When an ob.gyn. hospitalist program starts at a hospital, there is often a varying degree of distrust, resistance, and uncertainty about how hospitalists fit into the rhythm of the labor and delivery department.

In the initial stages, the ob.gyn. hospitalist may be relegated to the sidelines and just used in a limited capacity – for an emergency or for patients without a physician, for example.

In established programs, it can be the other end of the spectrum, as ob.gyn. hospitalists are looked to for oversight, leadership, and standardization, and provide these skills, often facilitating how the L&D department operates overall. They can evolve into the manager of labor and delivery rather than only providing coverage.

I was recently intrigued by an article in the New Yorker entitled,

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Big Med by Dr. Atul Gawande, a surgeon, writer, and public health researcher, in which he compares the operation of his local Cheesecake Factory restaurant to hospital medicine. He observes how, unlike in medicine, the Cheesecake Factory has figured out how to "deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality." Lamenting the current state of hospital care, Dr. Gawande rightly states: "Our costs are soaring, the service is typically mediocre, and the quality is unreliable."

Dr. Gawande also points out that doctors are paid for services, not results. Unlike a restaurant, historically medicine is not service oriented. Medicine is becoming like a chain restaurant as large corporations transform it into a Southwest Airlines approach to health care – a high-quality, low-cost product.

We need to keep working toward what the Institute for Healthcare Improvement calls the

Triple Aim, which seeks to improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the per capita cost of health care.

We need to demonstrate our value by continuing to emphasize our commitment to safety and quality outcomes.

It is necessary to demonstrate that our commitment to safety and quality outcomes translates into real improvement as well as real patient satisfaction. This is going to require data collection as well as new skills and competencies on our part. Not only will we have to hone our clinical skills, but we will also have to step up as leaders to work with the other members of the health care team.

How do quality and cost control occur? Is it even possible to deliver high-quality yet low-cost hospital medicine? And who is actually in charge to help make this happen?

Change in the medical world does not happen quickly; however, the adoption of ob.gyn. hospitalists is one way hospitals can immediately start addressing these issues.

Ob.gyn. hospitalists can be used in a leadership role with responsibility for a patient’s overall care, medical costs, and results. The can coordinate who cares for the patient and how, help reduce costs in malpractice by being physically present in L&D to handle emergencies or other challenging situations, oversee collaboration on standardization to deliver consistency and best practice medicine, and ensure good patient outcomes through their presence, clinical skills, and experience.

The military uses the term C4 – command, control, coordination, and communication. Adapting this for the medical environment could look something like this:

• Oversight instead of command. This can be done by facilitating how the department runs, prioritizing and assigning assets, and being the diplomat and intermediary between hospital administration and L&D.

• Leadership instead of control. This is accomplished by instituting standardization, ensuring best practices, and facilitating policy integration to enable collaboration and consensus to achieve the best possible outcomes at the lowest cost.

• Coordination. The ob.gyn. hospitalist can coordinate between patients and their family physician, midwife, or obstetrician; coordinate between the private practitioner and the ob.gyn. hospitalist; and coordinate between nurses and physicians in L&D, and the patient during follow-up.

• Communication. The ob.gyn. hospitalist can work to ensure that everyone from the L&D floor to the hospital administrators knows what is going on all of the time.

It is fascinating to watch this process occur in real time and to be part of this transformation. There are so many different variations of how ob.gyn. hospitalists are used in different programs. However, I think this gradual shift from coverage only toward oversight, leadership, coordination, and communication is inevitable. Because this transformation makes common sense and because it leads to greater patient safety with better outcomes at the same time, it reduces stress and improves working lifestyles for the private ob.gyn. as well as family physicians, midwives, and the labor and delivery nurses.

Dr. Olson is an ob.gyn. hospitalist in Bellingham, Wash.; the founding president of the Society of Ob/Gyn Hospitalists; and the founder of www.obgynhospitalist.com. He is a consultant for ob.gyn. hospitalist programs.

Leadership Role in Quality and Cost Control