite leadership model, hospitalist leaders said. It promotes consistency of care and operations across sites and facilitates sharing of resources and best practices.

“The most basic reason to have a multisite director is to share staffing when a new group is starting up in the same market,” said Dr. Deruelle. “The established group can help support the new group's growth and development until it has enough critical mass to have its own director.”

(To facilitate flexibility in scheduling, both IPC and Carolinas Hospitalist Group require that all hospitalists become credentialed for all locations in their geographic region. Some other groups encourage but do not require cross-credentialing.)

On the other hand, overseeing multiple sites can often seem like a balancing act between paying attention to individual sites and dealing with system-wide issues, hospitalists said, all while keeping your hand in as a working clinician.

“It's important to understand the subculture of each site,” said Dr. Beddow. “You don't want to change that subculture but work with it, and you have learn how not to force issues unless a particular site is dysfunctional.”

Since multisite directors have limited time to spend at each site, it's critical to delegate and help others develop leadership skills, said Dr. Thomas. You need an inner circle of trusted associate directors as well as close working relationships with the administrative teams in each hospital.

“Some of my primary customers are the chief executive, chief medical, and chief nursing officers at each hospital,” he said. “It's a challenge, but it's necessary to maintain good communication and relationships with all of them.”

People skills are essential in a multisite leader, added Dr. Thomas. The job requires patience, excellent listening skills, and an appreciation for different learning and communication styles. “The ideal that I strive for is to communicate anything that affects someone's job as soon as possible,” he said. “You have to let people know how processes will affect their day-to-day workflow.”

As systems get larger, maintaining a sense of teamwork becomes more difficult, said Dr. Rissmiller. He currently serves on a subcommittee of the Society of Hospital Medicine charged with recommending best practices for communicating and encouraging engagement across large hospitalist groups.

“It's all about communicating often and in person as much as you can,” he said. “We're looking at how best to utilize technology to extend leaders in these larger groups. You really have to be proactive and mindful of it.”