Opinion

Mini-incision carotid surgery was first reported (not necessarily performed) by Ascher et al. in 2005. In light of this report and an ever-growing patient demand for minimally invasive procedures, it is surprising that this procedure has not been widely adopted by the vascular surgical community. The reasons for this are probably multifactorial and may include a concern that cranial nerve injuries are more likely to occur as well as an added difficulty in placing a shunt or sewing in a patch. These concerns are mitigated by a thorough knowledge of the usual and variant anatomy of this area and a broad experience in carotid surgery. If performed properly, mini-incision is not synonymous with mini exposure carotid surgery.

Photos courtesy Dr. Alan Dietzek

It is important to identify the carotid bifurcation with duplex ultrasound prior to making the skin incision. It is my preference to make a vertical skin incision which extends from approximately 2 cm above to below the carotid bifurcation at a slight outside to inside angle to the anterior border of the sternocleidomastoid muscle (some surgeons prefer a transverse skin incision). The platysma muscle is identified and divided for a short distance between forceps.

The edges of the platysma are grasped with DeBakey forceps while the skin is retracted as far inferiorly as possible.

The platysma is then divided to this point following which this is repeated at the superior aspect of the wound. The extended division of the platysma is what allows for an exposure equal to that of a much larger incision. Now adequate visualization of the common and internal carotid arteries is achieved by use of a small retractor applied alternately to the inferior and superior ends of the wound respectively.

Using this technique, I have easily been able to perform both standard and eversion endarterectomies (as in photo), place a shunt when necessary, and/or sew on a carotid patch.

Once completed the platysma is closed with an absorbable suture and skin is closed with an absorbable monofilament suture.

In my experience, patients have less postoperative pain than those with a larger neck incision. They are also exceptionally pleased with the small, barely visible, neck scar. Finally, I have used the mini-incision for my carotid surgeries for more than 10 years during which time no patient has suffered a permanent cranial nerve injury.

Dr. Dietzek is the chief of the vascular and endovascular surgery section and the Linda and Stephen R. Cohen chair in vascular surgery at Danbury Hospital, Danbury Conn. He is also a clinical associate professor of surgery at the University of Vermont College of Medicine in Burlington.

Editor’s Note: If you would like to submit a similarly useful Tips and Tricks, contact us at vascularspecialist@frontlinemedcom.com.

Mini-incision carotid surgery was first reported (not necessarily performed) by Ascher et al. in 2005. In light of this report and an ever-growing patient demand for minimally invasive procedures, it is surprising that this procedure has not been widely adopted by the vascular surgical community. The reasons for this are probably multifactorial and may include a concern that cranial nerve injuries are more likely to occur as well as an added difficulty in placing a shunt or sewing in a patch. These concerns are mitigated by a thorough knowledge of the usual and variant anatomy of this area and a broad experience in carotid surgery. If performed properly, mini-incision is not synonymous with mini exposure carotid surgery.

Photos courtesy Dr. Alan Dietzek

It is important to identify the carotid bifurcation with duplex ultrasound prior to making the skin incision. It is my preference to make a vertical skin incision which extends from approximately 2 cm above to below the carotid bifurcation at a slight outside to inside angle to the anterior border of the sternocleidomastoid muscle (some surgeons prefer a transverse skin incision). The platysma muscle is identified and divided for a short distance between forceps.

The edges of the platysma are grasped with DeBakey forceps while the skin is retracted as far inferiorly as possible.

The platysma is then divided to this point following which this is repeated at the superior aspect of the wound. The extended division of the platysma is what allows for an exposure equal to that of a much larger incision. Now adequate visualization of the common and internal carotid arteries is achieved by use of a small retractor applied alternately to the inferior and superior ends of the wound respectively.

Using this technique, I have easily been able to perform both standard and eversion endarterectomies (as in photo), place a shunt when necessary, and/or sew on a carotid patch.

Once completed the platysma is closed with an absorbable suture and skin is closed with an absorbable monofilament suture.

In my experience, patients have less postoperative pain than those with a larger neck incision. They are also exceptionally pleased with the small, barely visible, neck scar. Finally, I have used the mini-incision for my carotid surgeries for more than 10 years during which time no patient has suffered a permanent cranial nerve injury.

Dr. Dietzek is the chief of the vascular and endovascular surgery section and the Linda and Stephen R. Cohen chair in vascular surgery at Danbury Hospital, Danbury Conn. He is also a clinical associate professor of surgery at the University of Vermont College of Medicine in Burlington.

Editor’s Note: If you would like to submit a similarly useful Tips and Tricks, contact us at vascularspecialist@frontlinemedcom.com.

Mini-incision carotid surgery was first reported (not necessarily performed) by Ascher et al. in 2005. In light of this report and an ever-growing patient demand for minimally invasive procedures, it is surprising that this procedure has not been widely adopted by the vascular surgical community. The reasons for this are probably multifactorial and may include a concern that cranial nerve injuries are more likely to occur as well as an added difficulty in placing a shunt or sewing in a patch. These concerns are mitigated by a thorough knowledge of the usual and variant anatomy of this area and a broad experience in carotid surgery. If performed properly, mini-incision is not synonymous with mini exposure carotid surgery.

Photos courtesy Dr. Alan Dietzek

It is important to identify the carotid bifurcation with duplex ultrasound prior to making the skin incision. It is my preference to make a vertical skin incision which extends from approximately 2 cm above to below the carotid bifurcation at a slight outside to inside angle to the anterior border of the sternocleidomastoid muscle (some surgeons prefer a transverse skin incision). The platysma muscle is identified and divided for a short distance between forceps.

The edges of the platysma are grasped with DeBakey forceps while the skin is retracted as far inferiorly as possible.

The platysma is then divided to this point following which this is repeated at the superior aspect of the wound. The extended division of the platysma is what allows for an exposure equal to that of a much larger incision. Now adequate visualization of the common and internal carotid arteries is achieved by use of a small retractor applied alternately to the inferior and superior ends of the wound respectively.

Using this technique, I have easily been able to perform both standard and eversion endarterectomies (as in photo), place a shunt when necessary, and/or sew on a carotid patch.

Once completed the platysma is closed with an absorbable suture and skin is closed with an absorbable monofilament suture.

In my experience, patients have less postoperative pain than those with a larger neck incision. They are also exceptionally pleased with the small, barely visible, neck scar. Finally, I have used the mini-incision for my carotid surgeries for more than 10 years during which time no patient has suffered a permanent cranial nerve injury.

Dr. Dietzek is the chief of the vascular and endovascular surgery section and the Linda and Stephen R. Cohen chair in vascular surgery at Danbury Hospital, Danbury Conn. He is also a clinical associate professor of surgery at the University of Vermont College of Medicine in Burlington.

Editor’s Note: If you would like to submit a similarly useful Tips and Tricks, contact us at vascularspecialist@frontlinemedcom.com.

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Let’s call them multi-site, hospital medicine group leaders, or just multi-site HMG leaders. Once rare, they’re now becoming common, and among the many people now holding this job are:

• Dr. Doug Apple at Spectrum Health Medical Group in Grand Rapids, Mich;
• Dr. Tierza Stephan at Allina Health in Minneapolis, Minn.;
• Dr. Darren Thomas at St. John Health System in Tulsa, Okla.;
• Dr. Thomas McIlraith at Dignity Health in Sacremento, Calif.; and
• Dr. Rohit Uppal at Ohio Health in Columbus, Ohio.

The career path that led to their current position usually follows a standard pattern. They are a successful leader of a single-site hospitalist program when, through merger or acquisition, their hospital becomes part of a larger system. The executives responsible for this larger system—typically four to eight hospitals—realize that the HMGs serving each hospital in the system vary significantly in their cost, productivity, and performance on things like patient satisfaction and quality metrics. So they tap the leader of the largest (or best performing) HMG in the system to be system-wide hospitalist medical director. They nearly always choose an internal candidate rather than recruiting from outside, which brings some level of cohesion in operations and performance improvement.

Multi-Site Challenges

This is not an easy job. After all, it isn’t easy to serve as lead hospitalist for a single-site group, so it makes sense that the difficulties and challenges only increase when trying to manage groups at different locations.

The new multi-site HMG leader is busy from the first day on the job. The HMG at one site is short on staffing and needs help right away, patient satisfaction scores are poor at the next site, and so on. Although putting out these fires is important, the new leader also needs to think about how to accomplish a broader mission: ensuring greater cohesion across all groups.

I don’t think there is a secret recipe to ensure success in such a job. Prerequisites include the usual leadership skills, such as patience, good listening, and diplomacy (collectively, one’s EQ, or emotional quotient), along with lots of energy and decisive action. But there are a number of practical matters to address that can influence the level of success.

Cohesion vs. Independence

In most situations, a health system will benefit from some common operating principles across all the HMGs who serve its hospitals. For example, it usually makes sense for any portion of compensation tied to performance (e.g., a bonus) to be based on the same performance domains at all sites. For example, if metrics such as the observed-to-expected mortality ratio (O:E ratio) and patient satisfaction are important to the hospital system, then they should probably influence hospitalist compensation at every site. However, it might be reasonable to target a level of performance for any given domain higher at one site than at another.

Among the many things that should be the same across all sites are operational practices: charge capture, coding audits, performance reviews, dashboard elements and format, and credentialing for new hires. Other things, like individual hospitalist productivity, work schedule, and method and amount of compensation, should vary by site because of the unique attributes of the work at each place.

Fixed Locale vs. Rotations

The travel time between hospitals and the value of extensive experience in the details of how each particular hospital operates usually make it most practical for each individual hospitalist to work nearly all of the time at one hospital. But every doctor should be credentialed at every other hospital in the system so that he can cover a staffing shortage elsewhere.

And, hospitalists hired to work primarily at one of the small hospitals would probably benefit from working at the large referral hospital for the first few weeks of employment. This seems like a great way for them to become familiar with the people and operations at the big hospital, especially since they will be transferring patients there periodically.

Governance

Some mix of central control vs. local autonomy in decision making at each site is important for success. There aren’t any clear guidelines here, but providing the local doctors at each location with the ability to make their own decisions on things like work schedule will contribute to their sense of ownership of the practice. That feeling is valuable and supports good performance.

My bias is that each site in a practice could adopt the same “internal governance” guidelines, or rules by which they make decisions when unable to reach consensus (see “Play by the Rules,” December 2007, for sample guidelines.)

There should also be some form of “umbrella” governance structure in which the local site leaders meet regularly with the multi-site HMG leader.

Patient Transfers

One reason hospitals merge into a single system is the hope that they can more effectively meet the needs of all patients in the system’s hospitals. A typical configuration is several small hospitals, along with a single, large, referral center, to which patients are sent if the small hospital can’t meet their needs. The hope is that if all the hospitals are in the same system, the process of transfer can be smoother and more efficient.

A large portion—maybe even the majority—of all transfers in the system will be between a hospitalist at the small hospital and a partner hospitalist at the large hospital. Things will work best when the transferring and receiving hospitalists know something about the strengths and weaknesses of each other’s hospitals. And, you only know one another reasonably well from working together on committees or being on clinical service together at the same hospital, as well as social functions that include hospitalists from all sites.

Therefore, the multi-site HMG leader should think deliberately about how to ensure that the hospitalists interact with one another often, and not just when a transfer needs to take place.

A written agreement outlining the criteria for an appropriate transfer can be helpful. But such agreements cannot address all the situations that will arise, so good relationships between doctors at the different sites are invaluable and worth taking the time to cultivate.

Communication

Like the five people I mentioned above, anyone holding the position of multi-site HMG leader would benefit from talking with others in the same position. I’m working to arrange some forum for such communication, potentially including an in-person meeting at HM14 in Las Vegas in March (www.hospitalmedicine2014.org). If you are a health system-employed, multi-site HMG leader and want to be part of this conversation, I would love to hear from you.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at wfwhit@comcast.net.

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at wfwhit@comcast.net.

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at wfwhit@comcast.net.

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).

For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.

In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.

More Details on FTE Definition

MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.

For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.

I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.

As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).

Data Application

My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.

Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.

It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.

Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.

Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.

Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.

Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.

Does It Really Matter?

The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at john.nelson@nelsonflores.com.

The View from

Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.

In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.

Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.

The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).

October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.

Close the Loop on HVBP

How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).

Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.

Let’s look at two examples:

Hospital 1

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
• Net change in base DRG payment: +0.23%.

Hospital 2

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
• Net change in base DRG payment: -0.17%.

Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.

In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).

Readmissions and Penalties

For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.

For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.

Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.^1,2

New Definition of an Admission

Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.

Plan of Attack

For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.

For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.

For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!

References

1. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
2. Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The View from

Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.

In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.

Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.

The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).

October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.

Close the Loop on HVBP

How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).

Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.

Let’s look at two examples:

Hospital 1

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
• Net change in base DRG payment: +0.23%.

Hospital 2

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
• Net change in base DRG payment: -0.17%.

Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.

In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).

Readmissions and Penalties

For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.

For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.

Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.^1,2

New Definition of an Admission

Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.

Plan of Attack

For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.

For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.

For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!

References

1. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
2. Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The View from

Looking for more information to formulate a plan of attack? SHM offers a variety of HVBP resources to orient hospitalists and hospital leaders. The “What Every Hospitalist Should Know About Hospital Value-Based Purchasing” webinar and SHM’s free resource library (www.hospitalmedicine.org/hvbp) offer basic orientation on what to expect on pay-for-performance-related issues. The HVBP resource center also provides multiple case studies from various hospitals across the country, with success stories related to reducing readmissions, increasing evidence-based care focus, and enhancing performance on core measures.

In order to proactively address CMS’ new 30-day readmissions criteria for COPD, SHM’s COPD Resource Center (www.hospitalmedicine.org/copd) provides hospitalists with the most up-to-date guidelines, reviews, and peer-reviewed clinical trials that define evidence-based practice for the care of the COPD patient.

Hospitalists not only are under pressure to help improve hospital-level performance, but also will need to begin reporting physician-level measures. Beginning in 2015, CMS’s Physician Quality Reporting System (PQRS) will apply a penalty to all physicians who do not satisfactorily report data on quality measures for covered professional services.

The time to act is now. Reporting during the 2013 PQRS program year will be used to determine whether a 1.5% penalty applies in 2015. SHM has partnered with CECity to offer discounted access to PQRIwizard, a tool that facilitates PQRS reporting through SHM’s Learning Portal (www.shmlearningportal.org).

October is the beginning of a new year—in this case, fiscal-year 2014 for the Centers for Medicare & Medicaid Services (CMS). It’s a time when the new rules kick in. This month, we’ll look at some highlights, focusing on the new developments affecting your practice. Because you are held accountable for hospital-side performance on programs such as hospital value-based purchasing (HVBP) and the Readmissions Reduction Program, a working knowledge of the 2014 edition of the programs is crucial.

Close the Loop on HVBP

How will your hospital get paid under the 2014 version of HVBP? This past July, your hospital received a report outlining how its Medicare payments will be affected based on your hospital’s performance on process of care (heart failure, pneumonia, myocardial infarction, and surgery), patient experience (HCAHPS), and outcomes (30-day mortality for heart failure, pneumonia, and myocardial infarction).

Here are two hypothetical hospitals and how their performance in the program affects their 2014 payment. As background, in 2014, all hospitals have their base diagnosis related group (DRG) payments reduced by 1.25% for HVBP. They can earn back some, all, or an amount in excess of the 1.25% based on their performance. Payment is based on performance during the April 1 to Dec. 31, 2012, period. Under HVBP, CMS incentive payments occur at the level of individual patients, each of which is assigned a DRG.

Let’s look at two examples:

Hospital 1

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.48%.
• Net change in base DRG payment: +0.23%.

Hospital 2

• Base DRG payment reduction: 1.25% (all hospitals).
• Portion of base DRG earned back based on performance (process/patient experience/outcome metrics): 1.08%.
• Net change in base DRG payment: -0.17%.

Hospital 1 performed relatively well, getting a bump of 0.23% in its base DRG rate. Hospital 2 did not perform so well, so it took a 0.17% hit on its base DRG rate.

In order to determine total dollars made or lost for your hospital, one multiplies the total number of eligible Medicare inpatients for 2014 times the base DRG payment times the percent change in base DRG payment. If Hospital 1 has 10,000 eligible patients in 2014 and a base DRG payment of $5,000, the value is 10,000 x $5,000 x 0.0023 (0.23%) = $115,000 gained. Hospital 2, with the same number of patients and base DRG payment, loses (10,000 x $5,000 x 0.0017 = $85,000).

Readmissions and Penalties

For 2014, CMS is adding 30-day readmissions for COPD to readmissions for heart failure, pneumonia, and myocardial infarction for its penalty program. CMS added COPD because it is the fourth-leading cause of readmissions, according to a recent Medicare Payment Advisory Commission report, and because there is wide variation in the rates (from 18% to 25%) of COPD hospital readmissions.

For 2014, CMS raises the ceiling on readmission penalties to a maximum of 2% of reimbursement for all of a hospital’s Medicare inpatients. (The maximum hit during the first round of readmission penalties, which began in October 2012, was 1%.) More than 2,200 U.S. hospitals will face some financial penalty for excess 30-day readmissions.

Disappointingly, CMS did not add a risk adjustment for socioeconomic status despite being under pressure to do so. There is growing evidence that these factors have a major impact on readmission rates.^1,2

New Definition of an Admission

Amidst confusion from many and major blowback from beneficiaries saddled with large out-of-pocket expenses for observation stays and subsequent skilled-nursing-facility stays, CMS is clarifying the definition of an inpatient admission. The agency will define an admission as a hospital stay that spans at least two midnights. If a patient is in the hospital for a shorter period of time, CMS will deem the patient to be on observation status, unless medical record documentation supports a physician’s expectation “that the beneficiary would need care spanning at least two midnights” but unanticipated events led to a shorter stay.

Plan of Attack

For HVBP, make contact with your director of quality to understand your hospital’s performance and payment for 2014. If you have incentive compensation riding on HVBP, make sure you understand how your employer or contracted hospital is calculating the payout (because, for example, the performance period was in 2012!) and that your hospitalist group understands the payout calculation.

For COPD readmissions prevention, ensure patients have a home management plan; appropriate specialist follow-up and that they understand medication use, including inhalers and supplemental oxygen; and that you consider early referral for pulmonary rehabilitation for eligible patients.

For the new definition of inpatient admission, work with your hospital’s physician advisor and case management to ensure your group is getting appropriate guidance on documentation requirements. You are probably being held accountable for your hospital’s total number of observation hours, so remember to track these metrics following implementation of the new rule, as they (hopefully) should decrease. If they do, take some of the credit!

References

1. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA. 2011;305(7):675-681.
2. Lindenauer PK, Lagu T, Rothberg MB, et al. Income inequality and 30 day outcomes after acute myocardial infarction, heart failure, and pneumonia: retrospective cohort study. BMJ. 2013;346:f521.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. Email him at wfwhit@comcast.net.

The underlying pathophysiology of chronic venous insufficiency is complex and involves many factors. Studies have shown that average venous ulcers may need 6-12 months for complete healing with an anticipated recurrence rate exceeding 2/3 cases in 5 years. These numbers reflect the magnitude of the problem and mandate deploying all efforts to stop progression of the disease. Our group has found the following 10 tips have significantly improved our healing rates.

1. First, rule out any associated arterial, immunologic, endocrine, or other systemic causes for leg/foot ulceration.

2. Be aggressive to stop progression of the disease (fight CEAP 6): any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt reflux study to evaluate for incompetent perforators.

3. Venous ulcers are associated with an incompetent perforator within 2 cm of the ulcer area.

4. Recurrent venous ulcers at the same location may be associated with venous outflow obstruction, (May-Thurner syndrome is an underestimated pathology) which affects mainly the left leg.

5. When performing iliac vein venograms, make liberal use of intravascular ultrasound.

6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.

7. Pentoxifylline (Trental) 800 mg, 3 times daily.

8. Frequent debridement and frequent objective evaluation for ulcer area with each office visit.

9. Bi-layered living cell treatment (Apligraf?) to promote healing.

10. Office/clinic visit every 3 months after complete healing (CEAP 5) and further testing as needed.

Dr. Mousa is an associate professor at the Department of Surgery, West Virginia University, Morgantown.

The underlying pathophysiology of chronic venous insufficiency is complex and involves many factors. Studies have shown that average venous ulcers may need 6-12 months for complete healing with an anticipated recurrence rate exceeding 2/3 cases in 5 years. These numbers reflect the magnitude of the problem and mandate deploying all efforts to stop progression of the disease. Our group has found the following 10 tips have significantly improved our healing rates.

1. First, rule out any associated arterial, immunologic, endocrine, or other systemic causes for leg/foot ulceration.

2. Be aggressive to stop progression of the disease (fight CEAP 6): any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt reflux study to evaluate for incompetent perforators.

3. Venous ulcers are associated with an incompetent perforator within 2 cm of the ulcer area.

4. Recurrent venous ulcers at the same location may be associated with venous outflow obstruction, (May-Thurner syndrome is an underestimated pathology) which affects mainly the left leg.

5. When performing iliac vein venograms, make liberal use of intravascular ultrasound.

6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.

7. Pentoxifylline (Trental) 800 mg, 3 times daily.

8. Frequent debridement and frequent objective evaluation for ulcer area with each office visit.

9. Bi-layered living cell treatment (Apligraf?) to promote healing.

10. Office/clinic visit every 3 months after complete healing (CEAP 5) and further testing as needed.

Dr. Mousa is an associate professor at the Department of Surgery, West Virginia University, Morgantown.

The underlying pathophysiology of chronic venous insufficiency is complex and involves many factors. Studies have shown that average venous ulcers may need 6-12 months for complete healing with an anticipated recurrence rate exceeding 2/3 cases in 5 years. These numbers reflect the magnitude of the problem and mandate deploying all efforts to stop progression of the disease. Our group has found the following 10 tips have significantly improved our healing rates.

1. First, rule out any associated arterial, immunologic, endocrine, or other systemic causes for leg/foot ulceration.

2. Be aggressive to stop progression of the disease (fight CEAP 6): any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt reflux study to evaluate for incompetent perforators.

3. Venous ulcers are associated with an incompetent perforator within 2 cm of the ulcer area.

4. Recurrent venous ulcers at the same location may be associated with venous outflow obstruction, (May-Thurner syndrome is an underestimated pathology) which affects mainly the left leg.

5. When performing iliac vein venograms, make liberal use of intravascular ultrasound.

6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.

7. Pentoxifylline (Trental) 800 mg, 3 times daily.

8. Frequent debridement and frequent objective evaluation for ulcer area with each office visit.

9. Bi-layered living cell treatment (Apligraf?) to promote healing.

10. Office/clinic visit every 3 months after complete healing (CEAP 5) and further testing as needed.

Dr. Mousa is an associate professor at the Department of Surgery, West Virginia University, Morgantown.