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Hospitalists Stretched as their Responsibilities Broaden
The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.
Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.
And hospitalists are right in the middle of this changing dynamic.
Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.
At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.
Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.
But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.
Palliative Care
There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.
Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.
Critical Care
Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.
Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.
Post-Acute Care
For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.
In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.
Preoperative Care
Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.
Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.
SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.
Working through a Dilemma
The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.
SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.
Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.
The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.
Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.
And hospitalists are right in the middle of this changing dynamic.
Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.
At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.
Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.
But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.
Palliative Care
There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.
Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.
Critical Care
Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.
Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.
Post-Acute Care
For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.
In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.
Preoperative Care
Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.
Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.
SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.
Working through a Dilemma
The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.
SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.
Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.
The very nature of America’s hospitals is changing. At one time in the not too distant past, hospitals could charge “cost-plus,” tacking on a profit above their actual expenses. Hospitals generated most of their revenue from procedures on horizontal patients with long stays in house. Physicians viewed the hospital as a swap meet, with each physician having an autonomous booth and not caring much what went on elsewhere in the facility.
Today, hospitals are under tough cost pressures, with changes in payments from Medicare, Medicaid, and private insurers. Many hospitals now get more than 50% of their revenue from vertical patients from what was previously considered the outpatient segment of healthcare. Physicians have moved from being revenue providers to being potential competitors or, in the best-case scenario, active partners and teammates with their hospital.
And hospitalists are right in the middle of this changing dynamic.
Because the hospital and the healthcare system are rapidly evolving, it should not surprise anyone that the very nature of hospital medicine is changing rapidly. Some would say too rapidly.
At a strategic planning session I led almost 20 years when the National Association of Inpatient Physicians (NAIP), the precursor to SHM, was just starting out, the prevailing consensus was that hospitalists might take over inpatient services for 50% of family physicians and 25% of internists. Obviously, the penetrance of hospital medicine into almost every hospital in the U.S. and the transfer of the acute-care management of most of the inpatients previously handled by family physicians and internists are just part of the growth in hospital medicine.
Even more innovative and disruptive has been the almost relentless scope creep as hospitalists now actively comanage many surgical and subspecialty patients. As the neurologists have given up most of their acute-care duties, hospitalists are now the de facto inpatient neurologists. Hospitalists also now manage the majority of inpatient senior citizens and have become the inpatient geriatricians without the formal training. In-hospital procedures (e.g., central line, ultrasound, intubation, etc.) previously done by surgeons or critical-care or primary-care physicians now are done by default by hospitalists.
But these expansions of hospitalist scope pale in comparison with the continued broadening of responsibilities that continues to stretch even the most well-trained hospitalists beyond their training or capacity.
Palliative Care
There are not enough trained and certified palliative-care physicians to allocate one of them to each hospital. Yet treatment and survival of cancer and other serious diseases as well as the aging of the population demand that hospitals be prepared to provide the most compassionate and up-to-date palliative approach possible. Palliative care is more than just end-of-life care. It involves hospice as well as pain and symptom management. It is aimed at improvement in quality of life and is used in the presence or absence of curative strategies.
Hospitalists have been thrust into the breach and are being asked more and more to provide palliative-care services. SHM has recognized the gap between the increasing demand on hospitalists and the inadequate training we all receive in residency. That’s why we’re working with palliative-care societies and experts to develop educational and training initiatives to close these gaps.
Critical Care
Our hospitals are becoming increasingly critical care intensive as simpler cases are treated as outpatients and only the very ill come to be admitted to hospital. This has created an increasing demand for more physicians trained in critical care at a time when older intensivists are retiring or going into sleep medicine and younger physicians, who might have chosen a career in critical care, are becoming hospitalists. The shortage of trained critical-care providers is reaching a crisis point in many American hospitals, with hospitalists being asked to be the critical-care extender.
Over the years, SHM has partnered with the Society of Critical Care Medicine (SCCM) to propose innovative training options (e.g., one-year critical-care fellowship obtained midcareer), but the boards and others in the critical-care establishment have not been supportive. SHM plans to continue to work with open-minded critical-care thought leaders to develop and promote additional training in critical-care skills for hospitalists, who continue to be thrust into this role at their local hospitals.
Post-Acute Care
For many of hospital medicine’s larger national and regional companies, the management of the care in the post-acute-care space of skilled nursing facilities, long-term acute-care facilities, and the like has been the fastest-growing part of their business in the last few years. Skills and process improvement that have helped improve effectiveness and efficiency in our nation’s hospitals are being applied to post-acute-care facilities. Once again, hospitalists are finding themselves being asked to perform at a high level in environments that are new to them.
In this arena, the hospitalist’s ability to impact care is evident in managing transfers and information as well as providing leadership in patient safety. Determining the correct postdischarge disposition is the largest driver of costs in the acute-care and post-acute-care setting. Hospitalists and the hospital medicine organizations are providing key direction.
Preoperative Care
Many may not know that bundled into the anesthesia fee is the funding to cover pre-op assessment and post-op management as well as the intraoperative oversight of anesthesia and vital signs for the surgical patient. In reality, the role of perioperative management has fallen for many years initially to internists and more recently to hospitalists.
Hospitalists have been active in optimizing the patient for surgery and medically clearing the patient. Hospitalists work with surgeons to manage comorbidities; prevent complications, such as infections, DVTs, and pulmonary emboli; and help with pain management and transitions to discharge from the hospital. Hospitalists have worked with surgeons to create efficiencies like reduced length of stay and prevention of readmission as well as to help the patient return to function postoperatively.
SHM’s Perioperative Care Work Group is publishing a set of Perioperative Care Guidelines in the Journal of Hospital Medicine. SHM is actively working with the American College of Surgeons on a teamwork approach to the surgical patient as well as innovative alternative payment models with bundling at the level of the individual surgical patients, which the Centers for Medicare & Medicaid Services is currently evaluating.
Working through a Dilemma
The one thing all these expansions of scope have in common is that there is an unfilled need and hospitalists are being thrust onto the front lines, thrown into the deep water without the benefit of thorough training that should be requisite with the responsibilities. This is not a turf battle where we have stolen someone’s cheese. This is pure and simple where need is trumping training, and if not done properly, the patient may suffer, and hospitalists will bear the uncomfortable feeling of being asked to do more than we should.
SHM and our national hospitalist thought leaders see this dilemma. We are working diligently with other professional medical societies and key specialty educators and thought leaders to create training pathways to support the expansion of the hospitalist’s scope. This is building the boat while you are going down a rapidly moving river. It is not easy stuff. But our patients and our hospitalists demand this, and SHM will step up. Help is on the way.
Larry Wellikson, MD, MHM, is CEO of the Society of Hospital Medicine.
Podcast Series "Before the White Coat" Explores Early Lives of Hospitalists
Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.
When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.
The Unique Paths of Hospitalist Careers
But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.
That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.
Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.
They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.
That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.
Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.
—Larry Wellikson, MD, MHM
Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.
I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.
Podcast: A Format That Works for Hospitalists
Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.
And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.
In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”
Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.
How to Listen and Share
I hope you’ll join their ranks today. Here’s how:
- Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
- iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
- And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.
This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.
Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.
As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.
Larry Wellikson is CEO of the Society of Hospital Medicine.
Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.
When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.
The Unique Paths of Hospitalist Careers
But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.
That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.
Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.
They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.
That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.
Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.
—Larry Wellikson, MD, MHM
Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.
I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.
Podcast: A Format That Works for Hospitalists
Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.
And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.
In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”
Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.
How to Listen and Share
I hope you’ll join their ranks today. Here’s how:
- Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
- iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
- And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.
This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.
Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.
As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.
Larry Wellikson is CEO of the Society of Hospital Medicine.
Editor’s note: This article is adapted from a June 2015 post on SHM’s official blog, “The Hospital Leader”.
When you see him on stage, it’s like he’s always been here. Bob Wachter, MD, one of the pioneers of the hospital medicine movement, has taken the podium at SHM’s annual meetings for more than a decade. Whether he’s uncovering important issues in electronic medical records or covering Elton John songs, he seems like a fixture in our world—and in healthcare.
The Unique Paths of Hospitalist Careers
But, rather than being a fixed, static thing, the life of any hospitalist—including the leaders of the movement—is a progression.
That progression starts in a different place for every hospitalist and is influenced by the people and events in their lives. Some hospitalists knew they wanted to be in medicine from a young age. Others found their calling much later in life.
Every one of those progressions is interspersed with moments of humor. For instance, this piece of hospitalist trivia: Dr. Wachter was the Penn Quaker mascot for the University of Pennsylvania the last time its men’s basketball team made it to the Final Four.
They also include the kinds of profound experiences that get to the very root of what it means to be a hospitalist. For Bob, it was being a resident in the ICU at the University of California San Francisco in the 1980s, just as AIDS was beginning to be diagnosed and understood.
That’s why I’m proud to introduce “Before the White Coat,” a new podcast from SHM, available on iTunes and other podcast apps. “Before the White Coat” is a 20-minute podcast, presented every two weeks.
Today, you can listen to full interviews between me and Bob Wachter, Ron Greeno of IPC Health, Jeff Wiese at Tulane University, SHM President Bob Harrington, CMS's Chief Medical Officer Patrick Conway and UCLA's Nasim Afsar. And later in September, Before the White Coat will present exclusive insights into the lives of Brian Harte of the Cleveland Clinic and Mark Williams at the University of Kentucky.
—Larry Wellikson, MD, MHM
Next, you’ll hear from Ron Greeno, MD, MHM, FCCP, now chief strategy officer at IPC Healthcare. After that, I’ll talk with many of the other leaders every two weeks, including Pat Conway, MD, MSc, at the Centers for Medicare and Medicaid Services, Mary Jo Gorman, MD, MBA, who founded Advanced ICU Care, and Nasim Afsar, MD, FSHM, at UCLA.
I’m looking forward to exploring the progression of their lives and careers with you. These personal conversations complement the wealth of clinical and practice management information that SHM already offers.
Podcast: A Format That Works for Hospitalists
Hospitalists are busy people. Whether at the hospital or at home, they are almost constantly on their feet. We wanted to present “Before the White Coat” as a podcast—something you can listen to while on the way to the hospital—or on the way home. Or maybe during an off hour in either place.
And we know that hospitalists are interested in podcasts; podcasts produced and distributed by The Hospitalist have been downloaded more than 40,000 times.
In fact, this podcast is modeled on some of the most successful podcasts out there: National Public Radio’s industry-leading podcasts, the new podcasts from Gimlet Media, and Adam Corolla’s “Take a Knee.”
Those podcasts have proven that the format works—and that people are catching on quickly. According to new research from the Pew Research Center, one in three Americans have listened to a podcast, and the number of people who have listened to a podcast in the last month has doubled since 2008.
How to Listen and Share
I hope you’ll join their ranks today. Here’s how:
- Visit the “Before the White Coat” website, www.beforethewhitecoat.org.
- iTunes users can subscribe by searching “Before the White Coat” in the podcast section of iTunes.
- And listeners using other podcast apps can either search for “Before the White Coat” or find details on the podcast website.
This is a new project for SHM, and I hope you’ll tell us what you think. You can tweet your reaction at @SHMLive—use the #B4theWC hashtag.
Finally, if you like it, I hope you’ll share it with friends, colleagues, and others in medicine.
As always, thank you for being an active part of the hospital medicine movement. I hope you’ll enjoy this newest piece of it.
Larry Wellikson is CEO of the Society of Hospital Medicine.
Hospitalists to the Rescue
Hospitals as major employers and community resources can do nothing but reflect the realities of our country’s recession, now in its second year. For hospitalists who are integral to a hospital’s performance and are, at the same time, dependent on the institution’s financial success, there is the shared concern often seen by passengers in a two-person airplane buffeted by storms and fierce winds.
Hospitals are hit by a variety of forces during recessions, including tightening credit, increased borrowing costs, reduced returns from investments, decreased philanthropic donations, and the unkindest cut of all: more patients with less ability to pay.
American hospitals, which employ more than 5 million people, have witnessed all these forces magnify the long-standing issue of under-reimbursements from Medicare and Medicaid, which generally don’t even cover the rising costs of labor and technology. In New Jersey, 47% of hospitals were in the red in 2007, and five of the state’s 79 acute-care hospitals closed in 2008.
According to recent data, more than 65% of surveyed hospitals saw decreases in elective procedures and an increase in nonpaying patients. The hit to hospitals’ investments has mirrored the 401(k) crisis. More than 550 hospitals watched their recent investment declines combine for a total loss of $832 million in the third quarter of 2008, compared with a $396 million aggregate gain in the same time period in 2007. All this bad news led Moody’s to change its 12- to 18-month outlook for both profit and nonprofit hospitals from stable to negative due to increasing bad debt, credit tightening, and loss of investments.
Hospitals are keenly affected by local employment, too. When local businesses have layoffs, former employees often lose their insurance coverage. When companies cut back on expenses to hold on to their workers, often that translates into no health insurance or very high deductibles. When patients lose their jobs or their insurance, they stop getting preventive care; they stop buying prescriptions. The end result is increased ED visits and admissions for decompensated heart failure, flu that turns into pneumonia, or out-of-control diabetes.
More admissions might mean more business for hospitals and hospitalists, but it certainly does not mean more money. It likely means more no-pays and increasing bad debt. It means turning a precarious, marginally balanced bottom line into losses and layoffs.
As if that weren’t bad enough, 44 of our 50 states are operating in the red and looking at trimming big-ticket items to stem the losses. For most states, the budget items under scrutiny include education, prisons, and healthcare. Medicaid payments—already inadequate—are shrinking further at a time when more people need a safety net.
Prove Thy Worth
These are tough times to be running a hospital, but aren’t hospitalists, so dependent on the viability of their hospitals, also on a slippery slope—and running downhill? Actually, these tough times might make hospitalists—and our value—all the more important to their hospitals, helping administrators weather the storm and be resources for their healthcare communities.
Hospitalists can deliver just what we need today—efficient and effective care with appropriate use of resources, better hospital throughput, attention to safety, and measurable efforts to improve performance.
In addition, as primary-care physicians (PCPs), surgeons, and subspecialists retrench to stay away from no-pays so they can find a better payor mix in order to survive, patients keep coming to hospitals, and hospitalists are positioned to pick up the slack and jump right in. Obviously, there is the chance PCPs and others in difficult times might actually come back to inpatient care as office and procedure revenues dwindle, but this is less likely to affect hospitalists when we seem to always have far more work than we have staff or time to manage.
Change Agents
Times of crisis create opportunities for real change. President Obama and many key legislators and thought leaders have signaled a genuine desire to change a system that rewards performance (value-based purchasing) and bundles hospital and physician payments, which will be tied to key outcomes and performance. SHM has been able to show Washington decision-makers that hospitalists can reduce preventable deep vein thrombosis (DVT) in hospitalized patients from 50 per year to three per year. We have shown that hospitalists, using SHM’s BOOST protocols, can improve the discharge process, identify high-risk patients, and reduce ED visits and readmissions. This is just the type of system improvement that leads to better care at a lower cost—the Holy Grail in hard times.
Couple all this with the Institute of Medicine’s call to further reduce residency hours, which only leads to a greater need for hospitalists in teaching institutions, and there is an increasing demand for hospitalists seemingly everywhere. And even in a recession, high demand with a small supply leads to the need to nurture and reward hospitalists, especially those who are experienced and can deliver efficient and effective inpatient care.
At a national level, we will see experimentation with demonstration projects to look at rewarding performance and bundling payments for inpatient care. Similarly, hospitalists should be emboldened to use the current crisis to experiment locally by using teams of hospitalists, nurses, pharmacists, and case managers to revise the way care is delivered. There are opportunities to responsibly involve nurse practitioners and physician assistants as integral parts of your hospitalist team.
While the rest of medicine might be forced to look out for themselves in tough times, hospitalists, by their very positioning, must focus on the survival and improvement of the system, of their hospital, and of the healthcare community. In hospital medicine, we recognize that the days of “Lone Ranger” physicians carving out their own destinies are long gone. In many ways, physicians are intricately intertwined. And that forces us to survive or fail together. That will be hospitalists’ salvation in these hard times: knowing there are better times ahead for us, our hospitals, and our patients. TH
Larry Wellikson is CEO of SHM.
Hospitals as major employers and community resources can do nothing but reflect the realities of our country’s recession, now in its second year. For hospitalists who are integral to a hospital’s performance and are, at the same time, dependent on the institution’s financial success, there is the shared concern often seen by passengers in a two-person airplane buffeted by storms and fierce winds.
Hospitals are hit by a variety of forces during recessions, including tightening credit, increased borrowing costs, reduced returns from investments, decreased philanthropic donations, and the unkindest cut of all: more patients with less ability to pay.
American hospitals, which employ more than 5 million people, have witnessed all these forces magnify the long-standing issue of under-reimbursements from Medicare and Medicaid, which generally don’t even cover the rising costs of labor and technology. In New Jersey, 47% of hospitals were in the red in 2007, and five of the state’s 79 acute-care hospitals closed in 2008.
According to recent data, more than 65% of surveyed hospitals saw decreases in elective procedures and an increase in nonpaying patients. The hit to hospitals’ investments has mirrored the 401(k) crisis. More than 550 hospitals watched their recent investment declines combine for a total loss of $832 million in the third quarter of 2008, compared with a $396 million aggregate gain in the same time period in 2007. All this bad news led Moody’s to change its 12- to 18-month outlook for both profit and nonprofit hospitals from stable to negative due to increasing bad debt, credit tightening, and loss of investments.
Hospitals are keenly affected by local employment, too. When local businesses have layoffs, former employees often lose their insurance coverage. When companies cut back on expenses to hold on to their workers, often that translates into no health insurance or very high deductibles. When patients lose their jobs or their insurance, they stop getting preventive care; they stop buying prescriptions. The end result is increased ED visits and admissions for decompensated heart failure, flu that turns into pneumonia, or out-of-control diabetes.
More admissions might mean more business for hospitals and hospitalists, but it certainly does not mean more money. It likely means more no-pays and increasing bad debt. It means turning a precarious, marginally balanced bottom line into losses and layoffs.
As if that weren’t bad enough, 44 of our 50 states are operating in the red and looking at trimming big-ticket items to stem the losses. For most states, the budget items under scrutiny include education, prisons, and healthcare. Medicaid payments—already inadequate—are shrinking further at a time when more people need a safety net.
Prove Thy Worth
These are tough times to be running a hospital, but aren’t hospitalists, so dependent on the viability of their hospitals, also on a slippery slope—and running downhill? Actually, these tough times might make hospitalists—and our value—all the more important to their hospitals, helping administrators weather the storm and be resources for their healthcare communities.
Hospitalists can deliver just what we need today—efficient and effective care with appropriate use of resources, better hospital throughput, attention to safety, and measurable efforts to improve performance.
In addition, as primary-care physicians (PCPs), surgeons, and subspecialists retrench to stay away from no-pays so they can find a better payor mix in order to survive, patients keep coming to hospitals, and hospitalists are positioned to pick up the slack and jump right in. Obviously, there is the chance PCPs and others in difficult times might actually come back to inpatient care as office and procedure revenues dwindle, but this is less likely to affect hospitalists when we seem to always have far more work than we have staff or time to manage.
Change Agents
Times of crisis create opportunities for real change. President Obama and many key legislators and thought leaders have signaled a genuine desire to change a system that rewards performance (value-based purchasing) and bundles hospital and physician payments, which will be tied to key outcomes and performance. SHM has been able to show Washington decision-makers that hospitalists can reduce preventable deep vein thrombosis (DVT) in hospitalized patients from 50 per year to three per year. We have shown that hospitalists, using SHM’s BOOST protocols, can improve the discharge process, identify high-risk patients, and reduce ED visits and readmissions. This is just the type of system improvement that leads to better care at a lower cost—the Holy Grail in hard times.
Couple all this with the Institute of Medicine’s call to further reduce residency hours, which only leads to a greater need for hospitalists in teaching institutions, and there is an increasing demand for hospitalists seemingly everywhere. And even in a recession, high demand with a small supply leads to the need to nurture and reward hospitalists, especially those who are experienced and can deliver efficient and effective inpatient care.
At a national level, we will see experimentation with demonstration projects to look at rewarding performance and bundling payments for inpatient care. Similarly, hospitalists should be emboldened to use the current crisis to experiment locally by using teams of hospitalists, nurses, pharmacists, and case managers to revise the way care is delivered. There are opportunities to responsibly involve nurse practitioners and physician assistants as integral parts of your hospitalist team.
While the rest of medicine might be forced to look out for themselves in tough times, hospitalists, by their very positioning, must focus on the survival and improvement of the system, of their hospital, and of the healthcare community. In hospital medicine, we recognize that the days of “Lone Ranger” physicians carving out their own destinies are long gone. In many ways, physicians are intricately intertwined. And that forces us to survive or fail together. That will be hospitalists’ salvation in these hard times: knowing there are better times ahead for us, our hospitals, and our patients. TH
Larry Wellikson is CEO of SHM.
Hospitals as major employers and community resources can do nothing but reflect the realities of our country’s recession, now in its second year. For hospitalists who are integral to a hospital’s performance and are, at the same time, dependent on the institution’s financial success, there is the shared concern often seen by passengers in a two-person airplane buffeted by storms and fierce winds.
Hospitals are hit by a variety of forces during recessions, including tightening credit, increased borrowing costs, reduced returns from investments, decreased philanthropic donations, and the unkindest cut of all: more patients with less ability to pay.
American hospitals, which employ more than 5 million people, have witnessed all these forces magnify the long-standing issue of under-reimbursements from Medicare and Medicaid, which generally don’t even cover the rising costs of labor and technology. In New Jersey, 47% of hospitals were in the red in 2007, and five of the state’s 79 acute-care hospitals closed in 2008.
According to recent data, more than 65% of surveyed hospitals saw decreases in elective procedures and an increase in nonpaying patients. The hit to hospitals’ investments has mirrored the 401(k) crisis. More than 550 hospitals watched their recent investment declines combine for a total loss of $832 million in the third quarter of 2008, compared with a $396 million aggregate gain in the same time period in 2007. All this bad news led Moody’s to change its 12- to 18-month outlook for both profit and nonprofit hospitals from stable to negative due to increasing bad debt, credit tightening, and loss of investments.
Hospitals are keenly affected by local employment, too. When local businesses have layoffs, former employees often lose their insurance coverage. When companies cut back on expenses to hold on to their workers, often that translates into no health insurance or very high deductibles. When patients lose their jobs or their insurance, they stop getting preventive care; they stop buying prescriptions. The end result is increased ED visits and admissions for decompensated heart failure, flu that turns into pneumonia, or out-of-control diabetes.
More admissions might mean more business for hospitals and hospitalists, but it certainly does not mean more money. It likely means more no-pays and increasing bad debt. It means turning a precarious, marginally balanced bottom line into losses and layoffs.
As if that weren’t bad enough, 44 of our 50 states are operating in the red and looking at trimming big-ticket items to stem the losses. For most states, the budget items under scrutiny include education, prisons, and healthcare. Medicaid payments—already inadequate—are shrinking further at a time when more people need a safety net.
Prove Thy Worth
These are tough times to be running a hospital, but aren’t hospitalists, so dependent on the viability of their hospitals, also on a slippery slope—and running downhill? Actually, these tough times might make hospitalists—and our value—all the more important to their hospitals, helping administrators weather the storm and be resources for their healthcare communities.
Hospitalists can deliver just what we need today—efficient and effective care with appropriate use of resources, better hospital throughput, attention to safety, and measurable efforts to improve performance.
In addition, as primary-care physicians (PCPs), surgeons, and subspecialists retrench to stay away from no-pays so they can find a better payor mix in order to survive, patients keep coming to hospitals, and hospitalists are positioned to pick up the slack and jump right in. Obviously, there is the chance PCPs and others in difficult times might actually come back to inpatient care as office and procedure revenues dwindle, but this is less likely to affect hospitalists when we seem to always have far more work than we have staff or time to manage.
Change Agents
Times of crisis create opportunities for real change. President Obama and many key legislators and thought leaders have signaled a genuine desire to change a system that rewards performance (value-based purchasing) and bundles hospital and physician payments, which will be tied to key outcomes and performance. SHM has been able to show Washington decision-makers that hospitalists can reduce preventable deep vein thrombosis (DVT) in hospitalized patients from 50 per year to three per year. We have shown that hospitalists, using SHM’s BOOST protocols, can improve the discharge process, identify high-risk patients, and reduce ED visits and readmissions. This is just the type of system improvement that leads to better care at a lower cost—the Holy Grail in hard times.
Couple all this with the Institute of Medicine’s call to further reduce residency hours, which only leads to a greater need for hospitalists in teaching institutions, and there is an increasing demand for hospitalists seemingly everywhere. And even in a recession, high demand with a small supply leads to the need to nurture and reward hospitalists, especially those who are experienced and can deliver efficient and effective inpatient care.
At a national level, we will see experimentation with demonstration projects to look at rewarding performance and bundling payments for inpatient care. Similarly, hospitalists should be emboldened to use the current crisis to experiment locally by using teams of hospitalists, nurses, pharmacists, and case managers to revise the way care is delivered. There are opportunities to responsibly involve nurse practitioners and physician assistants as integral parts of your hospitalist team.
While the rest of medicine might be forced to look out for themselves in tough times, hospitalists, by their very positioning, must focus on the survival and improvement of the system, of their hospital, and of the healthcare community. In hospital medicine, we recognize that the days of “Lone Ranger” physicians carving out their own destinies are long gone. In many ways, physicians are intricately intertwined. And that forces us to survive or fail together. That will be hospitalists’ salvation in these hard times: knowing there are better times ahead for us, our hospitals, and our patients. TH
Larry Wellikson is CEO of SHM.
Editorial
Founded in 1997 by 2 community‐based hospitalists, Win Whitcomb and John Nelson, the National Association of Inpatient Physicians was renamed the Society of Hospital Medicine in 2003 and celebrates its 10th anniversary this year. Evolving from the enthusiastic engagement by the attendees at the first hospital medicine CME meeting in the spring of 1997,1 this new organization has grown into a robust voice for improving the care of hospitalized patients. The Society has actively attempted to represent a big tent welcoming participation from everyone involved in hospital care. The name change to the Society of Hospital Medicine (SHM) reflected the recognition that a team is needed to achieve the goal of optimizing care of the hospitalized patient. Merriam‐Webster defines society as companionship or association with one's fellows and a voluntary association of individuals for common ends; especially an organized group working together or periodically meeting because of common interests, beliefs, or profession.2 The hospital medicine team working together includes nurses, pharmacists, case managers, social workers, physicians, and administrators in addition to dieticians, respiratory therapists, and physical and occupational therapists. With a focus on patient‐centered care and quality improvement, SHM eagerly anticipates future changes in health care, seeking to help its membership adapt to and manage the expected change.
As an integral component of the hospital care delivery team, physicians represent the bulk of membership in SHM. Thus, development of hospital medicine as a medical specialty has concerned many of its members. Fortunately, progress is being made, and Bob Wachter is chairing a task force on this for the American Board of Internal Medicine.3 Certainly, content in the field is growing exponentially, with textbooks (including possibly 3 separate general references for adult and pediatric hospital medicine), multiple printed periodicals, and this successful peer‐reviewed journal listed in MEDLINE and PubMed. In addition, most academic medical centers now have thriving groups of hospitalists, and many are establishing or plan separate divisions within their respective departments of medicine (eg, Northwestern, UCSan Francisco, UCSan Diego, Duke, Mayo Clinic). These events confirm how hospital medicine has progressed to become a true specialty of medicine and justify the publication of its own set of core competencies.4 We believe some form of certification is inevitable. This will be supported by development of residency tracks and fellowships in hospital medicine.5
Most remarkable about the Society of Hospital Medicine has been its ability to collaborate with multiple medical societies, governmental agencies, foundations, and organizations seeking to improve care for hospitalized patients (see Table 1). These relationships represent the teamwork approach that hospitalists take into their hospitals on a daily basis. We hope to build on these collaborations and work toward more interactive efforts to identify optimal delivery of health care in the hospital setting, while also reaching out to ambulatory‐based providers to ensure smooth transitions of care. Such efforts will require innovative approaches to educating SHM members and altering the standard approach to continuing medical education (CME). Investment in the concept of hospitalists by the John A. Hartford Foundation with a $1.4 million grant to improve the discharge process (Improving Hospital Care Transitions for Older Adults) exemplifies SHM's commitment to collaboration, with more than 10 organizations participating on the advisory board.
| Agency for Healthcare Research and Quality (AHRQ) |
| Alliance of Academic Internal Medicine |
| Ambulatory Pediatric Association |
| American Academy of Clinical Endocrinology |
| American Academy of Pediatricians |
| American Association of Critical Care Nurses |
| American Board of Internal Medicine |
| American College of Health Executives |
| American College of Chest Physicians |
| American College of Emergency Physicians |
| American College of Physicians |
| American College of Physician Executives |
| American Diabetes Association |
| American Geriatric Society |
| American Hospital Association |
| American Society of Health System Pharmacists |
| AMA's Physician Consortium for Performance Improvement |
| Association of American Medical Colleges |
| Case Management Society of America |
| Centers for Disease Control and Prevention (CDC) |
| Centers for Medicare & Medicaid Services (CMS) |
| The Hartford Foundation |
| Hospital Quality Alliance |
| Institute of Healthcare Improvement |
| The Joint Commission |
| National Quality Forum |
| Society of Critical Care Medicine |
| Society of General Internal Medicine |
As SHM and its growing membership, which now exceeds 6500, stride into the future, we embrace advances in educational approaches to enhancing health care delivery and expect to play a leadership role in applying them. Increasingly, use of pay‐for‐performance (P4P) will attempt to align payment incentives to promote better quality care by rewarding providers that perform well.6 SHM aims to train hospitalists through use of knowledge translation which combines the right educational tools with involvement of the entire health care team, yielding truly effective CME.7 A reinvention of CME that links it to care delivery and improving performance, it is supported by governmental health care leaders.8 This approach moves CME to where hospitalists deliver care, targets all participants (patients, nurses, pharmacists, and doctors), and has content based around initiatives to improve health care.
Such a quality improvement model would take advantage of SHM's Quality Improvement Resource Rooms (hospitalmedicine.org), marking an important shift toward translating evidence into practice. SHM will also continue with its efforts to lead in nonclinical training, as exemplified by its popular biannual leadership training courses. We expect this will expand to provide much‐needed QI training in the future.
In its first 10 years SHM has accomplished much already, but the best days for hospital medicine lie ahead of us. There will be more than 30,000 hospitalists practicing at virtually every hospital in the United States, with high expectations for teams of health professionals providing patient‐centered care with documented quality standards. SHM is poised to work with all our partner organizations to do our part to create the hospital of the future. Our patients are counting on all of us.
- .Reflections: the hospitalist movement a decade later.J Hosp Med.2006;1:248–252.
- Available at: www.merriam‐webster.com. accessed April 2,2007.
- .What will board certification be—and mean—for hospitalists?J Hosp Med.2007;2:102–104.
- ,,,,.Core competencies of hospital medicine: development and methodology.J Hosp Med.2006;1:48–56
- ,,,.Hospital medicine fellowships: in progress.Am J Med.2006;119:72.e1–e7.
- Committee on Redesigning Health Insurance Performance Measures Payment and Performance Improvement Programs.Rewarding Provider Performance: Aligning Incentives in Medicare.Washington, DC:National Academies Press;2007.
- ,,, et al.The case for knowledge translation: shortening the journey from evidence to effect.BMJ.2003;327:33–35.
- .Commentary: reinventing continuing medical education.BMJ.2004;4:181.
Founded in 1997 by 2 community‐based hospitalists, Win Whitcomb and John Nelson, the National Association of Inpatient Physicians was renamed the Society of Hospital Medicine in 2003 and celebrates its 10th anniversary this year. Evolving from the enthusiastic engagement by the attendees at the first hospital medicine CME meeting in the spring of 1997,1 this new organization has grown into a robust voice for improving the care of hospitalized patients. The Society has actively attempted to represent a big tent welcoming participation from everyone involved in hospital care. The name change to the Society of Hospital Medicine (SHM) reflected the recognition that a team is needed to achieve the goal of optimizing care of the hospitalized patient. Merriam‐Webster defines society as companionship or association with one's fellows and a voluntary association of individuals for common ends; especially an organized group working together or periodically meeting because of common interests, beliefs, or profession.2 The hospital medicine team working together includes nurses, pharmacists, case managers, social workers, physicians, and administrators in addition to dieticians, respiratory therapists, and physical and occupational therapists. With a focus on patient‐centered care and quality improvement, SHM eagerly anticipates future changes in health care, seeking to help its membership adapt to and manage the expected change.
As an integral component of the hospital care delivery team, physicians represent the bulk of membership in SHM. Thus, development of hospital medicine as a medical specialty has concerned many of its members. Fortunately, progress is being made, and Bob Wachter is chairing a task force on this for the American Board of Internal Medicine.3 Certainly, content in the field is growing exponentially, with textbooks (including possibly 3 separate general references for adult and pediatric hospital medicine), multiple printed periodicals, and this successful peer‐reviewed journal listed in MEDLINE and PubMed. In addition, most academic medical centers now have thriving groups of hospitalists, and many are establishing or plan separate divisions within their respective departments of medicine (eg, Northwestern, UCSan Francisco, UCSan Diego, Duke, Mayo Clinic). These events confirm how hospital medicine has progressed to become a true specialty of medicine and justify the publication of its own set of core competencies.4 We believe some form of certification is inevitable. This will be supported by development of residency tracks and fellowships in hospital medicine.5
Most remarkable about the Society of Hospital Medicine has been its ability to collaborate with multiple medical societies, governmental agencies, foundations, and organizations seeking to improve care for hospitalized patients (see Table 1). These relationships represent the teamwork approach that hospitalists take into their hospitals on a daily basis. We hope to build on these collaborations and work toward more interactive efforts to identify optimal delivery of health care in the hospital setting, while also reaching out to ambulatory‐based providers to ensure smooth transitions of care. Such efforts will require innovative approaches to educating SHM members and altering the standard approach to continuing medical education (CME). Investment in the concept of hospitalists by the John A. Hartford Foundation with a $1.4 million grant to improve the discharge process (Improving Hospital Care Transitions for Older Adults) exemplifies SHM's commitment to collaboration, with more than 10 organizations participating on the advisory board.
| Agency for Healthcare Research and Quality (AHRQ) |
| Alliance of Academic Internal Medicine |
| Ambulatory Pediatric Association |
| American Academy of Clinical Endocrinology |
| American Academy of Pediatricians |
| American Association of Critical Care Nurses |
| American Board of Internal Medicine |
| American College of Health Executives |
| American College of Chest Physicians |
| American College of Emergency Physicians |
| American College of Physicians |
| American College of Physician Executives |
| American Diabetes Association |
| American Geriatric Society |
| American Hospital Association |
| American Society of Health System Pharmacists |
| AMA's Physician Consortium for Performance Improvement |
| Association of American Medical Colleges |
| Case Management Society of America |
| Centers for Disease Control and Prevention (CDC) |
| Centers for Medicare & Medicaid Services (CMS) |
| The Hartford Foundation |
| Hospital Quality Alliance |
| Institute of Healthcare Improvement |
| The Joint Commission |
| National Quality Forum |
| Society of Critical Care Medicine |
| Society of General Internal Medicine |
As SHM and its growing membership, which now exceeds 6500, stride into the future, we embrace advances in educational approaches to enhancing health care delivery and expect to play a leadership role in applying them. Increasingly, use of pay‐for‐performance (P4P) will attempt to align payment incentives to promote better quality care by rewarding providers that perform well.6 SHM aims to train hospitalists through use of knowledge translation which combines the right educational tools with involvement of the entire health care team, yielding truly effective CME.7 A reinvention of CME that links it to care delivery and improving performance, it is supported by governmental health care leaders.8 This approach moves CME to where hospitalists deliver care, targets all participants (patients, nurses, pharmacists, and doctors), and has content based around initiatives to improve health care.
Such a quality improvement model would take advantage of SHM's Quality Improvement Resource Rooms (hospitalmedicine.org), marking an important shift toward translating evidence into practice. SHM will also continue with its efforts to lead in nonclinical training, as exemplified by its popular biannual leadership training courses. We expect this will expand to provide much‐needed QI training in the future.
In its first 10 years SHM has accomplished much already, but the best days for hospital medicine lie ahead of us. There will be more than 30,000 hospitalists practicing at virtually every hospital in the United States, with high expectations for teams of health professionals providing patient‐centered care with documented quality standards. SHM is poised to work with all our partner organizations to do our part to create the hospital of the future. Our patients are counting on all of us.
Founded in 1997 by 2 community‐based hospitalists, Win Whitcomb and John Nelson, the National Association of Inpatient Physicians was renamed the Society of Hospital Medicine in 2003 and celebrates its 10th anniversary this year. Evolving from the enthusiastic engagement by the attendees at the first hospital medicine CME meeting in the spring of 1997,1 this new organization has grown into a robust voice for improving the care of hospitalized patients. The Society has actively attempted to represent a big tent welcoming participation from everyone involved in hospital care. The name change to the Society of Hospital Medicine (SHM) reflected the recognition that a team is needed to achieve the goal of optimizing care of the hospitalized patient. Merriam‐Webster defines society as companionship or association with one's fellows and a voluntary association of individuals for common ends; especially an organized group working together or periodically meeting because of common interests, beliefs, or profession.2 The hospital medicine team working together includes nurses, pharmacists, case managers, social workers, physicians, and administrators in addition to dieticians, respiratory therapists, and physical and occupational therapists. With a focus on patient‐centered care and quality improvement, SHM eagerly anticipates future changes in health care, seeking to help its membership adapt to and manage the expected change.
As an integral component of the hospital care delivery team, physicians represent the bulk of membership in SHM. Thus, development of hospital medicine as a medical specialty has concerned many of its members. Fortunately, progress is being made, and Bob Wachter is chairing a task force on this for the American Board of Internal Medicine.3 Certainly, content in the field is growing exponentially, with textbooks (including possibly 3 separate general references for adult and pediatric hospital medicine), multiple printed periodicals, and this successful peer‐reviewed journal listed in MEDLINE and PubMed. In addition, most academic medical centers now have thriving groups of hospitalists, and many are establishing or plan separate divisions within their respective departments of medicine (eg, Northwestern, UCSan Francisco, UCSan Diego, Duke, Mayo Clinic). These events confirm how hospital medicine has progressed to become a true specialty of medicine and justify the publication of its own set of core competencies.4 We believe some form of certification is inevitable. This will be supported by development of residency tracks and fellowships in hospital medicine.5
Most remarkable about the Society of Hospital Medicine has been its ability to collaborate with multiple medical societies, governmental agencies, foundations, and organizations seeking to improve care for hospitalized patients (see Table 1). These relationships represent the teamwork approach that hospitalists take into their hospitals on a daily basis. We hope to build on these collaborations and work toward more interactive efforts to identify optimal delivery of health care in the hospital setting, while also reaching out to ambulatory‐based providers to ensure smooth transitions of care. Such efforts will require innovative approaches to educating SHM members and altering the standard approach to continuing medical education (CME). Investment in the concept of hospitalists by the John A. Hartford Foundation with a $1.4 million grant to improve the discharge process (Improving Hospital Care Transitions for Older Adults) exemplifies SHM's commitment to collaboration, with more than 10 organizations participating on the advisory board.
| Agency for Healthcare Research and Quality (AHRQ) |
| Alliance of Academic Internal Medicine |
| Ambulatory Pediatric Association |
| American Academy of Clinical Endocrinology |
| American Academy of Pediatricians |
| American Association of Critical Care Nurses |
| American Board of Internal Medicine |
| American College of Health Executives |
| American College of Chest Physicians |
| American College of Emergency Physicians |
| American College of Physicians |
| American College of Physician Executives |
| American Diabetes Association |
| American Geriatric Society |
| American Hospital Association |
| American Society of Health System Pharmacists |
| AMA's Physician Consortium for Performance Improvement |
| Association of American Medical Colleges |
| Case Management Society of America |
| Centers for Disease Control and Prevention (CDC) |
| Centers for Medicare & Medicaid Services (CMS) |
| The Hartford Foundation |
| Hospital Quality Alliance |
| Institute of Healthcare Improvement |
| The Joint Commission |
| National Quality Forum |
| Society of Critical Care Medicine |
| Society of General Internal Medicine |
As SHM and its growing membership, which now exceeds 6500, stride into the future, we embrace advances in educational approaches to enhancing health care delivery and expect to play a leadership role in applying them. Increasingly, use of pay‐for‐performance (P4P) will attempt to align payment incentives to promote better quality care by rewarding providers that perform well.6 SHM aims to train hospitalists through use of knowledge translation which combines the right educational tools with involvement of the entire health care team, yielding truly effective CME.7 A reinvention of CME that links it to care delivery and improving performance, it is supported by governmental health care leaders.8 This approach moves CME to where hospitalists deliver care, targets all participants (patients, nurses, pharmacists, and doctors), and has content based around initiatives to improve health care.
Such a quality improvement model would take advantage of SHM's Quality Improvement Resource Rooms (hospitalmedicine.org), marking an important shift toward translating evidence into practice. SHM will also continue with its efforts to lead in nonclinical training, as exemplified by its popular biannual leadership training courses. We expect this will expand to provide much‐needed QI training in the future.
In its first 10 years SHM has accomplished much already, but the best days for hospital medicine lie ahead of us. There will be more than 30,000 hospitalists practicing at virtually every hospital in the United States, with high expectations for teams of health professionals providing patient‐centered care with documented quality standards. SHM is poised to work with all our partner organizations to do our part to create the hospital of the future. Our patients are counting on all of us.
- .Reflections: the hospitalist movement a decade later.J Hosp Med.2006;1:248–252.
- Available at: www.merriam‐webster.com. accessed April 2,2007.
- .What will board certification be—and mean—for hospitalists?J Hosp Med.2007;2:102–104.
- ,,,,.Core competencies of hospital medicine: development and methodology.J Hosp Med.2006;1:48–56
- ,,,.Hospital medicine fellowships: in progress.Am J Med.2006;119:72.e1–e7.
- Committee on Redesigning Health Insurance Performance Measures Payment and Performance Improvement Programs.Rewarding Provider Performance: Aligning Incentives in Medicare.Washington, DC:National Academies Press;2007.
- ,,, et al.The case for knowledge translation: shortening the journey from evidence to effect.BMJ.2003;327:33–35.
- .Commentary: reinventing continuing medical education.BMJ.2004;4:181.
- .Reflections: the hospitalist movement a decade later.J Hosp Med.2006;1:248–252.
- Available at: www.merriam‐webster.com. accessed April 2,2007.
- .What will board certification be—and mean—for hospitalists?J Hosp Med.2007;2:102–104.
- ,,,,.Core competencies of hospital medicine: development and methodology.J Hosp Med.2006;1:48–56
- ,,,.Hospital medicine fellowships: in progress.Am J Med.2006;119:72.e1–e7.
- Committee on Redesigning Health Insurance Performance Measures Payment and Performance Improvement Programs.Rewarding Provider Performance: Aligning Incentives in Medicare.Washington, DC:National Academies Press;2007.
- ,,, et al.The case for knowledge translation: shortening the journey from evidence to effect.BMJ.2003;327:33–35.
- .Commentary: reinventing continuing medical education.BMJ.2004;4:181.
The Venous Thromboembolism Quality Improvement Resource Room
The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.
The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.
The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.
METHODS
Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.
| Phase 1 (January 2005April 2005): Executing the educational strategy |
|---|
| One‐hour conference calls |
| Curricular, clinical, technical, and creative aspects of production |
| Additional communication between members of working group between calls |
| Development of questionnaire for SHM membership, board, education, and hospital quality patient safety (HQPS) committees |
| Content freeze: fourth month of development |
| Implementation of revisions prior to April 2005 SHM Annual Meeting |
| Phase 2 (April 2005August 2005): revision based on feedback |
| Analysis of formative evaluation from Phase 1 |
| Launch of the VTE QI RR August 2005 |
| Secondary phases and venues for implementation |
| Workshops at hospital medicine educational events |
| SHM Quality course |
| Formal recognition of the learning, experience, or proficiency acquired by users |
| The working editorial team for the first resource room |
| Dedicated project manager (SHM staff) |
| Senior adviser for planning and development (SHM staff) |
| Senior adviser for education (SHM staff) |
| Content expert |
| Education editor |
| Hospital quality editor |
| Managing editor |
Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.
The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.
The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.
Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.
RESULTS
The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).
Why Should You Act?
The visual center of the QI RR layout presents sobering statisticsalthough pulmonary embolism from deep vein thrombosis is the most common cause of preventable hospital death, most hospitalized medical patients at risk do not receive appropriate prophylaxisand then encourages hospitalist‐led action to reduce hospital‐acquired VTE. The role of the hospitalist is extracted from the competencies articulated in the Venous Thromboembolism, Quality Improvement, and Hospitalist as Teacher chapters of The Core Competencies in Hospital Medicine.2
Awareness
In the Awareness area of the VTE QI RR, materials to raise clinician, hospital staff, and patient awareness are suggested and made available. Through the SHM's lead sponsorship of the national DVT Awareness Month campaign, suggested Steps to Action depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem.
Evidence
The Evidence section aggregates a list of the most pertinent VTE prophylaxis literature to help ground any QI effort firmly in the evidence base. Through an agreement with the American College of Physicians (ACP), VTE prophylaxis articles reviewed in the ACP Journal Club are presented here.12 Although the listed literature focuses on prophylaxis, plans are in place to include references on diagnosis and treatment.
Experience
Resource room visitors interested in tapping into the experience of hospitalists and other leaders of QI efforts can navigate directly to this area. Interactive resources here include downloadable and adaptable protocols for VTE prophylaxis and, most importantly, improvement stories profiling actual QI successes. The Experience section features comments from an author of a seminal trial that studied computer alerts for high‐risk patients not receiving prophylaxis.10 The educational goal of this section of the QI RR is to provide opportunities to learn from successful QI projects, from the composition of the improvement team to the relevant metrics, implementation plan, and next steps.
Ask the Expert
The most interactive part of the resource room, the Ask the Expert forum, provides a hybrid of experience and evidence. A visitor who posts a clinical or improvement question to this discussion community receives a multidisciplinary response. For each question posted, a hospitalist moderator collects and aggregates responses from a panel of VTE experts, QI experts, hospitalist teachers, and pharmacists. The online exchange permitted by this forum promotes wider debate and learning. The questions and responses are archived and thus are available for subsequent users to read.
Improve
This area features the focal point of the entire resource room, the VTE QI workbook, which was written and designed to provide action‐oriented learning in quality improvement. The workbook is a downloadable project outline to guide and document efforts aimed at reducing rates of hospital‐acquired VTE. Hospitalists who complete the workbook should have acquired familiarity with and a working proficiency in leading system‐level efforts to drive better patient care. Users new to the theory and practice of QI can also review key concepts from a slide presentation in this part of the resource room.
Educate
This content area profiles the hospital medicine core competencies that relate to VTE and QI while also offering teaching materials and advice for teachers of VTE or QI. Teaching resources for clinician educators include online CME and an up‐to‐date slide lecture about VTE prophylaxis. The lecture presentation can be downloaded and customized to serve the needs of the speaker and the audience, whether students, residents, or other hospital staff. Clinician educators can also share or review teaching pearls used by hospitalist colleagues who serve as ward attendings.
DISCUSSION
A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.
Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.
Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?
The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.
The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.
The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.
We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.
The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.
As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.
As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.
Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.
CONCLUSIONS
The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.
The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.
Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.
- Society of Hospital Medicine Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1(suppl 1).
- ,,,,,.Physician practices in the prevention of venous thromboembolism.Arch Intern Med.1991;151:933–938.
- Kohn LT,Corrigan JM,Donaldson MS, eds.To Err Is Human.Washington, DC:National Academy Press;2000.
- Institute of Medicinehttp://www.iom.edu/CMS/3718.aspx
- Shojania KG,Duncan BW,McDonald KM,Wachter RM, eds.Making health care safer: a critical analysis of patient safety practices.Agency for Healthcare Research and Quality, Publication 01‐E058;2001.
- Joint Commission on the Accreditation of Health Care Organizations. Public policy initiatives. Available at: http://www.jcaho.org/about+us/public+policy+initiatives/pay_for_performance.htm
- .Curriculum Development for Medical Education: A Six‐Step Approach.Baltimore, Md:Johns Hopkins University Press;1998.
- ,;DVT FREE Steering Committee.A prospective registry of 5,451 patients with ultrasound‐confirmed deep vein thrombosis.Am J Cardiol.2004;93:259.
- ,,, et al.Electronic alerts to prevent venous thromboembolism among hospitalized patients.N Engl J Med.2005;352:969.
- ,,.Teaching the Case Method.3rd ed.Cambridge, Mass :Harvard Business School.
- American College of Physicians. Available at: http://www.acpjc.org/?hp
- ,,, et al.MEDENOX trial.N Engl J Med.1999;341:793–800.
- ,,.Fondaparinux versus placebo for the prevention of VTE in acutely ill medical patients (ARTEMIS).J Thromb Haemost.2003;1(suppl 1):2046.
- ,,,,,.PREVENT Medical Thromboprophylaxis Study Group.Circulation.2004;110:874–879.
- ,.Comparing the costs, risks and benefits of competing strategies for the primary prevention of VTE.Circulation.2004;110:IV25–IV32.
- Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/acWebsite/programDir/pd_index.asp.
The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.
The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.
The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.
METHODS
Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.
| Phase 1 (January 2005April 2005): Executing the educational strategy |
|---|
| One‐hour conference calls |
| Curricular, clinical, technical, and creative aspects of production |
| Additional communication between members of working group between calls |
| Development of questionnaire for SHM membership, board, education, and hospital quality patient safety (HQPS) committees |
| Content freeze: fourth month of development |
| Implementation of revisions prior to April 2005 SHM Annual Meeting |
| Phase 2 (April 2005August 2005): revision based on feedback |
| Analysis of formative evaluation from Phase 1 |
| Launch of the VTE QI RR August 2005 |
| Secondary phases and venues for implementation |
| Workshops at hospital medicine educational events |
| SHM Quality course |
| Formal recognition of the learning, experience, or proficiency acquired by users |
| The working editorial team for the first resource room |
| Dedicated project manager (SHM staff) |
| Senior adviser for planning and development (SHM staff) |
| Senior adviser for education (SHM staff) |
| Content expert |
| Education editor |
| Hospital quality editor |
| Managing editor |
Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.
The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.
The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.
Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.
RESULTS
The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).
Why Should You Act?
The visual center of the QI RR layout presents sobering statisticsalthough pulmonary embolism from deep vein thrombosis is the most common cause of preventable hospital death, most hospitalized medical patients at risk do not receive appropriate prophylaxisand then encourages hospitalist‐led action to reduce hospital‐acquired VTE. The role of the hospitalist is extracted from the competencies articulated in the Venous Thromboembolism, Quality Improvement, and Hospitalist as Teacher chapters of The Core Competencies in Hospital Medicine.2
Awareness
In the Awareness area of the VTE QI RR, materials to raise clinician, hospital staff, and patient awareness are suggested and made available. Through the SHM's lead sponsorship of the national DVT Awareness Month campaign, suggested Steps to Action depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem.
Evidence
The Evidence section aggregates a list of the most pertinent VTE prophylaxis literature to help ground any QI effort firmly in the evidence base. Through an agreement with the American College of Physicians (ACP), VTE prophylaxis articles reviewed in the ACP Journal Club are presented here.12 Although the listed literature focuses on prophylaxis, plans are in place to include references on diagnosis and treatment.
Experience
Resource room visitors interested in tapping into the experience of hospitalists and other leaders of QI efforts can navigate directly to this area. Interactive resources here include downloadable and adaptable protocols for VTE prophylaxis and, most importantly, improvement stories profiling actual QI successes. The Experience section features comments from an author of a seminal trial that studied computer alerts for high‐risk patients not receiving prophylaxis.10 The educational goal of this section of the QI RR is to provide opportunities to learn from successful QI projects, from the composition of the improvement team to the relevant metrics, implementation plan, and next steps.
Ask the Expert
The most interactive part of the resource room, the Ask the Expert forum, provides a hybrid of experience and evidence. A visitor who posts a clinical or improvement question to this discussion community receives a multidisciplinary response. For each question posted, a hospitalist moderator collects and aggregates responses from a panel of VTE experts, QI experts, hospitalist teachers, and pharmacists. The online exchange permitted by this forum promotes wider debate and learning. The questions and responses are archived and thus are available for subsequent users to read.
Improve
This area features the focal point of the entire resource room, the VTE QI workbook, which was written and designed to provide action‐oriented learning in quality improvement. The workbook is a downloadable project outline to guide and document efforts aimed at reducing rates of hospital‐acquired VTE. Hospitalists who complete the workbook should have acquired familiarity with and a working proficiency in leading system‐level efforts to drive better patient care. Users new to the theory and practice of QI can also review key concepts from a slide presentation in this part of the resource room.
Educate
This content area profiles the hospital medicine core competencies that relate to VTE and QI while also offering teaching materials and advice for teachers of VTE or QI. Teaching resources for clinician educators include online CME and an up‐to‐date slide lecture about VTE prophylaxis. The lecture presentation can be downloaded and customized to serve the needs of the speaker and the audience, whether students, residents, or other hospital staff. Clinician educators can also share or review teaching pearls used by hospitalist colleagues who serve as ward attendings.
DISCUSSION
A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.
Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.
Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?
The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.
The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.
The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.
We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.
The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.
As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.
As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.
Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.
CONCLUSIONS
The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.
The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.
Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.
The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.
The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.
The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.
METHODS
Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.
| Phase 1 (January 2005April 2005): Executing the educational strategy |
|---|
| One‐hour conference calls |
| Curricular, clinical, technical, and creative aspects of production |
| Additional communication between members of working group between calls |
| Development of questionnaire for SHM membership, board, education, and hospital quality patient safety (HQPS) committees |
| Content freeze: fourth month of development |
| Implementation of revisions prior to April 2005 SHM Annual Meeting |
| Phase 2 (April 2005August 2005): revision based on feedback |
| Analysis of formative evaluation from Phase 1 |
| Launch of the VTE QI RR August 2005 |
| Secondary phases and venues for implementation |
| Workshops at hospital medicine educational events |
| SHM Quality course |
| Formal recognition of the learning, experience, or proficiency acquired by users |
| The working editorial team for the first resource room |
| Dedicated project manager (SHM staff) |
| Senior adviser for planning and development (SHM staff) |
| Senior adviser for education (SHM staff) |
| Content expert |
| Education editor |
| Hospital quality editor |
| Managing editor |
Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.
The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.
The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.
Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.
RESULTS
The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).
Why Should You Act?
The visual center of the QI RR layout presents sobering statisticsalthough pulmonary embolism from deep vein thrombosis is the most common cause of preventable hospital death, most hospitalized medical patients at risk do not receive appropriate prophylaxisand then encourages hospitalist‐led action to reduce hospital‐acquired VTE. The role of the hospitalist is extracted from the competencies articulated in the Venous Thromboembolism, Quality Improvement, and Hospitalist as Teacher chapters of The Core Competencies in Hospital Medicine.2
Awareness
In the Awareness area of the VTE QI RR, materials to raise clinician, hospital staff, and patient awareness are suggested and made available. Through the SHM's lead sponsorship of the national DVT Awareness Month campaign, suggested Steps to Action depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem.
Evidence
The Evidence section aggregates a list of the most pertinent VTE prophylaxis literature to help ground any QI effort firmly in the evidence base. Through an agreement with the American College of Physicians (ACP), VTE prophylaxis articles reviewed in the ACP Journal Club are presented here.12 Although the listed literature focuses on prophylaxis, plans are in place to include references on diagnosis and treatment.
Experience
Resource room visitors interested in tapping into the experience of hospitalists and other leaders of QI efforts can navigate directly to this area. Interactive resources here include downloadable and adaptable protocols for VTE prophylaxis and, most importantly, improvement stories profiling actual QI successes. The Experience section features comments from an author of a seminal trial that studied computer alerts for high‐risk patients not receiving prophylaxis.10 The educational goal of this section of the QI RR is to provide opportunities to learn from successful QI projects, from the composition of the improvement team to the relevant metrics, implementation plan, and next steps.
Ask the Expert
The most interactive part of the resource room, the Ask the Expert forum, provides a hybrid of experience and evidence. A visitor who posts a clinical or improvement question to this discussion community receives a multidisciplinary response. For each question posted, a hospitalist moderator collects and aggregates responses from a panel of VTE experts, QI experts, hospitalist teachers, and pharmacists. The online exchange permitted by this forum promotes wider debate and learning. The questions and responses are archived and thus are available for subsequent users to read.
Improve
This area features the focal point of the entire resource room, the VTE QI workbook, which was written and designed to provide action‐oriented learning in quality improvement. The workbook is a downloadable project outline to guide and document efforts aimed at reducing rates of hospital‐acquired VTE. Hospitalists who complete the workbook should have acquired familiarity with and a working proficiency in leading system‐level efforts to drive better patient care. Users new to the theory and practice of QI can also review key concepts from a slide presentation in this part of the resource room.
Educate
This content area profiles the hospital medicine core competencies that relate to VTE and QI while also offering teaching materials and advice for teachers of VTE or QI. Teaching resources for clinician educators include online CME and an up‐to‐date slide lecture about VTE prophylaxis. The lecture presentation can be downloaded and customized to serve the needs of the speaker and the audience, whether students, residents, or other hospital staff. Clinician educators can also share or review teaching pearls used by hospitalist colleagues who serve as ward attendings.
DISCUSSION
A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.
Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.
Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?
The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.
The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.
The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.
We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.
The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.
As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.
As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.
Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.
CONCLUSIONS
The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.
The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.
Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.
- Society of Hospital Medicine Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1(suppl 1).
- ,,,,,.Physician practices in the prevention of venous thromboembolism.Arch Intern Med.1991;151:933–938.
- Kohn LT,Corrigan JM,Donaldson MS, eds.To Err Is Human.Washington, DC:National Academy Press;2000.
- Institute of Medicinehttp://www.iom.edu/CMS/3718.aspx
- Shojania KG,Duncan BW,McDonald KM,Wachter RM, eds.Making health care safer: a critical analysis of patient safety practices.Agency for Healthcare Research and Quality, Publication 01‐E058;2001.
- Joint Commission on the Accreditation of Health Care Organizations. Public policy initiatives. Available at: http://www.jcaho.org/about+us/public+policy+initiatives/pay_for_performance.htm
- .Curriculum Development for Medical Education: A Six‐Step Approach.Baltimore, Md:Johns Hopkins University Press;1998.
- ,;DVT FREE Steering Committee.A prospective registry of 5,451 patients with ultrasound‐confirmed deep vein thrombosis.Am J Cardiol.2004;93:259.
- ,,, et al.Electronic alerts to prevent venous thromboembolism among hospitalized patients.N Engl J Med.2005;352:969.
- ,,.Teaching the Case Method.3rd ed.Cambridge, Mass :Harvard Business School.
- American College of Physicians. Available at: http://www.acpjc.org/?hp
- ,,, et al.MEDENOX trial.N Engl J Med.1999;341:793–800.
- ,,.Fondaparinux versus placebo for the prevention of VTE in acutely ill medical patients (ARTEMIS).J Thromb Haemost.2003;1(suppl 1):2046.
- ,,,,,.PREVENT Medical Thromboprophylaxis Study Group.Circulation.2004;110:874–879.
- ,.Comparing the costs, risks and benefits of competing strategies for the primary prevention of VTE.Circulation.2004;110:IV25–IV32.
- Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/acWebsite/programDir/pd_index.asp.
- Society of Hospital Medicine Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Quality_Improvement_Resource_Rooms1(suppl 1).
- ,,,,,.Physician practices in the prevention of venous thromboembolism.Arch Intern Med.1991;151:933–938.
- Kohn LT,Corrigan JM,Donaldson MS, eds.To Err Is Human.Washington, DC:National Academy Press;2000.
- Institute of Medicinehttp://www.iom.edu/CMS/3718.aspx
- Shojania KG,Duncan BW,McDonald KM,Wachter RM, eds.Making health care safer: a critical analysis of patient safety practices.Agency for Healthcare Research and Quality, Publication 01‐E058;2001.
- Joint Commission on the Accreditation of Health Care Organizations. Public policy initiatives. Available at: http://www.jcaho.org/about+us/public+policy+initiatives/pay_for_performance.htm
- .Curriculum Development for Medical Education: A Six‐Step Approach.Baltimore, Md:Johns Hopkins University Press;1998.
- ,;DVT FREE Steering Committee.A prospective registry of 5,451 patients with ultrasound‐confirmed deep vein thrombosis.Am J Cardiol.2004;93:259.
- ,,, et al.Electronic alerts to prevent venous thromboembolism among hospitalized patients.N Engl J Med.2005;352:969.
- ,,.Teaching the Case Method.3rd ed.Cambridge, Mass :Harvard Business School.
- American College of Physicians. Available at: http://www.acpjc.org/?hp
- ,,, et al.MEDENOX trial.N Engl J Med.1999;341:793–800.
- ,,.Fondaparinux versus placebo for the prevention of VTE in acutely ill medical patients (ARTEMIS).J Thromb Haemost.2003;1(suppl 1):2046.
- ,,,,,.PREVENT Medical Thromboprophylaxis Study Group.Circulation.2004;110:874–879.
- ,.Comparing the costs, risks and benefits of competing strategies for the primary prevention of VTE.Circulation.2004;110:IV25–IV32.
- Accreditation Council for Graduate Medical Education. Available at: http://www.acgme.org/acWebsite/programDir/pd_index.asp.
Copyright © 2006 Society of Hospital Medicine
