If you are a hospitalist working for Kaiser, IPC, or another of the large healthcare systems, you may wonder what the Veterans Health Administration Healthcare System (VA) could possibly have to do with your practice. In many ways, the VA is the prototype, risk-adjusted, capitated accountable care organization (ACO) focused on expanding access to affordable healthcare, lowering costs, and improving quality. We care for complex, diverse, often vulnerable patient populations. We are incented to keep them healthy and out of the hospital. As a highly integrated healthcare system with 152 medical centers and more than 400 hospitalists, the VA has been able to coordinate hospital care, primary care, and post-acute care in a way that many health systems hope to achieve.

VA hospitalists care for veterans with multiple issues, including acute MI, heart failure, pneumonia, and COPD. In short, we care for the same types of patients as hospitalists across the country, with measured outcomes of similar or better quality as non-VA patients.

The VA has utilized an advanced electronic health record (CPRS) since 1997. It allows for effective patient care and is successfully leveraged for large-scale health services research.

The VA has been the site of groundbreaking, Nobel Prize-winning research that has shaped the care of hospitalized patients worldwide: beta blockers for heart failure, steroids for COPD exacerbations, and the invention of implantable cardiac pacemakers and computerized axial tomography (CAT) scans all have as their foundation research performed at VAs.

VA hospitalists educate the next generation of physicians through robust academic affiliations with most of our nation’s most-renowned medical schools and have administered residency training programs for almost 60 years. More than half of all medical students and residents complete part of their training at VAs.

VA hospitalists are also leaders in quality and patient safety.

Over the next year, SHM’s VA Task Force will be sharing 10 of the innovative approaches VA hospitalists are taking to provide care for our nation’s heroes. We will dispel a few myths about the “VA Spa” along the way and, hopefully, share some ideas you can use to better care for your patients.

Many of The Hospitalist’s readers have family members who have served in the military. For all of you, this IS your granddad’s VA—and it’s pretty darn good.

Dr. Odden is a hospitalist at the VA in Ann Arbor, Mich. Dr. Kartha is a hospitalist at the VA in Boston. Both are members of SHM’s VA Task Force.

If you are a hospitalist working for Kaiser, IPC, or another of the large healthcare systems, you may wonder what the Veterans Health Administration Healthcare System (VA) could possibly have to do with your practice. In many ways, the VA is the prototype, risk-adjusted, capitated accountable care organization (ACO) focused on expanding access to affordable healthcare, lowering costs, and improving quality. We care for complex, diverse, often vulnerable patient populations. We are incented to keep them healthy and out of the hospital. As a highly integrated healthcare system with 152 medical centers and more than 400 hospitalists, the VA has been able to coordinate hospital care, primary care, and post-acute care in a way that many health systems hope to achieve.

VA hospitalists care for veterans with multiple issues, including acute MI, heart failure, pneumonia, and COPD. In short, we care for the same types of patients as hospitalists across the country, with measured outcomes of similar or better quality as non-VA patients.

The VA has utilized an advanced electronic health record (CPRS) since 1997. It allows for effective patient care and is successfully leveraged for large-scale health services research.

The VA has been the site of groundbreaking, Nobel Prize-winning research that has shaped the care of hospitalized patients worldwide: beta blockers for heart failure, steroids for COPD exacerbations, and the invention of implantable cardiac pacemakers and computerized axial tomography (CAT) scans all have as their foundation research performed at VAs.

VA hospitalists educate the next generation of physicians through robust academic affiliations with most of our nation’s most-renowned medical schools and have administered residency training programs for almost 60 years. More than half of all medical students and residents complete part of their training at VAs.

VA hospitalists are also leaders in quality and patient safety.

Over the next year, SHM’s VA Task Force will be sharing 10 of the innovative approaches VA hospitalists are taking to provide care for our nation’s heroes. We will dispel a few myths about the “VA Spa” along the way and, hopefully, share some ideas you can use to better care for your patients.

Many of The Hospitalist’s readers have family members who have served in the military. For all of you, this IS your granddad’s VA—and it’s pretty darn good.

Dr. Odden is a hospitalist at the VA in Ann Arbor, Mich. Dr. Kartha is a hospitalist at the VA in Boston. Both are members of SHM’s VA Task Force.

If you are a hospitalist working for Kaiser, IPC, or another of the large healthcare systems, you may wonder what the Veterans Health Administration Healthcare System (VA) could possibly have to do with your practice. In many ways, the VA is the prototype, risk-adjusted, capitated accountable care organization (ACO) focused on expanding access to affordable healthcare, lowering costs, and improving quality. We care for complex, diverse, often vulnerable patient populations. We are incented to keep them healthy and out of the hospital. As a highly integrated healthcare system with 152 medical centers and more than 400 hospitalists, the VA has been able to coordinate hospital care, primary care, and post-acute care in a way that many health systems hope to achieve.

VA hospitalists care for veterans with multiple issues, including acute MI, heart failure, pneumonia, and COPD. In short, we care for the same types of patients as hospitalists across the country, with measured outcomes of similar or better quality as non-VA patients.

The VA has utilized an advanced electronic health record (CPRS) since 1997. It allows for effective patient care and is successfully leveraged for large-scale health services research.

The VA has been the site of groundbreaking, Nobel Prize-winning research that has shaped the care of hospitalized patients worldwide: beta blockers for heart failure, steroids for COPD exacerbations, and the invention of implantable cardiac pacemakers and computerized axial tomography (CAT) scans all have as their foundation research performed at VAs.

VA hospitalists educate the next generation of physicians through robust academic affiliations with most of our nation’s most-renowned medical schools and have administered residency training programs for almost 60 years. More than half of all medical students and residents complete part of their training at VAs.

VA hospitalists are also leaders in quality and patient safety.

Over the next year, SHM’s VA Task Force will be sharing 10 of the innovative approaches VA hospitalists are taking to provide care for our nation’s heroes. We will dispel a few myths about the “VA Spa” along the way and, hopefully, share some ideas you can use to better care for your patients.

Many of The Hospitalist’s readers have family members who have served in the military. For all of you, this IS your granddad’s VA—and it’s pretty darn good.

Dr. Odden is a hospitalist at the VA in Ann Arbor, Mich. Dr. Kartha is a hospitalist at the VA in Boston. Both are members of SHM’s VA Task Force.

The Hospitalist has grabbed the attention and interest of physicians and industry professionals across the country for 18 years. Now, it has the attention of another type of professional

body—the Awards for Publication Excellence (APEX), which presented the publication with the APEX Grand Award for Magazines, Journals, and Tabloids. [http://www.apexawards.com/A2014_Win.List.pdf].

The annual awards, presented to corporate and nonprofit publications, received 2,075 total applications, including nearly 500 entries to the Magazines, Journals, and Tabloids category. Only 10 Grand Awards were presented in the category.

The Hospitalist also received an Award of Excellence in Health and Medical Writing for writer Bryn Nelson’s special report on the Affordable Care Act in the January 2014 issue.

On the APEX website [www.apexawards.com/apex2014grandawardcomments], category judges complimented The Hospitalist for its “appealing spreads, effective use of sidebars, numbered lists, and a bold headline schedule—all combining to complement the well written copy, which is informative and clearly well researched. The Obamacare special report insert is particularly informative and well designed.”

Published by Wiley Inc., The Hospitalist is the official newsmagazine of the Society of Hospital Medicine. The monthly newsmagazine has a circulation of about 25,000 and provides news, features, and information specific to hospitalists and the healthcare industry.

SHM President Burke Kealey, MD, SFHM, expressed his pride for the individuals who bring The Hospitalist together.

“SHM constantly strives to bring the very best to our members and other leaders in healthcare. These two APEX awards, especially the Grand Award, are evidence that we are delivering on that goal,” he wrote in an e-mail.

The Hospitalist has garnered seven APEX Awards in the past six years, as well as attaining finalist status for “Best Healthcare Business Publication” from Medical Marketing and Media in 2009.

Physician Editor Danielle Scheurer, MD, MSCR, SFHM, considers the high quality of writing and practical, relevant article topics two of the magazine’s biggest strengths. She thanked the editors for designing a creative repertoire of stories and for thinking of new ways to cover topics.

“A huge part of our success is keeping our finger on the pulse of our customer base and trying to figure out…what kind of information they’re seeking from a magazine like The Hospitalist,” she said. “We are continuously ensuring that we’re hearing the voice of the customer.”

Erin Petenko is a contributing writer for The Hospitalist.

The Hospitalist has grabbed the attention and interest of physicians and industry professionals across the country for 18 years. Now, it has the attention of another type of professional

body—the Awards for Publication Excellence (APEX), which presented the publication with the APEX Grand Award for Magazines, Journals, and Tabloids. [http://www.apexawards.com/A2014_Win.List.pdf].

The annual awards, presented to corporate and nonprofit publications, received 2,075 total applications, including nearly 500 entries to the Magazines, Journals, and Tabloids category. Only 10 Grand Awards were presented in the category.

The Hospitalist also received an Award of Excellence in Health and Medical Writing for writer Bryn Nelson’s special report on the Affordable Care Act in the January 2014 issue.

On the APEX website [www.apexawards.com/apex2014grandawardcomments], category judges complimented The Hospitalist for its “appealing spreads, effective use of sidebars, numbered lists, and a bold headline schedule—all combining to complement the well written copy, which is informative and clearly well researched. The Obamacare special report insert is particularly informative and well designed.”

Published by Wiley Inc., The Hospitalist is the official newsmagazine of the Society of Hospital Medicine. The monthly newsmagazine has a circulation of about 25,000 and provides news, features, and information specific to hospitalists and the healthcare industry.

SHM President Burke Kealey, MD, SFHM, expressed his pride for the individuals who bring The Hospitalist together.

“SHM constantly strives to bring the very best to our members and other leaders in healthcare. These two APEX awards, especially the Grand Award, are evidence that we are delivering on that goal,” he wrote in an e-mail.

The Hospitalist has garnered seven APEX Awards in the past six years, as well as attaining finalist status for “Best Healthcare Business Publication” from Medical Marketing and Media in 2009.

Physician Editor Danielle Scheurer, MD, MSCR, SFHM, considers the high quality of writing and practical, relevant article topics two of the magazine’s biggest strengths. She thanked the editors for designing a creative repertoire of stories and for thinking of new ways to cover topics.

“A huge part of our success is keeping our finger on the pulse of our customer base and trying to figure out…what kind of information they’re seeking from a magazine like The Hospitalist,” she said. “We are continuously ensuring that we’re hearing the voice of the customer.”

Erin Petenko is a contributing writer for The Hospitalist.

The Hospitalist has grabbed the attention and interest of physicians and industry professionals across the country for 18 years. Now, it has the attention of another type of professional

body—the Awards for Publication Excellence (APEX), which presented the publication with the APEX Grand Award for Magazines, Journals, and Tabloids. [http://www.apexawards.com/A2014_Win.List.pdf].

The annual awards, presented to corporate and nonprofit publications, received 2,075 total applications, including nearly 500 entries to the Magazines, Journals, and Tabloids category. Only 10 Grand Awards were presented in the category.

The Hospitalist also received an Award of Excellence in Health and Medical Writing for writer Bryn Nelson’s special report on the Affordable Care Act in the January 2014 issue.

On the APEX website [www.apexawards.com/apex2014grandawardcomments], category judges complimented The Hospitalist for its “appealing spreads, effective use of sidebars, numbered lists, and a bold headline schedule—all combining to complement the well written copy, which is informative and clearly well researched. The Obamacare special report insert is particularly informative and well designed.”

Published by Wiley Inc., The Hospitalist is the official newsmagazine of the Society of Hospital Medicine. The monthly newsmagazine has a circulation of about 25,000 and provides news, features, and information specific to hospitalists and the healthcare industry.

SHM President Burke Kealey, MD, SFHM, expressed his pride for the individuals who bring The Hospitalist together.

“SHM constantly strives to bring the very best to our members and other leaders in healthcare. These two APEX awards, especially the Grand Award, are evidence that we are delivering on that goal,” he wrote in an e-mail.

The Hospitalist has garnered seven APEX Awards in the past six years, as well as attaining finalist status for “Best Healthcare Business Publication” from Medical Marketing and Media in 2009.

Physician Editor Danielle Scheurer, MD, MSCR, SFHM, considers the high quality of writing and practical, relevant article topics two of the magazine’s biggest strengths. She thanked the editors for designing a creative repertoire of stories and for thinking of new ways to cover topics.

“A huge part of our success is keeping our finger on the pulse of our customer base and trying to figure out…what kind of information they’re seeking from a magazine like The Hospitalist,” she said. “We are continuously ensuring that we’re hearing the voice of the customer.”

Erin Petenko is a contributing writer for The Hospitalist.

Summary

Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”

Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.

Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.

SHM identifies five keys to success for hospitalist co-management programs:

1. Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
2. Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
3. Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
4. Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
5. Address financial issues. Most programs require some financial support to supplement billing revenue.

Summary

Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”

Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.

Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.

SHM identifies five keys to success for hospitalist co-management programs:

1. Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
2. Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
3. Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
4. Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
5. Address financial issues. Most programs require some financial support to supplement billing revenue.

Summary

Co-management is a growing area of pediatric HM involving both surgical and medical subspecialties. According to SHM, co-management is “shared responsibility, authority, and accountability for the care of a hospitalized patient across clinical specialties.”

Motivation for starting a co-management program may come from administrators concerned about quality, safety, or nursing; surgeons or subspecialists driven by time or knowledge constraints; or hospitalists looking to enhance patient safety, clinical skills, and practice development.

Pitfalls for hospitalists include patient “dumping,” care fragmentation, and working outside their scope of practice.

SHM identifies five keys to success for hospitalist co-management programs:

1. Identify obstacles and challenges, including the program’s stakeholders, goals, risks, and assumptions.
2. Clarify roles and responsibilities for areas such as admission and discharge, communication, documentation, and delineation of responsibilities. These should be specified in a service agreement.
3. Identify champions, ideally to include a surgeon or subspecialist, hospitalist, and administrator, as well as input from a family advisory council.
4. Measure performance in areas such as length of stay, resource utilization, quality, and safety metrics.
5. Address financial issues. Most programs require some financial support to supplement billing revenue.

Summary

One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of overdiagnosis in pediatric HM and its contribution to patient harm. The first key point was the distinction between overdiagnosis and misdiagnosis. Overdiagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from misdiagnosis or incorrect diagnosis. Overdiagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and the increasing use of screening tests.

The speakers outlined many, varied drivers of overdiagnosis, including physicians’ unawareness of overdiagnosis, physicians’ discomfort with uncertainty, physicians’ inherent belief in technology and its results, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and system incentives such as fee for service, which reimburses or rewards increased testing. The classic example of overdiagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing and an increase in diagnosis but no change in mortality. A current example is children receiving head CT scans for minor head trauma, which can lead to a diagnosis of small asymptomatic head bleeds or nondisplaced skull fractures, which can in turn lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.

From the patient perspective, overdiagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary to a diagnosis or disease label.

Summary

One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of overdiagnosis in pediatric HM and its contribution to patient harm. The first key point was the distinction between overdiagnosis and misdiagnosis. Overdiagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from misdiagnosis or incorrect diagnosis. Overdiagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and the increasing use of screening tests.

The speakers outlined many, varied drivers of overdiagnosis, including physicians’ unawareness of overdiagnosis, physicians’ discomfort with uncertainty, physicians’ inherent belief in technology and its results, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and system incentives such as fee for service, which reimburses or rewards increased testing. The classic example of overdiagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing and an increase in diagnosis but no change in mortality. A current example is children receiving head CT scans for minor head trauma, which can lead to a diagnosis of small asymptomatic head bleeds or nondisplaced skull fractures, which can in turn lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.

From the patient perspective, overdiagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary to a diagnosis or disease label.

Summary

One of PHM2014’s first breakout sessions, coming on the heels of Dr. Meuthing’s opening talk on reducing serious safety events, focused on the topic of overdiagnosis in pediatric HM and its contribution to patient harm. The first key point was the distinction between overdiagnosis and misdiagnosis. Overdiagnosis is the identification of an abnormality where detection will not benefit the patient. This is different from misdiagnosis or incorrect diagnosis. Overdiagnosis has grown over the years due to several causes, including our fear of missing a diagnosis and the increasing use of screening tests.

The speakers outlined many, varied drivers of overdiagnosis, including physicians’ unawareness of overdiagnosis, physicians’ discomfort with uncertainty, physicians’ inherent belief in technology and its results, quality measures based on usage and testing, a perceived imperative to use testing and technology because it is available, and system incentives such as fee for service, which reimburses or rewards increased testing. The classic example of overdiagnosis in pediatrics is asymptomatic urinary screening for neuroblastomas, where studies showed an increase in testing and an increase in diagnosis but no change in mortality. A current example is children receiving head CT scans for minor head trauma, which can lead to a diagnosis of small asymptomatic head bleeds or nondisplaced skull fractures, which can in turn lead to PICU admissions, transfers to higher level centers, prophylactic administration of anti-seizure medications, and repeat CT scans.

From the patient perspective, overdiagnosis can lead to unnecessary hospitalizations, inappropriate medications and treatments, and increased patient or parental anxiety secondary to a diagnosis or disease label.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

Behavioral emergencies occur when a patient is physically aggressive or potentially harmful to himself/herself or others. Although they may be rare, behavioral emergencies are high-risk situations, and untrained staff might be uncomfortable dealing with these events.

Patients with underlying psychiatric or developmental disorders, those who have ingested substances, or those who have a medication side effect are at the highest risk for becoming violent. Triggers for these events could be pain, hunger, isolation, change in routine, or even the hospital’s physical environment. Early warning signs for a behavioral emergency can include verbal threats, yelling, or silence. Physical signs may include pacing, crossed arms, furrowed brow, or throwing objects.

The first response to a potential behavioral emergency is to try to de-escalate the situation. Speak in a quiet, calm voice; back off and give personal space. Try to reduce a source of discomfort, and use distractions or rewards. If de-escalation is not successful and a patient becomes violent, the provider’s first role is to be safe: Get away and get help. Hospitals should have—or should develop—a violent patient response team, which may then physically restrain the patient. Medications can be used to treat medical issues but should not be used solely for chemical restraint.

Once a patient is safely restrained, a number of Joint Commission on Accreditation of Healthcare Organizations-mandated actions must occur. The legal guardian and attending of record must be notified. A debrief must occur regarding the events; this must be documented in the medical record. Finally, a strategy must be formulated to enable the patient to be safely removed from restraints as soon as it is safe.

The presenters demonstrated various personal safety techniques to escape from a violent patient, as well as the use of physical restraints. Participants engaged in a mock behavioral emergency to experience the chaos of these events.

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

• Establish the rationale for the program and include all stakeholders;
• Determine financial expectations;
• Define scope of practice;
• Organize nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Establish referral base; and
• Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

• Establish the rationale for the program and include all stakeholders;
• Determine financial expectations;
• Define scope of practice;
• Organize nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Establish referral base; and
• Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Summary

“Master the basics of a good hospitalist program and keep revisiting your core values, and you will continue to have a high quality and sustainable program,” says Dr. Dan Hale at the PHM14 workshop “Building Blocks in the Evolution of a Successful Distributed Hospitalist Program.”

Dr. Elisabeth Schainker, chief of pediatric hospitalist medicine at The Floating Hospital for Children at Tufts Medical Center in Boston, and Dr. Hale, a hospitalist at The Floating Hospital and site director of the Lawrence General Hospital affiliated pediatric hospitalist program, allowed participants to share their experiences in program development.

This workshop reviewed the fundamentals programs should review before starting and also, periodically, after they’ve been established. Program changes should be made as needed. The workshop used an assessment tool to evaluate the basic elements of the participants’ programs. The February 2014 article “Key Principles and Characteristics of an Effective Hospital Medicine Group” in the Journal of Hospital Medicine was used as a starting point for program self-evaluation.

These “building blocks” include the following:

• Establish the rationale for the program and include all stakeholders;
• Determine financial expectations;
• Define scope of practice;
• Organize nursing and referral physician collaboration;
• Assess staffing and workload expectations;
• Establish referral base; and
• Ensure basic code and emergency preparedness.

Ongoing development elements of a program were discussed as well. These components help further integrate a hospitalist program with the hospital as a whole and help add value. These ongoing “building blocks” include:

• Communication and collaboration with other hospital departments (e.g. emergency, radiology, surgery);
• Newborn medicine care;
• Internal group clinical practice guidelines;
• Co-management of surgical or specialty patients;
• Transfers from other hospitals or continuing care from tertiary care centers;
• Pediatric code teams and rapid response teams;
• Advanced code and emergency preparedness and mock code training; and
• Nursing education.

These additive features may be different at each program. Not all of these components are applicable or needed at all hospitals. Thoughtful approaches and thorough planning can create synergy with other components of a program.

The essentials of a successful distributed network of multiple hospitalist program sites were also described.

After assuring that the fundamentals are present at each site, transparency and institutional alignment are imperative.

Surrounded by the bucolic grounds of the Disney Yacht and Beach Club Resort in Lake Buena Vista, Fla., more than 800 pediatric hospitalists gathered in July for Pediatric Hospital Medicine 2014 (PHM14). Preceded by the Society for Pediatric Sedation’s pre-course, PHM14 began in earnest with a warm welcome from Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs at St. Louis (Mo.) Children’s Hospital and chair of the PHM14 organizing committee.

The first day of the conference started with Patrick Conway, MD, MSc, FAAP, MHM, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), who gave an update of ongoing reforms in the U.S. health delivery system, with a focus on pediatrics. With three years of experience as CMS’ top doc, Dr. Conway related the difficulties of going from an unsustainable fee-for-service system to a people-centered, outcomes-driven system.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement and population health.” This practice, he added, means that the six goals of the CMS Quality Strategy align well with ongoing efforts in PHM.

Despite the difficulties of instituting change in a system that handles $3 billion daily, Dr. Conway, formerly a pediatric hospitalist at Cincinnati Children’s Hospital, said he’s witnessed many signs of improvement in the CMS landscape. Preliminary data from 2012-2014, he said, have shown a 9% reduction in hospital-acquired conditions across all measures, and overall hospital utilization is “dropping like a rock.”

While “having a foot in the boat and a foot on the dock” has been difficult, the transition, through its alphabet soup of innovation programs, is now beginning to pay off. Giving providers a pathway through the changing landscape of risk, Dr. Conway said, is an ongoing priority.

Wrapping up the first day, three healthcare system CEOs took the stage to answer questions from the audience, with Mark Shen, MD, SFHM, president of Dell Children’s Medical Center of Central Texas in Austin, Texas, posing questions like a seasoned talk show host. Panel members included David J. Bailey, MD, MBA, president and CEO of the Nemours Foundation; Steve Narang, MD, MHCM, FAAP, CEO of Banner Good Samaritan Medical Center in Phoenix, Ariz.; and Jeff Sperring, MD, FAAP, president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis.

Questions were wide-ranging.

Q: How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

Q: What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds. …It depends on ACO penetration, whether quality or volume will be the driver over the next three to five years,” Dr. Narang said.

Q: If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. I don’t think we’re going to be at a point where certification will limit being a hospitalist anytime soon,” Dr. Shen said.

Q: What are the three most important things, from a CEO perspective, that a hospitalist should know?

“Know where your organization wants to go,” Dr. Sperring said.

The next day kicked off with an inspiring call to action by Steve Meuthing, MD, vice president for safety at Cincinnati Children’s Hospital Medical Center. He called on pediatric hospitalists to eliminate all serious harm from children’s hospitals in the U.S. As a part of the Children’s Hospitals’ Solutions for Patient Safety (SPS) network, an organization accounting for 25% of all children hospitalized in the U.S., Dr. Meuthing related the need to employ high reliability theory, along with operational and cultural changes, to improve reliability in patient safety.

“If you don’t standardize, the rest is just chaos,” he said. “We have to make it easy to do these things.”

Dr. Meuthing said improving process reliability is key to reducing adverse outcomes, and high reliability organizations have utilized this approach to reduce serious harm events across the 81 SPS hospitals. While prevention of patient harm is the goal, an additional benefit is cost savings. He estimated $27 million of cost savings was realized within SPS network hospitals in 2012-2013.

Oral abstract and conundrum presentations, concurrent with 23 sessions across nine tracks, kept attendees busy. Topics ranged from a PHM circumcision service to decreasing overuse of continuous pulse oximetry. The day’s talks wrapped up with the respective presidents of the meeting’s co-sponsors—the American Academy of Pediatrics, the American Pediatrics Association, and SHM—sharing their organizations’ visions of PHM’s future in a town hall format.

The second full day began with an update of the Joint Council of Pediatric Hospital Medicine’s efforts to further advance PHM as a field. The process of submitting a petition to the American Board of Pediatrics was reviewed, as were the current status and time course of the move toward Accreditation Council for Graduate Medical Education certification.

After lunch, the highly anticipated “Top Articles” session was presented by Robert Dudas, MD, medical director of the pediatric hospitalist program at Johns Hopkins Bayview Medical Center in Baltimore, and Karen Wilson, MD, MPH, section head for pediatric hospital medicine at Children’s Hospital Colorado in Aurora. The presenters reviewed literature from the past year on topics ranging from nebulized hypertonic saline for bronchiolitis to antibiotic prophylaxis in vesicoureteral reflux.

The final day commenced with a talk by Alberto Puig, MD, PhD, FACP, associate director of undergraduate education at Massachusetts General Hospital in Boston, whose experiences as an internist provided insight regarding the history of the physical examination, from the aphorisms of Hippocrates to the family-centered bedside rounding of today.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Dr. O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Dr. Hale is a past member of Team Hospitalist and a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Surrounded by the bucolic grounds of the Disney Yacht and Beach Club Resort in Lake Buena Vista, Fla., more than 800 pediatric hospitalists gathered in July for Pediatric Hospital Medicine 2014 (PHM14). Preceded by the Society for Pediatric Sedation’s pre-course, PHM14 began in earnest with a warm welcome from Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs at St. Louis (Mo.) Children’s Hospital and chair of the PHM14 organizing committee.

The first day of the conference started with Patrick Conway, MD, MSc, FAAP, MHM, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), who gave an update of ongoing reforms in the U.S. health delivery system, with a focus on pediatrics. With three years of experience as CMS’ top doc, Dr. Conway related the difficulties of going from an unsustainable fee-for-service system to a people-centered, outcomes-driven system.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement and population health.” This practice, he added, means that the six goals of the CMS Quality Strategy align well with ongoing efforts in PHM.

Despite the difficulties of instituting change in a system that handles $3 billion daily, Dr. Conway, formerly a pediatric hospitalist at Cincinnati Children’s Hospital, said he’s witnessed many signs of improvement in the CMS landscape. Preliminary data from 2012-2014, he said, have shown a 9% reduction in hospital-acquired conditions across all measures, and overall hospital utilization is “dropping like a rock.”

While “having a foot in the boat and a foot on the dock” has been difficult, the transition, through its alphabet soup of innovation programs, is now beginning to pay off. Giving providers a pathway through the changing landscape of risk, Dr. Conway said, is an ongoing priority.

Wrapping up the first day, three healthcare system CEOs took the stage to answer questions from the audience, with Mark Shen, MD, SFHM, president of Dell Children’s Medical Center of Central Texas in Austin, Texas, posing questions like a seasoned talk show host. Panel members included David J. Bailey, MD, MBA, president and CEO of the Nemours Foundation; Steve Narang, MD, MHCM, FAAP, CEO of Banner Good Samaritan Medical Center in Phoenix, Ariz.; and Jeff Sperring, MD, FAAP, president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis.

Questions were wide-ranging.

Q: How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

Q: What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds. …It depends on ACO penetration, whether quality or volume will be the driver over the next three to five years,” Dr. Narang said.

Q: If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. I don’t think we’re going to be at a point where certification will limit being a hospitalist anytime soon,” Dr. Shen said.

Q: What are the three most important things, from a CEO perspective, that a hospitalist should know?

“Know where your organization wants to go,” Dr. Sperring said.

The next day kicked off with an inspiring call to action by Steve Meuthing, MD, vice president for safety at Cincinnati Children’s Hospital Medical Center. He called on pediatric hospitalists to eliminate all serious harm from children’s hospitals in the U.S. As a part of the Children’s Hospitals’ Solutions for Patient Safety (SPS) network, an organization accounting for 25% of all children hospitalized in the U.S., Dr. Meuthing related the need to employ high reliability theory, along with operational and cultural changes, to improve reliability in patient safety.

“If you don’t standardize, the rest is just chaos,” he said. “We have to make it easy to do these things.”

Dr. Meuthing said improving process reliability is key to reducing adverse outcomes, and high reliability organizations have utilized this approach to reduce serious harm events across the 81 SPS hospitals. While prevention of patient harm is the goal, an additional benefit is cost savings. He estimated $27 million of cost savings was realized within SPS network hospitals in 2012-2013.

Oral abstract and conundrum presentations, concurrent with 23 sessions across nine tracks, kept attendees busy. Topics ranged from a PHM circumcision service to decreasing overuse of continuous pulse oximetry. The day’s talks wrapped up with the respective presidents of the meeting’s co-sponsors—the American Academy of Pediatrics, the American Pediatrics Association, and SHM—sharing their organizations’ visions of PHM’s future in a town hall format.

The second full day began with an update of the Joint Council of Pediatric Hospital Medicine’s efforts to further advance PHM as a field. The process of submitting a petition to the American Board of Pediatrics was reviewed, as were the current status and time course of the move toward Accreditation Council for Graduate Medical Education certification.

After lunch, the highly anticipated “Top Articles” session was presented by Robert Dudas, MD, medical director of the pediatric hospitalist program at Johns Hopkins Bayview Medical Center in Baltimore, and Karen Wilson, MD, MPH, section head for pediatric hospital medicine at Children’s Hospital Colorado in Aurora. The presenters reviewed literature from the past year on topics ranging from nebulized hypertonic saline for bronchiolitis to antibiotic prophylaxis in vesicoureteral reflux.

The final day commenced with a talk by Alberto Puig, MD, PhD, FACP, associate director of undergraduate education at Massachusetts General Hospital in Boston, whose experiences as an internist provided insight regarding the history of the physical examination, from the aphorisms of Hippocrates to the family-centered bedside rounding of today.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Dr. O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Dr. Hale is a past member of Team Hospitalist and a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Surrounded by the bucolic grounds of the Disney Yacht and Beach Club Resort in Lake Buena Vista, Fla., more than 800 pediatric hospitalists gathered in July for Pediatric Hospital Medicine 2014 (PHM14). Preceded by the Society for Pediatric Sedation’s pre-course, PHM14 began in earnest with a warm welcome from Doug Carlson, MD, FAAP, chief of pediatric hospital medicine programs at St. Louis (Mo.) Children’s Hospital and chair of the PHM14 organizing committee.

The first day of the conference started with Patrick Conway, MD, MSc, FAAP, MHM, chief medical officer for the Centers for Medicare and Medicaid Services (CMS), who gave an update of ongoing reforms in the U.S. health delivery system, with a focus on pediatrics. With three years of experience as CMS’ top doc, Dr. Conway related the difficulties of going from an unsustainable fee-for-service system to a people-centered, outcomes-driven system.

“Pediatrics,” Dr. Conway said, “is a leader in patient and family engagement and population health.” This practice, he added, means that the six goals of the CMS Quality Strategy align well with ongoing efforts in PHM.

Despite the difficulties of instituting change in a system that handles $3 billion daily, Dr. Conway, formerly a pediatric hospitalist at Cincinnati Children’s Hospital, said he’s witnessed many signs of improvement in the CMS landscape. Preliminary data from 2012-2014, he said, have shown a 9% reduction in hospital-acquired conditions across all measures, and overall hospital utilization is “dropping like a rock.”

While “having a foot in the boat and a foot on the dock” has been difficult, the transition, through its alphabet soup of innovation programs, is now beginning to pay off. Giving providers a pathway through the changing landscape of risk, Dr. Conway said, is an ongoing priority.

Wrapping up the first day, three healthcare system CEOs took the stage to answer questions from the audience, with Mark Shen, MD, SFHM, president of Dell Children’s Medical Center of Central Texas in Austin, Texas, posing questions like a seasoned talk show host. Panel members included David J. Bailey, MD, MBA, president and CEO of the Nemours Foundation; Steve Narang, MD, MHCM, FAAP, CEO of Banner Good Samaritan Medical Center in Phoenix, Ariz.; and Jeff Sperring, MD, FAAP, president and CEO of Riley Hospital for Children at Indiana University Health in Indianapolis.

Questions were wide-ranging.

Q: How did you become a CEO?

“All I had to do was keep on saying ‘yes,’” Dr. Bailey said.

Q: What are you doing as a CEO to move from a fee-for-service system to a population-based system?

“We are still living in two different worlds. …It depends on ACO penetration, whether quality or volume will be the driver over the next three to five years,” Dr. Narang said.

Q: If PHM fellowship becomes a requirement, will your hospital fund them?

“It’s hard to define what we do, but we know there are core competencies. I don’t think we’re going to be at a point where certification will limit being a hospitalist anytime soon,” Dr. Shen said.

Q: What are the three most important things, from a CEO perspective, that a hospitalist should know?

“Know where your organization wants to go,” Dr. Sperring said.

The next day kicked off with an inspiring call to action by Steve Meuthing, MD, vice president for safety at Cincinnati Children’s Hospital Medical Center. He called on pediatric hospitalists to eliminate all serious harm from children’s hospitals in the U.S. As a part of the Children’s Hospitals’ Solutions for Patient Safety (SPS) network, an organization accounting for 25% of all children hospitalized in the U.S., Dr. Meuthing related the need to employ high reliability theory, along with operational and cultural changes, to improve reliability in patient safety.

“If you don’t standardize, the rest is just chaos,” he said. “We have to make it easy to do these things.”

Dr. Meuthing said improving process reliability is key to reducing adverse outcomes, and high reliability organizations have utilized this approach to reduce serious harm events across the 81 SPS hospitals. While prevention of patient harm is the goal, an additional benefit is cost savings. He estimated $27 million of cost savings was realized within SPS network hospitals in 2012-2013.

Oral abstract and conundrum presentations, concurrent with 23 sessions across nine tracks, kept attendees busy. Topics ranged from a PHM circumcision service to decreasing overuse of continuous pulse oximetry. The day’s talks wrapped up with the respective presidents of the meeting’s co-sponsors—the American Academy of Pediatrics, the American Pediatrics Association, and SHM—sharing their organizations’ visions of PHM’s future in a town hall format.

The second full day began with an update of the Joint Council of Pediatric Hospital Medicine’s efforts to further advance PHM as a field. The process of submitting a petition to the American Board of Pediatrics was reviewed, as were the current status and time course of the move toward Accreditation Council for Graduate Medical Education certification.

After lunch, the highly anticipated “Top Articles” session was presented by Robert Dudas, MD, medical director of the pediatric hospitalist program at Johns Hopkins Bayview Medical Center in Baltimore, and Karen Wilson, MD, MPH, section head for pediatric hospital medicine at Children’s Hospital Colorado in Aurora. The presenters reviewed literature from the past year on topics ranging from nebulized hypertonic saline for bronchiolitis to antibiotic prophylaxis in vesicoureteral reflux.

The final day commenced with a talk by Alberto Puig, MD, PhD, FACP, associate director of undergraduate education at Massachusetts General Hospital in Boston, whose experiences as an internist provided insight regarding the history of the physical examination, from the aphorisms of Hippocrates to the family-centered bedside rounding of today.

Dr. Chang is associate clinical professor of medicine and pediatrics at the University of California at San Diego School of Medicine and a hospitalist at both UCSD Medical Center and Rady Children’s Hospital. He is pediatric editor of The Hospitalist.

Dr. O’Callaghan is a clinical assistant professor of pediatrics at the University of Washington and a member of Team Hospitalist.

Dr. Hale is a past member of Team Hospitalist and a pediatric hospitalist at the Floating Hospital for Children at Tufts Medical Center in Boston.

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

Christine Lum Lung, MD, SFHM

When SHM received the Joint Commission’s John M. Eisenberg Patient Safety and Quality Award for 2011 for innovation in patient safety and quality at the national level, the award represented national recognition for the society’s three major hospital quality improvement initiatives. Moreover, it highlighted the integral role mentors play in each of the programs, helping physicians and hospitals make accelerated progress on important patient safety and quality issues.

Mentored implementation assigns a physician expert to train, guide, and work with the participating facilities’ hospitalist-led, multidisciplinary team through the life cycle of a QI initiative. The three programs focus on VTE prevention, glycemic control, and transitions of care. The first hospital cohort for VTE prevention—the VTE Prevention Collaborative—was in 2007. The care transitions program, known as Project BOOST, started in 2008. The Glycemic Control Mentored Implementation (GCMI) Program began in 2009. A fourth SHM mentored implementation program is MARQUIS, the Multi-Center Medication Reconciliation Quality Improvement Study.

In basic terms, mentoring is “coaching from a physician who has expertise both in the clinical subject matter and in implementing the processes and tools of quality improvement—usually because they’ve done it themselves,” says Gregory Maynard, MD, MSc, SFHM, senior vice president of SHM’s Center for Hospital Innovation and Improvement and a co-founder of two of its mentored implementation programs.

Mentors typically are paired with one or two participating hospitals for 12 to 18 months, conducting monthly conference calls with the team, sharing tools and resources from SHM’s online library, and offering advice on how to navigate the treacherous currents of culture change within a hospital. BOOST mentors also make in-person site visits. They are well versed in protocol and order set design and quality measurement strategies, and they know how to engage frontline professionals and institutional leadership, Dr. Maynard says.

Some mentors have received formal QI training, and many have attended Mentor University, a 1-1/2 day intensive training course offered by SHM that reinforces the nuances of coaching, the contents of SHM’s quality toolkits, and ideas for overcoming common barriers to improvement. SHM’s mentor support provides continuous professional development for the mentors, pairing new mentors with senior mentors to coach them in the process and hosting an online community with other mentors.

“What’s telling to me is that many of the people who have been mentored by SHM’s programs in one topic go on to become mentors in another topic, taking those portable skills and principles and applying them in other quality areas,” Dr. Maynard says. “We’re fostering leadership and quality improvement skills among hospitalists; that’s really one of our main goals. People learn the skill and then spread it within their system.”

Mark Williams, MD, FACP, MHM, Project BOOST principal investigator and a veteran SHM mentor, says that just providing educational materials to health professionals often isn’t enough for them to overcome the barriers to change.

“I’ve seen many large-scale quality projects that didn’t work, as they were simply disseminating information, content, or knowledge,” he says. Mentored implementation as practiced by SHM is “a model for disseminating quality improvement nationally,” he adds. “Pretty much any quality improvement project can be done this way.”

Key to the mentored implementation program’s success is the personalized approach and customized solutions.

“You directly meet with the team in their own setting and begin to see what’s going on,” Dr. Williams says. “You also meet with the hospital’s senior leadership. That’s when you start to see change.”

The Hospitalist connected with eight SHM mentors. The following are snapshots of their work in the mentorship program and some of the lessons they taught—and learned—from the program.

Christine Lum Lung, MD, SFHM

Christine Lum Lung, MD, SFHM

Title: Medical director, Northern Colorado Hospitalists, Fort Collins

Program: VTE Prevention Collaborative

Background: As a practicing hospitalist and medical director of the HM group for a two-hospital system, Dr. Lum Lung chaired its quality committee for VTE protocol development. “It was obvious at our hospitals that we needed to do better at VTE prevention,” she explains.

Dr. Lum Lung’s team received VTE mentorship from Dr. Maynard, who later asked her to become a VTE mentor. She also attended all three levels of SHM’s Leadership Academy and has since become a mentor for the new HP3 (Hospitalist Program Peak Performance) mentored implementation program, a one-year collaboration among SHM, Northwestern University, Blue Cross/Blue Shield of Illinois, and the Illinois Hospital Association that is designed to help hospitalist groups optimize their programs and build healthy group culture.

Teachable moment: The essential qualities of a good mentee, Dr. Lum Lung says, are drive and dedication. “You believe strongly about it, so you can sell it to others. You also need a thick skin to face the adversities that come up. When my mentor gave me tasks and deadlines, I met those deadlines.”

Success story: “I’ve been impressed with how hard groups and individuals can work.” Most of the teams she has worked with were facing significant external stressors—starting a new program, moving into a new hospital, rolling out a new EHR, becoming part of a growing medical group. “Yet each of them has been incredibly engaged in the process and dedicated to completing their projects.”

Lessons learned: “That we all have something to learn from each other. While I am officially the mentor, I have learned a lot about processes, teamwork, and flow issues from the sites that could potentially be incorporated in our program.”

Advice: Working on a project as a team can be very powerful, she says. Even seemingly ‘small’ projects have allowed teams to learn how to work better together on day-to-day issues. With the victory of a small project behind them, they make lists of the next thing that they want to tackle.

“Our profession is constantly changing. We need to be thinking ahead for how we will face those challenges,” Dr. Lum Lung says. “A team that works well together will have an advantage in this new environment. Even if you have people who are new to quality improvement, their participation can still be important.”

Jordan Messler, MD, SFHM

Jordan Messler, MD, SFHM

Title: Medical director, Morton Plant Hospitalists, Clearwater, Fla.

Program: GCMI; Project BOOST

Background: Dr. Messler’s interest in QI led him to work with colleagues in SHM who are national leaders in quality. “A couple of years ago, I enrolled in Emory’s Quality Academy, a sister course to Intermountain Health’s course on quality. Then I enrolled our hospital in both the GCMI Program and Project BOOST. My mentors for those programs were terrific guides, which led to my interest in seeing their side of the program as a mentor myself.”

Teachable moment: One program had difficulty implementing a VTE prevention tool and couldn’t get nursing support as it had expected, largely due to lack of nursing engagement on the project team, he says. “We started talking about the history of the projects, and prior interventions. In addition, we talked to the different disciplines separately. It seems there used to be an excellent system where nursing helped out on the project team for risk assessment.”

As VTE prevention became more of a priority, some physicians separately created a new tool to replace the nursing tool without involving the whole team. “And they couldn’t understand why nursing wasn’t buying into the new process.”

Success story: There are similar themes to success and failure. Sites that have strong administrative support (i.e., C-suite representation on the QI team), that have “accountability structure and stick to the basics of QI, with clear goals, ability to gather and report data, and use of a QI model [such as PDSA or Six Sigma] are the ones that succeed,” Dr. Messler says. “And the reverse is consistently true. Sustainable QI needs to be multidisciplinary, involving every voice, considering prior interventions and understanding of the culture.”

Lessons learned: “As mentors, we all continue to say we learn as much or more from these sites as they, hopefully, are learning from us. This collaboration and sharing of ideas has been instrumental to the success of the program.”

Advice: Get started today, and don’t give up. Follow the road map of QI projects, gather support, and get started. You will learn as much from your failures as your successes.

Dr. Messler says hospitals are looking for physician leaders to improve quality, and hospitalists are perfectly positioned to be those QI leaders. These big projects can last for years, so quality teams and hospitals need to be prepared to take the long view.

Stephanie Rennke, MD

Stephanie Rennke, MD

Title: Associate clinical professor of medicine, co-director of faculty development, division of hospital medicine, University of California San Francisco Medical Center.

Program: Project BOOST

Background: “When I started as a hospitalist right out of residency, QI had not been part of my training. But I noticed that quality was at the forefront of the academic interests of all the hospitalists at UCSF. I was personally interested in transitions of care. I still do home visits after hours for at-risk patients when they leave the hospital.”

Dr. Rennke started in QI as a member of UCSF’s BOOST team in 2008. “I worked with other faculty in the division who had previous experience in quality improvement and transitions in care. One of the co-principal investigators for BOOST, Dr. Arpana Vidyarthi, suggested that it would be a really rewarding experience to mentor—and it was.”

Teachable moment: “I’ve been so impressed by the diversity of what’s out there. No hospitalist program or hospital is the same. There is no one-size-fits-all for quality improvement or transitions of care, so it is incredibly important that the mentor takes the time to get to know both the team and the hospital.”

Success story: “During a site visit, I had an opportunity to watch one of the nurses, who had received training from a competency-based Teach Back program, practice Teach Back with a patient at the bedside,” Dr. Rennke says. “I was doing a tour of the floor and went into the room of a patient about to be discharged. A young float nurse, not long out of school, sat down with the patient and went through the medications and discharge plan using Teach Back. It didn’t take more time, but the time was spent more constructively, with interaction back and forth. I remember that ‘aha’ moment for the patient and the look in her eyes. For me, as a mentor, it was exciting to think that something I had tried to bring to them had been incorporated by the site and was really working.”

Lessons learned: “I have learned that, while at a large institution like UCSF we tend to work in silos, smaller sites are often more integrated with the various disciplines. You can walk down the hall to the clinical pharmacist or have lunch with the charge nurse. So I’ve tried to bring back home a commitment to really get to know professional colleagues and have them feel that I’m interested in their perspectives.”

Advice: “Work in teams. You cannot do this alone. Include frontline staff. And don’t forget to advertise to others that the program exists. Get the word out—let people know.”

Jennifer Quartarolo, MD, SFHM

Jennifer Quartarolo, MD, SFHM

Title: Medical director, clinical resource management; associate clinical professor, division of hospital medicine, University of California San Diego Health System

Program: Project BOOST

Background: Dr. Quartarolo has 11 years of clinical experience as an academic hospitalist at two different medical centers, and she completed a training program in healthcare delivery and improvement through the Institute for Health Care Delivery Research in Salt Lake City, Utah. “At my own institution, I had been involved in multiple QI projects,” she says. “Since joining the faculty, I worked with our care transitions team for five years before becoming a mentor. We incorporated many elements from Project BOOST as we worked to improve our care transitions process,” which led to an invitation to be a mentor.

Teachable moment: “I had one site that I worked with that had a great new form they had developed to incorporate into their transition process; however, when they decided to implement the form, they got a lot of pushback from nursing,” she says. “Then they realized that they had not involved any frontline nurses in their planning. This example points out how important it is to have all the key players involved on your team, as improving transitions of care is a complex process requiring multidisciplinary collaboration.”

Success story: Dr. Quartarolo says she has worked with several hospitals that have seen significant improvement in their readmission rates after participating in Project BOOST and implementing its tools.

Lessons learned: “I am constantly impressed by the innovative ideas that teams come up with to deal with the challenges that their hospitals face,” she says. Every hospital is unique and needs to do self-evaluation before deciding what to focus on. “I have also worked with many sites that have challenges getting physicians engaged in their efforts, particularly if they do not have a hospitalist program.”

Advice: “We are in a unique role as hospitalists to identify systems issues and improve quality of care in the inpatient setting, and this is particularly useful in improving care transitions and decreasing readmissions rates.”

Rich Balaban, MD

Rich Balaban, MD

Title: Medical director, Hospital-to-Home Community Collaboration Program, Cambridge Health Alliance; assistant professor of medicine, Harvard Medical School, Boston

Program: Project BOOST

Background: Dr. Balaban has worked clinically in both the inpatient setting as a hospitalist and the outpatient setting as a primary care doctor. “I have seen hospital discharges as both a receiver and a sender, so [I] have been able to appreciate the challenges facing doctors, nurses, case managers, and patients involved in the care transition process,” he says.

Dr. Balaban also conducted a randomized controlled trial that demonstrated the benefits of engaging nurses at a patient’s primary care site to make outreach phone calls immediately after hospital discharge. Dr. Williams asked him to present on the study.

“It was a great opportunity for me to share the results of our work and for Mark to see my presentation skills,” he says. “When I asked if there were opportunities to get more involved in care transitions work, he invited me to consider becoming a BOOST mentor.”

Teachable moment: “Wearing my primary care hat, I believe that while it is very important to structure an effective discharge for the patient while in the hospital, success or failure ultimately is determined by what happens in the outpatient setting,” Dr. Balaban says. Even if a ‘perfect discharge’ occurs in the hospital, it can all quickly unravel once the patient arrives at home.

Success story: “At several sites, I have encouraged the inpatient care team to invite the outpatient care team to become part of the care transitions team. This has frequently brought an important viewpoint and voice to the care transitions table. While hospitalists have initiated the discussion about care transitions, they need an effective outpatient partner to create a truly effective process.”

Lessons learned: “I have learned to hold judgment until seeing with my own eyes,” Dr. Balaban says. “One of the first sites I visited had developed a post-discharge clinic, which they were excited to show me. From my point of view, I thought that after discharge, patient care should be assumed by the primary care office as soon as possible, and a post-discharge clinic would only delay that process.

“To my great surprise, their post-discharge clinic provided an ideal bridge between the hospital and primary care. The post-discharge clinic really worked and provided patients with a wonderful resource. … I’ve learned that there are many ways to solve problems, often based on the available resources at a specific site.”

Advice: In order to best understand the challenges of hospital discharge, it is critical that you understand what happens to patients after they leave the hospital. Make a home visit to a recently discharged patient to really understand the challenges that patients face when they return home.

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Amitkumar R. Patel, MD, MBA, FACP, SFHM

Title: Clinical instructor in hospital medicine, Feinberg School of Medicine, Northwestern University, Chicago

Program: Project BOOST; also working with critical access hospitals in Illinois through PREP (Preventing Readmissions through Effective Partnerships)

Background: Although he now works in an urban teaching hospital, Dr. Patel also did private practice as a community hospitalist and has pursued formal healthcare management-focused training.

“I became a mentor because my experience and interest in quality improvement fit well with Project BOOST,” he says. “I enjoy coaching teams as they face challenges in quality improvement, especially in relation to readmissions reduction. My work with critical access hospitals is the result of my first year as a mentor with the PREP collaborative in Illinois.”

PREP, a collaborative initiative of SHM and the Illinois Hospital Association that is funded by Blue Cross/Blue Shield of Illinois, aims to help hospitals focus on quality initiatives, including BOOST.

Teachable moment/success story: One of Dr. Patel’s BOOST sites believed the team included all appropriate personnel to obtain discharge appointments prior to patients’ discharges. But as they began to work through the process of making sure each appointment was appropriately documented, the various team members assigned to this process could not consistently complete the task within their workflow.

The pilot unit secretaries were not part of the BOOST team initially but saw that they could fulfill this role quickly and easily. They knew who to call at the physicians’ offices to avoid getting stuck in the phone menu trees, and they used this knowledge to reach the schedulers directly. The BOOST team quickly realized the unit secretaries were the most appropriate personnel to capture this information and work with the patients or their families/caregivers to obtain the most convenient appointments. This role was added to the team, and the unit secretaries took ownership of this process. Other teams may also want to look beyond the customary team members to roles that may not be thought of as quality team members.

Lessons learned: “The biggest take-away for me involves the unique culture that exists in many of our urban and rural communities,” he says. Every BOOST site implements the project’s elements in its own unique way, and what works well in one location may not fit the needs of another. The role of the mentor is to balance the need for community-specific advice with unique attributes of the facility and the elements of Project BOOST. “Often, we use our mentor calls to brainstorm solutions, and the teams are teaching me what will work best in their environment.”

Advice: “Responsibility for hospital change management should not be abdicated to administrators or quality improvement staff members,” he says. “QI is not a sometime thing for some staff; it’s an all-the-time process for every staff member, including physicians, to participate in and actively manage.”

Cheryl O’Malley, MD, FHM

Cheryl O’Malley, MD, FHM

Title: Internal medicine residency program director, Banner Good Samaritan Medical Center, Phoenix

Program: GCMI

Background: Banner Good Samaritan has participated in the BOOST, VTE, and GCMI programs. Dr. O’Malley brought her experience from developing, implementing, and leading local glycemic control efforts to mentoring others.

“When I first started working on our hospital’s process, I had so many questions and asked one of my mentors from residency, Dr. Greg Maynard,” she says. “He helped me to see that people around the country were asking the same questions and invited me to join SHM’s glycemic control work group. When the GCMI program started, I was asked to be a mentor.”

Teachable moment: “When I was a new attending on the wards after residency, my patients would ask me why their blood sugars were so much better controlled at home than in the hospital. Usually, the answer was that they were put on a sliding scale when they came into the hospital,” she says, noting that what was done at home wasn’t going to work in the hospital. Patients needed a different regimen—a more proactive approach than just the customary sliding scale.

“I started to learn more about basal rates, nutrition, and correction insulin regimens in the hospital, but I realized that to really have adequate safety and direction for the nursing staff, it would require a formal order set and systematic approach,” she says.

Success story: “One of my sites invited me to come and present grand rounds at the hospital, and the local physician team leader invited the whole quality team to her home. It was a very exciting team and had achieved a lot. Fifteen or 20 of us spent the evening talking about the project but also just enjoying the collegiality,” Dr. O’Malley says. “Even though we had never seen one another, I instantly knew everyone by voice from spending so much time on the phone. And we knew a lot about one another’s personal lives and careers.”

Lessons learned: “Hearing a program describe what they are doing and knowing that they were far ahead of my own hospital in many ways but still being able to provide an insight or a perspective to help them achieve their own next steps. Everyone has something to learn from another hospital or another discipline. We can all leverage our experiences to improve patient care.”

Advice: “Be patient. This is a really long process of constant improvements. I have been working on glycemic control for 10 years now and still feel like we have many opportunities to further improve.”

Cheryl O’Malley, MD, FHM

Christopher Kim, MD, MBA, SFHM

Title: Clinical associate professor of internal medicine and assistant professor of pediatrics, University of Michigan Health System, Ann Arbor

Program: Project BOOST; Michigan Transitions of Care Collaborative (M-TC2)

Background: Dr. Kim brings clinical, quality improvement, leadership, collaborative learning, and discussion facilitation skills to his work as program director of M-TC2 and as mentor to the sites he works with.

The collaborative is part of a set of state collaborative quality initiatives funded by Blue Cross Blue Shield of Michigan. One of those initiatives is focused on improving care transitions between the hospital setting and ambulatory care providers, using Project BOOST tools—expanded to integrate more closely with primary care providers, physician organizations, and ambulatory care. The eight Michigan-based mentors for M-TC2 have all attended SHM’s Mentor University.

Teachable moment: There are local challenges and there are general challenges—those that are commonly shared by most hospitals, Dr. Kim explains. Both need to be overcome when working on an improvement project such as transitions of care. The local hospitalist brings expertise about the former—which are often more difficult to understand and overcome. The mentor brings knowledge and experience of the universal challenges, as well as the benefit of having seen or heard about what other programs have done. Together, they can work to help the organization become better equipped to improve the initiative at hand.

Success story: “One hospital in the collaborative realized that it could roll out the Teach Back concept to both nurses and physicians,” he says. They started to teach residents how to interact with patients and began using this approach in physician-nurse teams. Subsequently, the team shared with the collaborative how physicians have embraced the concept.

Lessons learned: Every site has its successes and challenges, he says. Sharing both sides of the story can only advance the mission of the collaborative, as each organization learns from the successes and failures of the others.

Mentored implementation really does what it’s intended to do—helping to support the sites and keeping an organization on track and accountable for the work it does, because someone external to the organization is working with it and providing information about what other sites are doing.

Advice: Talk with different disciplines and find out how much they long to work with other care providers, and then have discussions about how to make interdisciplinary practice happen. “At our collaborative meetings over time, many of the 24 participating sites have shared their progress—the good things and the struggles,” Dr. Kim says.

Larry Beresford is a freelance writer in Alameda, Calif.

EVIDENCE SUMMARY

A systematic review of the effect of combined OCPs on women with a family history of breast cancer found no additional increase in risk.¹ Investigators identified 3 retrospective cohort studies (N=66,500, with 8500 cases) and 7 case-control studies (total 10,500 cases) from the past 40 years, most including women from the United States and Canada, but one including women from 5 continents.

In most trials, women of reproductive age using combined OCPs had 1 or more first-degree female relatives with breast cancer, although a few trials also included second-degree relatives. Women ranged in age from 20 to 79 years at diagnosis, and most trials controlled for age, parity, menstrual and menopausal history, duration of OCP exposure, and age at first use. Follow-up intervals for the retrospective cohort studies ranged from 5 to 16 years. Investigators were unable to combine results because of heterogenous populations.

Three of the cohort studies found no significant difference in breast cancer risk between OCP users and nonusers, regardless of age or duration of use. One cohort study found an increased risk in women taking older, higher-dose OCPs from before 1975 (relative risk [RR]=3.3; 95% confidence interval [CI], 1.5-7.2). All of the case-control studies found no significant difference in breast cancer risk for any age of starting, duration of OCP use, or degree of relative with breast cancer.

A meta-analysis of 54 case-control studies (6757 cases), comprising approximately 90% of the epidemiologic information on this topic, also found no significant difference in breast cancer risk related to OCP use among women with one or more first-degree relatives with breast cancer.² Investigators found that neither recent OCP use (<10 years, RR=0.77; 95% CI, 0.54-1.11) nor past OCP use (>10 years, RR=1.01; 95% CI, 0.80-1.28) affected risk of developing breast cancer.

Three additional case-control studies involving women with a family history of breast cancer also found no significant association for breast cancer incidence among OCP users compared with nonusers.^3-5

 

 

Modern combined OCPs don’t raise risk in women with BRCA1/2 mutations


A meta-analysis of 5 studies (one retrospective cohort, 4 case-control, with a total of 2855 breast cancer cases and 2944 controls) evaluated whether combined OCPs increased the risk of breast cancer in women, all of whom were carrying BRCA1/2 mutations.⁶

Using modern combined OCPs didn’t raise the risk of breast cancer in BRCA1/2 carriers overall (RR=1.13; 95% CI, 0.88-1.45) or separately in BRCA1 carriers (5 studies, RR=1.09; 95% CI, 0.77-1.54) or BRCA2 carriers (3 studies, RR=1.15; 95% CI, 0.88-1.45).

However, pre-1975 (higher dose) combined OCPs produced significantly increased risk (RR=1.47; 95% CI, 1.06-2.04). Similarly, women who had used combined OCPs >10 years before the study (older women, likely to have been using pre-1975 OCPs) also had significantly increased risk (RR=1.46; 95% CI, 1.07-2.07).

A bit of good news:
 Combined OCPs reduce ovarian cancer risk

The analysis also determined that combined OCPs significantly reduced the risk of ovarian cancer in women carrying BRCA1/2 mutations (RR=0.50; 95% CI, 0.33-0.75), with an additional linear decrease in risk for each 10 years of OCP use (RR=0.64; 95% CI, 0.53-0.78).

RECOMMENDATIONS

Combined oral contraceptive pills significantly reduced the risk of ovarian cancer in women carrying BRCA1/2 mutations. The World Health Organization guidelines outlining criteria for contraceptive use state that OCPs don’t alter the risk of breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes.⁷

The American College of Obstetricians and Gynecologists (ACOG) says that a positive family history of breast cancer shouldn’t be regarded as a contraindication to OCP use.⁸ ACOG also says that women with the BRCA1 mutation have an increased risk of breast cancer if they used OCPs for longer than 5 years before age 30, but this risk may be more than balanced by the benefit of a greatly reduced risk of ovarian cancer.

EVIDENCE SUMMARY

A systematic review of the effect of combined OCPs on women with a family history of breast cancer found no additional increase in risk.¹ Investigators identified 3 retrospective cohort studies (N=66,500, with 8500 cases) and 7 case-control studies (total 10,500 cases) from the past 40 years, most including women from the United States and Canada, but one including women from 5 continents.

In most trials, women of reproductive age using combined OCPs had 1 or more first-degree female relatives with breast cancer, although a few trials also included second-degree relatives. Women ranged in age from 20 to 79 years at diagnosis, and most trials controlled for age, parity, menstrual and menopausal history, duration of OCP exposure, and age at first use. Follow-up intervals for the retrospective cohort studies ranged from 5 to 16 years. Investigators were unable to combine results because of heterogenous populations.

Three of the cohort studies found no significant difference in breast cancer risk between OCP users and nonusers, regardless of age or duration of use. One cohort study found an increased risk in women taking older, higher-dose OCPs from before 1975 (relative risk [RR]=3.3; 95% confidence interval [CI], 1.5-7.2). All of the case-control studies found no significant difference in breast cancer risk for any age of starting, duration of OCP use, or degree of relative with breast cancer.

A meta-analysis of 54 case-control studies (6757 cases), comprising approximately 90% of the epidemiologic information on this topic, also found no significant difference in breast cancer risk related to OCP use among women with one or more first-degree relatives with breast cancer.² Investigators found that neither recent OCP use (<10 years, RR=0.77; 95% CI, 0.54-1.11) nor past OCP use (>10 years, RR=1.01; 95% CI, 0.80-1.28) affected risk of developing breast cancer.

Three additional case-control studies involving women with a family history of breast cancer also found no significant association for breast cancer incidence among OCP users compared with nonusers.^3-5

 

 

Modern combined OCPs don’t raise risk in women with BRCA1/2 mutations


A meta-analysis of 5 studies (one retrospective cohort, 4 case-control, with a total of 2855 breast cancer cases and 2944 controls) evaluated whether combined OCPs increased the risk of breast cancer in women, all of whom were carrying BRCA1/2 mutations.⁶

Using modern combined OCPs didn’t raise the risk of breast cancer in BRCA1/2 carriers overall (RR=1.13; 95% CI, 0.88-1.45) or separately in BRCA1 carriers (5 studies, RR=1.09; 95% CI, 0.77-1.54) or BRCA2 carriers (3 studies, RR=1.15; 95% CI, 0.88-1.45).

However, pre-1975 (higher dose) combined OCPs produced significantly increased risk (RR=1.47; 95% CI, 1.06-2.04). Similarly, women who had used combined OCPs >10 years before the study (older women, likely to have been using pre-1975 OCPs) also had significantly increased risk (RR=1.46; 95% CI, 1.07-2.07).

A bit of good news:
 Combined OCPs reduce ovarian cancer risk

The analysis also determined that combined OCPs significantly reduced the risk of ovarian cancer in women carrying BRCA1/2 mutations (RR=0.50; 95% CI, 0.33-0.75), with an additional linear decrease in risk for each 10 years of OCP use (RR=0.64; 95% CI, 0.53-0.78).

RECOMMENDATIONS

Combined oral contraceptive pills significantly reduced the risk of ovarian cancer in women carrying BRCA1/2 mutations. The World Health Organization guidelines outlining criteria for contraceptive use state that OCPs don’t alter the risk of breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes.⁷

The American College of Obstetricians and Gynecologists (ACOG) says that a positive family history of breast cancer shouldn’t be regarded as a contraindication to OCP use.⁸ ACOG also says that women with the BRCA1 mutation have an increased risk of breast cancer if they used OCPs for longer than 5 years before age 30, but this risk may be more than balanced by the benefit of a greatly reduced risk of ovarian cancer.

EVIDENCE SUMMARY

A systematic review of the effect of combined OCPs on women with a family history of breast cancer found no additional increase in risk.¹ Investigators identified 3 retrospective cohort studies (N=66,500, with 8500 cases) and 7 case-control studies (total 10,500 cases) from the past 40 years, most including women from the United States and Canada, but one including women from 5 continents.

In most trials, women of reproductive age using combined OCPs had 1 or more first-degree female relatives with breast cancer, although a few trials also included second-degree relatives. Women ranged in age from 20 to 79 years at diagnosis, and most trials controlled for age, parity, menstrual and menopausal history, duration of OCP exposure, and age at first use. Follow-up intervals for the retrospective cohort studies ranged from 5 to 16 years. Investigators were unable to combine results because of heterogenous populations.

Three of the cohort studies found no significant difference in breast cancer risk between OCP users and nonusers, regardless of age or duration of use. One cohort study found an increased risk in women taking older, higher-dose OCPs from before 1975 (relative risk [RR]=3.3; 95% confidence interval [CI], 1.5-7.2). All of the case-control studies found no significant difference in breast cancer risk for any age of starting, duration of OCP use, or degree of relative with breast cancer.

A meta-analysis of 54 case-control studies (6757 cases), comprising approximately 90% of the epidemiologic information on this topic, also found no significant difference in breast cancer risk related to OCP use among women with one or more first-degree relatives with breast cancer.² Investigators found that neither recent OCP use (<10 years, RR=0.77; 95% CI, 0.54-1.11) nor past OCP use (>10 years, RR=1.01; 95% CI, 0.80-1.28) affected risk of developing breast cancer.

Three additional case-control studies involving women with a family history of breast cancer also found no significant association for breast cancer incidence among OCP users compared with nonusers.^3-5

 

 

Modern combined OCPs don’t raise risk in women with BRCA1/2 mutations


A meta-analysis of 5 studies (one retrospective cohort, 4 case-control, with a total of 2855 breast cancer cases and 2944 controls) evaluated whether combined OCPs increased the risk of breast cancer in women, all of whom were carrying BRCA1/2 mutations.⁶

Using modern combined OCPs didn’t raise the risk of breast cancer in BRCA1/2 carriers overall (RR=1.13; 95% CI, 0.88-1.45) or separately in BRCA1 carriers (5 studies, RR=1.09; 95% CI, 0.77-1.54) or BRCA2 carriers (3 studies, RR=1.15; 95% CI, 0.88-1.45).

However, pre-1975 (higher dose) combined OCPs produced significantly increased risk (RR=1.47; 95% CI, 1.06-2.04). Similarly, women who had used combined OCPs >10 years before the study (older women, likely to have been using pre-1975 OCPs) also had significantly increased risk (RR=1.46; 95% CI, 1.07-2.07).

A bit of good news:
 Combined OCPs reduce ovarian cancer risk

The analysis also determined that combined OCPs significantly reduced the risk of ovarian cancer in women carrying BRCA1/2 mutations (RR=0.50; 95% CI, 0.33-0.75), with an additional linear decrease in risk for each 10 years of OCP use (RR=0.64; 95% CI, 0.53-0.78).

RECOMMENDATIONS

Combined oral contraceptive pills significantly reduced the risk of ovarian cancer in women carrying BRCA1/2 mutations. The World Health Organization guidelines outlining criteria for contraceptive use state that OCPs don’t alter the risk of breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes.⁷

The American College of Obstetricians and Gynecologists (ACOG) says that a positive family history of breast cancer shouldn’t be regarded as a contraindication to OCP use.⁸ ACOG also says that women with the BRCA1 mutation have an increased risk of breast cancer if they used OCPs for longer than 5 years before age 30, but this risk may be more than balanced by the benefit of a greatly reduced risk of ovarian cancer.

Click here to listen to excerpts of our interview with Dr. Williams

Click here to listen to excerpts of our interview with Dr. Williams

Click here to listen to excerpts of our interview with Dr. Williams