9 PinnacleHealth System doctors resign over pressure to admit, discharge patients in ER [The Patriot-News, Harrisburg, Pa.]

Nov. 18--An effort to shorten emergency room waits might have broken the relationship between PinnacleHealth System and a group of doctors who specialize in caring for hospital patients.

The group of nine hospitalists led by Dr. Michael Hilden submitted resignations last week.

Hilden directed the hospitalists at Pinnacle. He said the resignations resulted from administrative interference in medical decisions and pressure to quickly admit or discharge patients.

Pinnacle officials said they don't know the doctors' exact reasons for resigning.

But they said it might have resulted from dissatisfaction over new policies intended to speed up the emergency room and increase quality and patient satisfaction.

Dr. Nirmal Joshi, a vice president involved with overall quality, said Pinnacle recently began pursuing a goal of ranking in the top 25 percent nationally in all measures related to quality and patient satisfaction.

The effort includes a pledge to see emergency room patients within 15 minutes of arrival. This requires emergency room doctors to quickly assess patients and decide whether to admit them to the main hospital, he said.

Joshi said quick decisions are needed for reasons including preventing the emergency room from getting backed up, and meeting expectations of patients and families who, when the patient needs admission, want it to happen quickly.

It requires a new level of collaboration and cooperation between emergency room doctor, hospitalists, nurses and other hospital staff, Joshi said.

He said Hilden and the others resigned as the new approach is being implemented, but he was uncertain if it prompted the resignations.

He said Pinnacle was satisfied with the doctors' work.

"These were all good doctors and we have nothing against them," he said.

Hilden spoke to a Patriot-News reporter last week, saying "There is no independence on what we can do and what we cannot do. ... They want people discharged before a proper workup is completed."

Repeated attempts to reach him this week were unsuccessful.

Pinnacle officials said the resignations won't impact staffing levels or patient care.

Pinnacle spokesman Gray Onobrakpeya said the push to reduce waiting times and improve quality isn't merely an effort to lower costs.

Rather, it's part of the effort to prepare for the Affordable Care Act -- the new health care reform law -- that will reward hospitals for medical quality and patient satisfaction, he said.

Historically, hospitals have been paid mostly based on volume of patients and medical procedures. It's widely believed that approach doesn't give an incentive for hospitals to provide the highest-quality care, and prevent things such as patient readmissions.

Joshi said Hilden's resignation was effective immediately. The others gave 90-day notices, and will remain through mid-February, he said.

Hospitalists are a relatively new type of medical specialist.

In the past, hospital patients were typically cared for by their own doctors, who made daily hospital rounds in addition to spending time at their private practices.

But about 10-15 years ago, Joshi said, hospital care was becoming ever more complex, and doctors were finding it hard to care for hospital patients while also manning their private practices. Some preferred to be relieved of hospital work.

That led to the rise of hospitalists, who specialize in hospital care and related matters, such as preparing patients for discharge to home or another health care facility.

Hospitalists typically have a background in internal medicine. Their schedules often involve a week of long shifts followed by a week off, Joshi said.

Pinnacle began employing hospitalists about a decade ago, and presently has about 20, including the ones who submitted resignations.

They work at Harrisburg and Community General Osteopathic hospitals.

Hilden had recruited the doctors who resigned with him, Joshi said.

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