Editorial

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.

As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged tuned up and stable to return home. Days later, however, you may learn that your best‐laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of patient noncompliance, such readmissions are now being recognized as system failures and reflect a discharge process that has been described as random events connected to highly variable actions with only a remote possibility of meeting implied expectations (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement).

Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are.

In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field.13 Specifically, each of these articles further raises awareness that a patient's transition out of the hospital often unfolds quickly in a fast‐paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission's finding that inadequate communication is the leading cause of sentinel events.4 In this respect, communication is more than simply the transfer of information; rather, it involves the need to ensure comprehension and provide an opportunity to have a 2‐way dialogue. Importantly, these articles share a common approach in fostering our understanding of the perspective of patients and family caregivers with a particular focus on disadvantaged populations.

Kripalani and colleagues conducted a comprehensive review of the state of the science for those key hospital discharge issues that pertain to hospitalists. They identified a number of challenges including communication between hospital‐ and ambulatory‐based clinicians, medication reconciliation, timely hospital follow‐up, and engaging patients in self‐care. For each of these priority areas, the authors provide pragmatic recommendations for improving care that could be implemented within the current state of practice, either individually or as a bundle of interventions.

Recognizing that patients are often the only common thread across different sites of care, Strunin and colleagues demonstrate the value of including the voice of the patient in helping clinicians to understand the challenges and larger context in which they attempt to follow through with discharge instructions. Strunin et al. found that among a range of factors that contribute to adherence problems, many were nonmedical. Fortunately, a number of these are modifiable and point to the need to both prioritize recommendations to patients and to simplify them whenever possible. The authors' findings resonate with a growing literature that examines the hospital discharge process from the patient's perspective.510

Flacker and colleagues surveyed older patients to gain greater insights into their information needs at discharge. From a process standpoint, they demonstrated that a posthospital survey was feasible and acceptable to older patients. In and of itself, this finding has important implications in the context of national efforts aimed at implementing performance measurement and accompanying public reporting. It also may reflect patients' eagerness to be contacted after discharge; hospitalization is a major event in patients' lives, and attentive follow‐up is appreciated. The authors found that more than half of patients did not recall being asked about how they would care for themselves on returning home from the hospital. Although there may be a variety of explanations for this finding, it nevertheless points to an immediate area for intervention.

Collectively, these 3 articles set the stage for a proposed clinical investigation agenda aimed at optimizing transitions out of the hospital (see Table 1).

These 5 recommendations have the potential to ensure that the gains patients make in our hospitals are maintained long after discharge.

• 1

  Greater Recognition for the Integral Role of Family Caregivers. The patient and family caregivers should be integrated into health care professionals' efforts to improve care coordination across settings. Family caregivers have been silent partners in health care delivery, functioning as de facto care coordinators. During care handoffs, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences; their role needs to be formally recognized and supported. An important initial step would be standardizing the approach to defining the types and intensity of the roles family caregivers play to facilitate improved communication. One proposed working definition is the FACED classification developed by one of the authors (E.C.). Modeled after the TNM system used in cancer, each letter of FACED refers to a different contribution made by a family caregiver: F = Financial; A = Advocacy; C = Care coordination; E = Emotional support; and D = Direct care provision. A simple numeric rating system could be developed whereby 0 = does not contribute in this area and 3 = makes significant contribution to this area. Such a straightforward approach would readily inform all members of the health care team about the caregivers' roles and capabilities and how they can optimally collaborate in the care plan.

• 2

  Empirically Define Appropriate Follow‐Up Interval. At present, patients are given rather arbitrary and generic instructions for when to obtain follow‐up with their outpatient primary care physician or specialist. Surgical patients are often instructed to follow up with their surgeon, and yet most of the readmissions of these patients are attributable to medical conditions (personal communication, Steven Jencks, MD, Centers for Medicare and Medicaid Services). Furthermore, a significant number of discharged medical and surgical patients are readmitted to the hospital within 30 days without any outpatient contact with a health professional. One may envision an evidence‐based tiered approach whereby patients are assigned a hospital readmission risk score at the time of discharge that then determines the timing of their follow‐up appointment. Using this framework, the highest‐risk patients may be encouraged to receive follow‐up within 2472 hours, whereas lower‐risk patients may be able to wait 1421 days. Of course, there will need to be sufficient access to outpatient physicians, who will need to be available, to ensure the success of this strategy.

• 3

  Define Physician Accountability for Patients Referred to Home Health on Hospital Discharge. Communication problems between the hospital and the home health care agency are a source of aggravation for both parties, not to mention patients. Typically, a hospitalist provides the initial order for services and then expects subsequent home care coordination to be managed by an outpatient physician. Unfortunately, in some cases the patient may not have an outpatient physician or the patient's primary physician may be unaware of the recent hospitalization and thus unwilling to assume management of an unfamiliar care plan. As a result, home care nurses often cannot identify a physician to respond to their questions or concerns. At the center of this problem lies a lack of understanding of where the responsibility of the ordering hospitalist ends and the outpatient physician assuming care begins. Recognizing the profound costs of failed home health care leading to hospital readmission, the nation's Quality Improvement Organizations launched a national campaign in 2006 to address this problem. Hospitalists should engage in this effort and not punt the entire responsibility to home health agenciesimagine if hospitals and hospitalists were financially penalized if a patient was readmitted.

• 4

  Delineate the Role of the Hospitalist in the Advanced Medical Home. Modeled after a concept with origins in pediatrics, the American College of Physicians and American Academy of Family Physicians are promoting the advanced medical home as a new care model that aims to provide comprehensive ambulatory care with an explicit focus on care coordination.11 The Centers for Medicare and Medicaid Services is planning to initiate a demonstration of this approach. What has not been adequately underscored is how the advanced medical home will communicate essential clinical information with the hospitalist and what, if any, will be the role of the hospitalist in relation to a patient's medical home? Ideally, the medical home approach will alleviate many of the current access problems that impede timely follow‐up.

• 5

  Develop Ability to Examine Episodes of Care. Patients with complex conditions often require care from different practitioners in multiple settings. From the vantage point of health care professionals, these may appear to occur as merely a string of individual interactions, including hospital admissions and discharges. However from the patient's perspective, the experience is more appropriately characterized as a journey across an aggregated episode of care. The National Quality Forum is currently exploring how to measure quality of care delivered across such an episode of care. Additionally, the Centers for Medicare and Medicaid Services is developing a new assessment tool that will transcend acute and postacute care settings, the Continuity Assessment Record and Evaluation (CARE). This tool will potentially enhance our ability to measure care across a predefined episode. Measurement can further pave the way for payment reform designed to align incentives toward higher‐quality care transitions. Currently, professional fees for coronary artery bypass grafting surgery are bundled across an episode, including hospital and posthospital care settings. Extending this approach to a wider array of conditions and services could encourage new perspectives on the timing of discharge and the use of posthospital care venues. For example, under bundled payment, incentives might support a plan to keep a patient in the hospital an extra 1 or 2 days in order to obviate a transfer to a skilled nursing facility and the concomitant risks of transfer‐related problems. Further, bundled payment may allow for the provision of additional services not currently covered, including transportation, as identified by Strunin and colleagues.3

Hospitalists are well positioned to offer leadership in these high‐leverage areas and thereby make a unique contribution to the quality and safety of care transitions. By so doing, they are poised to reaffirm their professionalism,12 ensuring that the excellent care that they provide in the hospital is sustained well into the future.

My hospital's electronic medical record helpfully informs me after 1 week on service that there are 524 data available for my attention, a statistic that would be paralyzing without a cognitive framework for organizing and interpreting them in a manner that can be shared among my colleagues. Accurate information flow among clinicians was identified early on as an imperative of hospital medicine. Much attention has been focused on communication during transitions of care, such as that between inpatient and outpatient services and between inpatient teams, taking the form of the discharge summary and the sign‐out, respectively. But communication among physicians, consultants, and allied therapists must and inevitably does occur continuously day by day during even the most uneventful hospital stay. On academic services the need to keep multiple and ever‐rotating team members on the same page, so to speak, is particularly pressing.

The succinct and accurate problem list, formulated at the end of the history and physical examination and propagated through daily progress notes, is a powerful tool for promoting clear diagnostic and therapeutic planning and is ideally suited to meeting the need for continuous information flow among clinicians. Sadly, this inexpensive and potentially elegant device has fallen into disuse and disrepair and is in need of restoration.

In the 1960s, Dr. Lawrence Weed, the inventor of the SOAP note and a pioneer of medical informatics, wrote of the power of the problem list to impose order on the chaos of clinical information and to aid clear diagnostic thinking, in contrast with the simply chronological record popular in earlier years:

Weed proposed that the product of our diagnostic thinking and investigations should be a concise list of diagnoses, as precisely as we are able to identify them, or, in their absence, a clear understanding of the specific problems awaiting resolution and a clear appreciation of the interrelationships among these entities:

These principles were widely praised and adopted. An editorial in the New England Journal of Medicine proclaimed that his system is the essence of education itself,3 and it reigned throughout my own formal medical education.

In the decade that has seen our specialty flourish, with the attendant imperatives of clear thinking and communication, in teaching hospitals the problem list seems to have become an endangered species. The general pattern of its decline is that it is often supplanted by a list of organs, or worse, medical subspecialties, each followed by some assessment of its condition, whether diseased or not. The format resembles that used in critical care units for patients with multiple vital functions in jeopardy, on which survival depends from minute to minute, sometimes regardless of the original etiology of their failure. It is not clear how these notes began to spread from the ICU to the medical floor, where puzzles are solved and progress has goals more varied than mere survival. None of the residents I have queried over the years seem to know. The prevalence of this habit is also unknown, but it is widespread at both institutions at which I have been recently affiliated, and from the generation of notes in this format by trainees freshly graduated from medical schools across the land, I infer that it is no mere regional phenomenon. There may be an unspoken assumption that if this format is used for the sickest patients, it must be the superior format to use for all patients. Perhaps it reflects subspecialists teaching inpatient medicine, equipping trainees with vast technical knowledge of specific diseases and placing less emphasis on formulating coherent assessments. I believe its effects are pernicious and far‐reaching, affecting not only the quality of information flow among clinicians, but also the quality and rigor of diagnostic thinking of those in our training programs.

The history and physical examination properly culminate in the formulation of a problem list that establishes the framework for subsequent investigations and therapy. For each problem a narrative thread is initiated that can be followed in progress notes to resolution and succinctly reviewed in the discharge summary. It is now common to see diagnostic formulations arranged not by problem but by organ or subspecialty, for example, Endocrine: DKA. As everyone understands DKA to be an endocrine problem, the organ system preface adds nothing useful and only serves to bury the diagnosis in text. More tortured prose follows attempts to cram into the header all organs or specialties touched by the problem; hence pneumonia is often preceded by pulmonary/ID. A more egregious recent example was an esophageal variceal hemorrhage designated GI/Heme. And efforts to force an undifferentiated problem into an organ group can reach absurdity: Heme: Asymmetric leg swelling raised concern for DVT, but ultrasound was negative.

The organ preface at best merely adds clutter; the difficulty is compounded when the actual diagnosis or problem is omitted entirely in favor of mention of the organs, for example, for pneumonia: Pulm/ID: begin antibiotics. The reader may be left to guess exactly what is being treated, as with CV: begin heparin and beta‐blocker. The assessment and subsequent notes become even more unwieldy when the unifying diagnosis is approached circuitously on paper by way of its component elements, as with a recent patient with typical lobar pneumonia who was assessed by the house officer as having (1) ID: fever probably due to pneumonia; (2) Pulm: Hypoxia, sputum production and infiltrate on CXR consistent with pneumonia; and (3) Heme: leukocytosis likely due to pneumonia as well. Synthesis, the holy grail of the H&P, is thus replaced by analysis. Each tree is closely inspected, but we are lost in the forest. Weed wrote of such notes:

Often, however, as in the example above, the physician fully understands the unifying diagnosis but nonetheless insists on addressing involved systems separately. Each feature is then apt to be separately followed in isolation through the progress notes, sometimes without any further mention of pneumonia as such. Many progress notes thus omit stating what is actually thought to be wrong with the patient.

The failure to commit to a diagnosis on paper, even when having done so in practice, ultimately can make its way to the discharge summary, propagating confusion to the outpatient department and ricocheting it into future admissions. It also robs us of the satisfaction of declaring a puzzle solved. I was compelled to write this piece in part by the recent case of a young woman who presented with fever and dyspnea. Through an elegant series of imaging studies and serologic tests, a diagnosis of lupus pericarditis was established, and steroid therapy produced dramatic remission of her symptomsa diagnostic triumph by any measure. How disheartening then to read the resident's final diagnosis for posterity in the discharge summary: fever and dyspnea.

The disembodied organ list thus sows confusion and redundant, convoluted prose throughout the medical record. Perhaps even more destructive is its effect on diagnostic thinking when applied to undifferentiated symptoms or problems, the general internist's pice de rsistance. Language shapes thought, and premature assignment of symptoms to a single organ or subspecialty constrains the imagination needed to puzzle things out. Examples are everywhere. Fever of unknown origin may be peremptorily designated ID, by implication excluding inflammatory, neoplastic, and iatrogenic causes from consideration. The asymmetrically swollen legs cited earlier are not hematologic, but they are still swollen. Undiagnosed problems should be labeled as such, with comment as to the differential diagnosis as it stands at the time and the status of the investigation. When a diagnosis is established, it should replace the undifferentiated symptom or abnormal finding in the list, with cardinal manifestations addressed as such when necessary. Thus, for example, fever in an intravenous drug user becomes endocarditis, and anasarca becomes nephrotic syndrome becomes glomerulonephritis as the diagnosis is established and refined. Weed saw the promise of the well‐groomed, problem‐based record in teaching diagnostic thinking:

Hospitalists as generalist clinician‐educators have an opportunity to teach fundamental principles of medicine that span subspecialties. These principles must include clear organization and prioritization of complex medical information to enable coherent diagnostic and therapeutic planning and smooth continuity of care. The sign‐out and the all‐important discharge summary can be only as clear and as logical as the diagnoses that inform them. To these ends, let us maintain and reinvigorate the art of the problem list. As an exercise at morning report and attending rounds, we should emphasize the development of an accurate, comprehensive list of active problems before moving on to detailed discussion of any single issue, as Weed suggested nearly 40 years ago:

We should expect this list to be formulated at the end of the admission history and physical examination. We must ensure that trainees can correctly identify the level of resolution achieved for each item. They must learn to distinguish among undifferentiated symptoms, for example, passed out; undifferentiated problems, expressed by medical terms with precise meaning, such as syncope; and precise etiologic diagnoses, such as ventricular tachycardia. Daily progress notes and sign‐out documents must reflect the progressive refinement in classification of each item and give the current status of the diagnostic evaluation. When therapy has been established, daily notes must reflect its precise status relative to its end points; examples include place in the timeline for antibiotics or, for a bleeding patient, a tally of blood products and their impact. In the end, we must ensure that the discharge summary reflects the highest level of diagnostic resolution achieved for each problem we have identified. In so doing, we will help to ensure coherent and efficient care for our patients, save time and spare confusion for our colleagues, and teach our trainees to think and communicate clearly about our collective efforts.

My hospital's electronic medical record helpfully informs me after 1 week on service that there are 524 data available for my attention, a statistic that would be paralyzing without a cognitive framework for organizing and interpreting them in a manner that can be shared among my colleagues. Accurate information flow among clinicians was identified early on as an imperative of hospital medicine. Much attention has been focused on communication during transitions of care, such as that between inpatient and outpatient services and between inpatient teams, taking the form of the discharge summary and the sign‐out, respectively. But communication among physicians, consultants, and allied therapists must and inevitably does occur continuously day by day during even the most uneventful hospital stay. On academic services the need to keep multiple and ever‐rotating team members on the same page, so to speak, is particularly pressing.

The succinct and accurate problem list, formulated at the end of the history and physical examination and propagated through daily progress notes, is a powerful tool for promoting clear diagnostic and therapeutic planning and is ideally suited to meeting the need for continuous information flow among clinicians. Sadly, this inexpensive and potentially elegant device has fallen into disuse and disrepair and is in need of restoration.

In the 1960s, Dr. Lawrence Weed, the inventor of the SOAP note and a pioneer of medical informatics, wrote of the power of the problem list to impose order on the chaos of clinical information and to aid clear diagnostic thinking, in contrast with the simply chronological record popular in earlier years:

Weed proposed that the product of our diagnostic thinking and investigations should be a concise list of diagnoses, as precisely as we are able to identify them, or, in their absence, a clear understanding of the specific problems awaiting resolution and a clear appreciation of the interrelationships among these entities:

These principles were widely praised and adopted. An editorial in the New England Journal of Medicine proclaimed that his system is the essence of education itself,3 and it reigned throughout my own formal medical education.

In the decade that has seen our specialty flourish, with the attendant imperatives of clear thinking and communication, in teaching hospitals the problem list seems to have become an endangered species. The general pattern of its decline is that it is often supplanted by a list of organs, or worse, medical subspecialties, each followed by some assessment of its condition, whether diseased or not. The format resembles that used in critical care units for patients with multiple vital functions in jeopardy, on which survival depends from minute to minute, sometimes regardless of the original etiology of their failure. It is not clear how these notes began to spread from the ICU to the medical floor, where puzzles are solved and progress has goals more varied than mere survival. None of the residents I have queried over the years seem to know. The prevalence of this habit is also unknown, but it is widespread at both institutions at which I have been recently affiliated, and from the generation of notes in this format by trainees freshly graduated from medical schools across the land, I infer that it is no mere regional phenomenon. There may be an unspoken assumption that if this format is used for the sickest patients, it must be the superior format to use for all patients. Perhaps it reflects subspecialists teaching inpatient medicine, equipping trainees with vast technical knowledge of specific diseases and placing less emphasis on formulating coherent assessments. I believe its effects are pernicious and far‐reaching, affecting not only the quality of information flow among clinicians, but also the quality and rigor of diagnostic thinking of those in our training programs.

The history and physical examination properly culminate in the formulation of a problem list that establishes the framework for subsequent investigations and therapy. For each problem a narrative thread is initiated that can be followed in progress notes to resolution and succinctly reviewed in the discharge summary. It is now common to see diagnostic formulations arranged not by problem but by organ or subspecialty, for example, Endocrine: DKA. As everyone understands DKA to be an endocrine problem, the organ system preface adds nothing useful and only serves to bury the diagnosis in text. More tortured prose follows attempts to cram into the header all organs or specialties touched by the problem; hence pneumonia is often preceded by pulmonary/ID. A more egregious recent example was an esophageal variceal hemorrhage designated GI/Heme. And efforts to force an undifferentiated problem into an organ group can reach absurdity: Heme: Asymmetric leg swelling raised concern for DVT, but ultrasound was negative.

The organ preface at best merely adds clutter; the difficulty is compounded when the actual diagnosis or problem is omitted entirely in favor of mention of the organs, for example, for pneumonia: Pulm/ID: begin antibiotics. The reader may be left to guess exactly what is being treated, as with CV: begin heparin and beta‐blocker. The assessment and subsequent notes become even more unwieldy when the unifying diagnosis is approached circuitously on paper by way of its component elements, as with a recent patient with typical lobar pneumonia who was assessed by the house officer as having (1) ID: fever probably due to pneumonia; (2) Pulm: Hypoxia, sputum production and infiltrate on CXR consistent with pneumonia; and (3) Heme: leukocytosis likely due to pneumonia as well. Synthesis, the holy grail of the H&P, is thus replaced by analysis. Each tree is closely inspected, but we are lost in the forest. Weed wrote of such notes:

Often, however, as in the example above, the physician fully understands the unifying diagnosis but nonetheless insists on addressing involved systems separately. Each feature is then apt to be separately followed in isolation through the progress notes, sometimes without any further mention of pneumonia as such. Many progress notes thus omit stating what is actually thought to be wrong with the patient.

The failure to commit to a diagnosis on paper, even when having done so in practice, ultimately can make its way to the discharge summary, propagating confusion to the outpatient department and ricocheting it into future admissions. It also robs us of the satisfaction of declaring a puzzle solved. I was compelled to write this piece in part by the recent case of a young woman who presented with fever and dyspnea. Through an elegant series of imaging studies and serologic tests, a diagnosis of lupus pericarditis was established, and steroid therapy produced dramatic remission of her symptomsa diagnostic triumph by any measure. How disheartening then to read the resident's final diagnosis for posterity in the discharge summary: fever and dyspnea.

The disembodied organ list thus sows confusion and redundant, convoluted prose throughout the medical record. Perhaps even more destructive is its effect on diagnostic thinking when applied to undifferentiated symptoms or problems, the general internist's pice de rsistance. Language shapes thought, and premature assignment of symptoms to a single organ or subspecialty constrains the imagination needed to puzzle things out. Examples are everywhere. Fever of unknown origin may be peremptorily designated ID, by implication excluding inflammatory, neoplastic, and iatrogenic causes from consideration. The asymmetrically swollen legs cited earlier are not hematologic, but they are still swollen. Undiagnosed problems should be labeled as such, with comment as to the differential diagnosis as it stands at the time and the status of the investigation. When a diagnosis is established, it should replace the undifferentiated symptom or abnormal finding in the list, with cardinal manifestations addressed as such when necessary. Thus, for example, fever in an intravenous drug user becomes endocarditis, and anasarca becomes nephrotic syndrome becomes glomerulonephritis as the diagnosis is established and refined. Weed saw the promise of the well‐groomed, problem‐based record in teaching diagnostic thinking:

Hospitalists as generalist clinician‐educators have an opportunity to teach fundamental principles of medicine that span subspecialties. These principles must include clear organization and prioritization of complex medical information to enable coherent diagnostic and therapeutic planning and smooth continuity of care. The sign‐out and the all‐important discharge summary can be only as clear and as logical as the diagnoses that inform them. To these ends, let us maintain and reinvigorate the art of the problem list. As an exercise at morning report and attending rounds, we should emphasize the development of an accurate, comprehensive list of active problems before moving on to detailed discussion of any single issue, as Weed suggested nearly 40 years ago:

We should expect this list to be formulated at the end of the admission history and physical examination. We must ensure that trainees can correctly identify the level of resolution achieved for each item. They must learn to distinguish among undifferentiated symptoms, for example, passed out; undifferentiated problems, expressed by medical terms with precise meaning, such as syncope; and precise etiologic diagnoses, such as ventricular tachycardia. Daily progress notes and sign‐out documents must reflect the progressive refinement in classification of each item and give the current status of the diagnostic evaluation. When therapy has been established, daily notes must reflect its precise status relative to its end points; examples include place in the timeline for antibiotics or, for a bleeding patient, a tally of blood products and their impact. In the end, we must ensure that the discharge summary reflects the highest level of diagnostic resolution achieved for each problem we have identified. In so doing, we will help to ensure coherent and efficient care for our patients, save time and spare confusion for our colleagues, and teach our trainees to think and communicate clearly about our collective efforts.

My hospital's electronic medical record helpfully informs me after 1 week on service that there are 524 data available for my attention, a statistic that would be paralyzing without a cognitive framework for organizing and interpreting them in a manner that can be shared among my colleagues. Accurate information flow among clinicians was identified early on as an imperative of hospital medicine. Much attention has been focused on communication during transitions of care, such as that between inpatient and outpatient services and between inpatient teams, taking the form of the discharge summary and the sign‐out, respectively. But communication among physicians, consultants, and allied therapists must and inevitably does occur continuously day by day during even the most uneventful hospital stay. On academic services the need to keep multiple and ever‐rotating team members on the same page, so to speak, is particularly pressing.

The succinct and accurate problem list, formulated at the end of the history and physical examination and propagated through daily progress notes, is a powerful tool for promoting clear diagnostic and therapeutic planning and is ideally suited to meeting the need for continuous information flow among clinicians. Sadly, this inexpensive and potentially elegant device has fallen into disuse and disrepair and is in need of restoration.

In the 1960s, Dr. Lawrence Weed, the inventor of the SOAP note and a pioneer of medical informatics, wrote of the power of the problem list to impose order on the chaos of clinical information and to aid clear diagnostic thinking, in contrast with the simply chronological record popular in earlier years:

Weed proposed that the product of our diagnostic thinking and investigations should be a concise list of diagnoses, as precisely as we are able to identify them, or, in their absence, a clear understanding of the specific problems awaiting resolution and a clear appreciation of the interrelationships among these entities:

These principles were widely praised and adopted. An editorial in the New England Journal of Medicine proclaimed that his system is the essence of education itself,3 and it reigned throughout my own formal medical education.

In the decade that has seen our specialty flourish, with the attendant imperatives of clear thinking and communication, in teaching hospitals the problem list seems to have become an endangered species. The general pattern of its decline is that it is often supplanted by a list of organs, or worse, medical subspecialties, each followed by some assessment of its condition, whether diseased or not. The format resembles that used in critical care units for patients with multiple vital functions in jeopardy, on which survival depends from minute to minute, sometimes regardless of the original etiology of their failure. It is not clear how these notes began to spread from the ICU to the medical floor, where puzzles are solved and progress has goals more varied than mere survival. None of the residents I have queried over the years seem to know. The prevalence of this habit is also unknown, but it is widespread at both institutions at which I have been recently affiliated, and from the generation of notes in this format by trainees freshly graduated from medical schools across the land, I infer that it is no mere regional phenomenon. There may be an unspoken assumption that if this format is used for the sickest patients, it must be the superior format to use for all patients. Perhaps it reflects subspecialists teaching inpatient medicine, equipping trainees with vast technical knowledge of specific diseases and placing less emphasis on formulating coherent assessments. I believe its effects are pernicious and far‐reaching, affecting not only the quality of information flow among clinicians, but also the quality and rigor of diagnostic thinking of those in our training programs.

The history and physical examination properly culminate in the formulation of a problem list that establishes the framework for subsequent investigations and therapy. For each problem a narrative thread is initiated that can be followed in progress notes to resolution and succinctly reviewed in the discharge summary. It is now common to see diagnostic formulations arranged not by problem but by organ or subspecialty, for example, Endocrine: DKA. As everyone understands DKA to be an endocrine problem, the organ system preface adds nothing useful and only serves to bury the diagnosis in text. More tortured prose follows attempts to cram into the header all organs or specialties touched by the problem; hence pneumonia is often preceded by pulmonary/ID. A more egregious recent example was an esophageal variceal hemorrhage designated GI/Heme. And efforts to force an undifferentiated problem into an organ group can reach absurdity: Heme: Asymmetric leg swelling raised concern for DVT, but ultrasound was negative.

The organ preface at best merely adds clutter; the difficulty is compounded when the actual diagnosis or problem is omitted entirely in favor of mention of the organs, for example, for pneumonia: Pulm/ID: begin antibiotics. The reader may be left to guess exactly what is being treated, as with CV: begin heparin and beta‐blocker. The assessment and subsequent notes become even more unwieldy when the unifying diagnosis is approached circuitously on paper by way of its component elements, as with a recent patient with typical lobar pneumonia who was assessed by the house officer as having (1) ID: fever probably due to pneumonia; (2) Pulm: Hypoxia, sputum production and infiltrate on CXR consistent with pneumonia; and (3) Heme: leukocytosis likely due to pneumonia as well. Synthesis, the holy grail of the H&P, is thus replaced by analysis. Each tree is closely inspected, but we are lost in the forest. Weed wrote of such notes:

Often, however, as in the example above, the physician fully understands the unifying diagnosis but nonetheless insists on addressing involved systems separately. Each feature is then apt to be separately followed in isolation through the progress notes, sometimes without any further mention of pneumonia as such. Many progress notes thus omit stating what is actually thought to be wrong with the patient.

The failure to commit to a diagnosis on paper, even when having done so in practice, ultimately can make its way to the discharge summary, propagating confusion to the outpatient department and ricocheting it into future admissions. It also robs us of the satisfaction of declaring a puzzle solved. I was compelled to write this piece in part by the recent case of a young woman who presented with fever and dyspnea. Through an elegant series of imaging studies and serologic tests, a diagnosis of lupus pericarditis was established, and steroid therapy produced dramatic remission of her symptomsa diagnostic triumph by any measure. How disheartening then to read the resident's final diagnosis for posterity in the discharge summary: fever and dyspnea.

The disembodied organ list thus sows confusion and redundant, convoluted prose throughout the medical record. Perhaps even more destructive is its effect on diagnostic thinking when applied to undifferentiated symptoms or problems, the general internist's pice de rsistance. Language shapes thought, and premature assignment of symptoms to a single organ or subspecialty constrains the imagination needed to puzzle things out. Examples are everywhere. Fever of unknown origin may be peremptorily designated ID, by implication excluding inflammatory, neoplastic, and iatrogenic causes from consideration. The asymmetrically swollen legs cited earlier are not hematologic, but they are still swollen. Undiagnosed problems should be labeled as such, with comment as to the differential diagnosis as it stands at the time and the status of the investigation. When a diagnosis is established, it should replace the undifferentiated symptom or abnormal finding in the list, with cardinal manifestations addressed as such when necessary. Thus, for example, fever in an intravenous drug user becomes endocarditis, and anasarca becomes nephrotic syndrome becomes glomerulonephritis as the diagnosis is established and refined. Weed saw the promise of the well‐groomed, problem‐based record in teaching diagnostic thinking:

Hospitalists as generalist clinician‐educators have an opportunity to teach fundamental principles of medicine that span subspecialties. These principles must include clear organization and prioritization of complex medical information to enable coherent diagnostic and therapeutic planning and smooth continuity of care. The sign‐out and the all‐important discharge summary can be only as clear and as logical as the diagnoses that inform them. To these ends, let us maintain and reinvigorate the art of the problem list. As an exercise at morning report and attending rounds, we should emphasize the development of an accurate, comprehensive list of active problems before moving on to detailed discussion of any single issue, as Weed suggested nearly 40 years ago:

We should expect this list to be formulated at the end of the admission history and physical examination. We must ensure that trainees can correctly identify the level of resolution achieved for each item. They must learn to distinguish among undifferentiated symptoms, for example, passed out; undifferentiated problems, expressed by medical terms with precise meaning, such as syncope; and precise etiologic diagnoses, such as ventricular tachycardia. Daily progress notes and sign‐out documents must reflect the progressive refinement in classification of each item and give the current status of the diagnostic evaluation. When therapy has been established, daily notes must reflect its precise status relative to its end points; examples include place in the timeline for antibiotics or, for a bleeding patient, a tally of blood products and their impact. In the end, we must ensure that the discharge summary reflects the highest level of diagnostic resolution achieved for each problem we have identified. In so doing, we will help to ensure coherent and efficient care for our patients, save time and spare confusion for our colleagues, and teach our trainees to think and communicate clearly about our collective efforts.

When I was four years old, Grandpa always cut off the crust of the bread before I ate my peanut butter and jelly sandwich.

When I was seven years old, Grandpa took me to the circus and bought me cotton candy. He didn't care when I got the sticky stuff all over my face and dress.

When I was nine years old, Grandpa took me out on my birthday for a chocolate ice cream cone with rainbow sprinkles on top.

I didn't know he had high blood pressure. And neither did he.

He made me laugh. He made me feel so good deep down inside.

At age eleven I returned home from school to find Grandpa had been taken to the hospital with a stroke.

I cut the crust off his bread, got him cotton candy and an ice cream cone so he would feel better.

I went with Mommy to see him. She was stopped at the nurses' station. They wanted to talk to her.

I broke away and ran down the hall to his room. His bed was empty. Grandpa had died. No one told me.

Grandpa never got to eat the peanut butter and jelly sandwich with the crust cut off.

Maybe if he had, things would have turned out differently.

When I was four years old, Grandpa always cut off the crust of the bread before I ate my peanut butter and jelly sandwich.

When I was seven years old, Grandpa took me to the circus and bought me cotton candy. He didn't care when I got the sticky stuff all over my face and dress.

When I was nine years old, Grandpa took me out on my birthday for a chocolate ice cream cone with rainbow sprinkles on top.

I didn't know he had high blood pressure. And neither did he.

He made me laugh. He made me feel so good deep down inside.

At age eleven I returned home from school to find Grandpa had been taken to the hospital with a stroke.

I cut the crust off his bread, got him cotton candy and an ice cream cone so he would feel better.

I went with Mommy to see him. She was stopped at the nurses' station. They wanted to talk to her.

I broke away and ran down the hall to his room. His bed was empty. Grandpa had died. No one told me.

Grandpa never got to eat the peanut butter and jelly sandwich with the crust cut off.

Maybe if he had, things would have turned out differently.

When I was four years old, Grandpa always cut off the crust of the bread before I ate my peanut butter and jelly sandwich.

When I was seven years old, Grandpa took me to the circus and bought me cotton candy. He didn't care when I got the sticky stuff all over my face and dress.

When I was nine years old, Grandpa took me out on my birthday for a chocolate ice cream cone with rainbow sprinkles on top.

I didn't know he had high blood pressure. And neither did he.

He made me laugh. He made me feel so good deep down inside.

At age eleven I returned home from school to find Grandpa had been taken to the hospital with a stroke.

I cut the crust off his bread, got him cotton candy and an ice cream cone so he would feel better.

I went with Mommy to see him. She was stopped at the nurses' station. They wanted to talk to her.

I broke away and ran down the hall to his room. His bed was empty. Grandpa had died. No one told me.

Grandpa never got to eat the peanut butter and jelly sandwich with the crust cut off.

Maybe if he had, things would have turned out differently.

Founded in 1997 by 2 community‐based hospitalists, Win Whitcomb and John Nelson, the National Association of Inpatient Physicians was renamed the Society of Hospital Medicine in 2003 and celebrates its 10th anniversary this year. Evolving from the enthusiastic engagement by the attendees at the first hospital medicine CME meeting in the spring of 1997,1 this new organization has grown into a robust voice for improving the care of hospitalized patients. The Society has actively attempted to represent a big tent welcoming participation from everyone involved in hospital care. The name change to the Society of Hospital Medicine (SHM) reflected the recognition that a team is needed to achieve the goal of optimizing care of the hospitalized patient. Merriam‐Webster defines society as companionship or association with one's fellows and a voluntary association of individuals for common ends; especially an organized group working together or periodically meeting because of common interests, beliefs, or profession.2 The hospital medicine team working together includes nurses, pharmacists, case managers, social workers, physicians, and administrators in addition to dieticians, respiratory therapists, and physical and occupational therapists. With a focus on patient‐centered care and quality improvement, SHM eagerly anticipates future changes in health care, seeking to help its membership adapt to and manage the expected change.

As an integral component of the hospital care delivery team, physicians represent the bulk of membership in SHM. Thus, development of hospital medicine as a medical specialty has concerned many of its members. Fortunately, progress is being made, and Bob Wachter is chairing a task force on this for the American Board of Internal Medicine.3 Certainly, content in the field is growing exponentially, with textbooks (including possibly 3 separate general references for adult and pediatric hospital medicine), multiple printed periodicals, and this successful peer‐reviewed journal listed in MEDLINE and PubMed. In addition, most academic medical centers now have thriving groups of hospitalists, and many are establishing or plan separate divisions within their respective departments of medicine (eg, Northwestern, UCSan Francisco, UCSan Diego, Duke, Mayo Clinic). These events confirm how hospital medicine has progressed to become a true specialty of medicine and justify the publication of its own set of core competencies.4 We believe some form of certification is inevitable. This will be supported by development of residency tracks and fellowships in hospital medicine.5

Most remarkable about the Society of Hospital Medicine has been its ability to collaborate with multiple medical societies, governmental agencies, foundations, and organizations seeking to improve care for hospitalized patients (see Table 1). These relationships represent the teamwork approach that hospitalists take into their hospitals on a daily basis. We hope to build on these collaborations and work toward more interactive efforts to identify optimal delivery of health care in the hospital setting, while also reaching out to ambulatory‐based providers to ensure smooth transitions of care. Such efforts will require innovative approaches to educating SHM members and altering the standard approach to continuing medical education (CME). Investment in the concept of hospitalists by the John A. Hartford Foundation with a $1.4 million grant to improve the discharge process (Improving Hospital Care Transitions for Older Adults) exemplifies SHM's commitment to collaboration, with more than 10 organizations participating on the advisory board.

As SHM and its growing membership, which now exceeds 6500, stride into the future, we embrace advances in educational approaches to enhancing health care delivery and expect to play a leadership role in applying them. Increasingly, use of pay‐for‐performance (P4P) will attempt to align payment incentives to promote better quality care by rewarding providers that perform well.6 SHM aims to train hospitalists through use of knowledge translation which combines the right educational tools with involvement of the entire health care team, yielding truly effective CME.7 A reinvention of CME that links it to care delivery and improving performance, it is supported by governmental health care leaders.8 This approach moves CME to where hospitalists deliver care, targets all participants (patients, nurses, pharmacists, and doctors), and has content based around initiatives to improve health care.

Such a quality improvement model would take advantage of SHM's Quality Improvement Resource Rooms (hospitalmedicine.org), marking an important shift toward translating evidence into practice. SHM will also continue with its efforts to lead in nonclinical training, as exemplified by its popular biannual leadership training courses. We expect this will expand to provide much‐needed QI training in the future.

In its first 10 years SHM has accomplished much already, but the best days for hospital medicine lie ahead of us. There will be more than 30,000 hospitalists practicing at virtually every hospital in the United States, with high expectations for teams of health professionals providing patient‐centered care with documented quality standards. SHM is poised to work with all our partner organizations to do our part to create the hospital of the future. Our patients are counting on all of us.

Founded in 1997 by 2 community‐based hospitalists, Win Whitcomb and John Nelson, the National Association of Inpatient Physicians was renamed the Society of Hospital Medicine in 2003 and celebrates its 10th anniversary this year. Evolving from the enthusiastic engagement by the attendees at the first hospital medicine CME meeting in the spring of 1997,1 this new organization has grown into a robust voice for improving the care of hospitalized patients. The Society has actively attempted to represent a big tent welcoming participation from everyone involved in hospital care. The name change to the Society of Hospital Medicine (SHM) reflected the recognition that a team is needed to achieve the goal of optimizing care of the hospitalized patient. Merriam‐Webster defines society as companionship or association with one's fellows and a voluntary association of individuals for common ends; especially an organized group working together or periodically meeting because of common interests, beliefs, or profession.2 The hospital medicine team working together includes nurses, pharmacists, case managers, social workers, physicians, and administrators in addition to dieticians, respiratory therapists, and physical and occupational therapists. With a focus on patient‐centered care and quality improvement, SHM eagerly anticipates future changes in health care, seeking to help its membership adapt to and manage the expected change.

As an integral component of the hospital care delivery team, physicians represent the bulk of membership in SHM. Thus, development of hospital medicine as a medical specialty has concerned many of its members. Fortunately, progress is being made, and Bob Wachter is chairing a task force on this for the American Board of Internal Medicine.3 Certainly, content in the field is growing exponentially, with textbooks (including possibly 3 separate general references for adult and pediatric hospital medicine), multiple printed periodicals, and this successful peer‐reviewed journal listed in MEDLINE and PubMed. In addition, most academic medical centers now have thriving groups of hospitalists, and many are establishing or plan separate divisions within their respective departments of medicine (eg, Northwestern, UCSan Francisco, UCSan Diego, Duke, Mayo Clinic). These events confirm how hospital medicine has progressed to become a true specialty of medicine and justify the publication of its own set of core competencies.4 We believe some form of certification is inevitable. This will be supported by development of residency tracks and fellowships in hospital medicine.5

Most remarkable about the Society of Hospital Medicine has been its ability to collaborate with multiple medical societies, governmental agencies, foundations, and organizations seeking to improve care for hospitalized patients (see Table 1). These relationships represent the teamwork approach that hospitalists take into their hospitals on a daily basis. We hope to build on these collaborations and work toward more interactive efforts to identify optimal delivery of health care in the hospital setting, while also reaching out to ambulatory‐based providers to ensure smooth transitions of care. Such efforts will require innovative approaches to educating SHM members and altering the standard approach to continuing medical education (CME). Investment in the concept of hospitalists by the John A. Hartford Foundation with a $1.4 million grant to improve the discharge process (Improving Hospital Care Transitions for Older Adults) exemplifies SHM's commitment to collaboration, with more than 10 organizations participating on the advisory board.

As SHM and its growing membership, which now exceeds 6500, stride into the future, we embrace advances in educational approaches to enhancing health care delivery and expect to play a leadership role in applying them. Increasingly, use of pay‐for‐performance (P4P) will attempt to align payment incentives to promote better quality care by rewarding providers that perform well.6 SHM aims to train hospitalists through use of knowledge translation which combines the right educational tools with involvement of the entire health care team, yielding truly effective CME.7 A reinvention of CME that links it to care delivery and improving performance, it is supported by governmental health care leaders.8 This approach moves CME to where hospitalists deliver care, targets all participants (patients, nurses, pharmacists, and doctors), and has content based around initiatives to improve health care.

Such a quality improvement model would take advantage of SHM's Quality Improvement Resource Rooms (hospitalmedicine.org), marking an important shift toward translating evidence into practice. SHM will also continue with its efforts to lead in nonclinical training, as exemplified by its popular biannual leadership training courses. We expect this will expand to provide much‐needed QI training in the future.

In its first 10 years SHM has accomplished much already, but the best days for hospital medicine lie ahead of us. There will be more than 30,000 hospitalists practicing at virtually every hospital in the United States, with high expectations for teams of health professionals providing patient‐centered care with documented quality standards. SHM is poised to work with all our partner organizations to do our part to create the hospital of the future. Our patients are counting on all of us.

Founded in 1997 by 2 community‐based hospitalists, Win Whitcomb and John Nelson, the National Association of Inpatient Physicians was renamed the Society of Hospital Medicine in 2003 and celebrates its 10th anniversary this year. Evolving from the enthusiastic engagement by the attendees at the first hospital medicine CME meeting in the spring of 1997,1 this new organization has grown into a robust voice for improving the care of hospitalized patients. The Society has actively attempted to represent a big tent welcoming participation from everyone involved in hospital care. The name change to the Society of Hospital Medicine (SHM) reflected the recognition that a team is needed to achieve the goal of optimizing care of the hospitalized patient. Merriam‐Webster defines society as companionship or association with one's fellows and a voluntary association of individuals for common ends; especially an organized group working together or periodically meeting because of common interests, beliefs, or profession.2 The hospital medicine team working together includes nurses, pharmacists, case managers, social workers, physicians, and administrators in addition to dieticians, respiratory therapists, and physical and occupational therapists. With a focus on patient‐centered care and quality improvement, SHM eagerly anticipates future changes in health care, seeking to help its membership adapt to and manage the expected change.

As an integral component of the hospital care delivery team, physicians represent the bulk of membership in SHM. Thus, development of hospital medicine as a medical specialty has concerned many of its members. Fortunately, progress is being made, and Bob Wachter is chairing a task force on this for the American Board of Internal Medicine.3 Certainly, content in the field is growing exponentially, with textbooks (including possibly 3 separate general references for adult and pediatric hospital medicine), multiple printed periodicals, and this successful peer‐reviewed journal listed in MEDLINE and PubMed. In addition, most academic medical centers now have thriving groups of hospitalists, and many are establishing or plan separate divisions within their respective departments of medicine (eg, Northwestern, UCSan Francisco, UCSan Diego, Duke, Mayo Clinic). These events confirm how hospital medicine has progressed to become a true specialty of medicine and justify the publication of its own set of core competencies.4 We believe some form of certification is inevitable. This will be supported by development of residency tracks and fellowships in hospital medicine.5

Most remarkable about the Society of Hospital Medicine has been its ability to collaborate with multiple medical societies, governmental agencies, foundations, and organizations seeking to improve care for hospitalized patients (see Table 1). These relationships represent the teamwork approach that hospitalists take into their hospitals on a daily basis. We hope to build on these collaborations and work toward more interactive efforts to identify optimal delivery of health care in the hospital setting, while also reaching out to ambulatory‐based providers to ensure smooth transitions of care. Such efforts will require innovative approaches to educating SHM members and altering the standard approach to continuing medical education (CME). Investment in the concept of hospitalists by the John A. Hartford Foundation with a $1.4 million grant to improve the discharge process (Improving Hospital Care Transitions for Older Adults) exemplifies SHM's commitment to collaboration, with more than 10 organizations participating on the advisory board.

As SHM and its growing membership, which now exceeds 6500, stride into the future, we embrace advances in educational approaches to enhancing health care delivery and expect to play a leadership role in applying them. Increasingly, use of pay‐for‐performance (P4P) will attempt to align payment incentives to promote better quality care by rewarding providers that perform well.6 SHM aims to train hospitalists through use of knowledge translation which combines the right educational tools with involvement of the entire health care team, yielding truly effective CME.7 A reinvention of CME that links it to care delivery and improving performance, it is supported by governmental health care leaders.8 This approach moves CME to where hospitalists deliver care, targets all participants (patients, nurses, pharmacists, and doctors), and has content based around initiatives to improve health care.

Such a quality improvement model would take advantage of SHM's Quality Improvement Resource Rooms (hospitalmedicine.org), marking an important shift toward translating evidence into practice. SHM will also continue with its efforts to lead in nonclinical training, as exemplified by its popular biannual leadership training courses. We expect this will expand to provide much‐needed QI training in the future.

In its first 10 years SHM has accomplished much already, but the best days for hospital medicine lie ahead of us. There will be more than 30,000 hospitalists practicing at virtually every hospital in the United States, with high expectations for teams of health professionals providing patient‐centered care with documented quality standards. SHM is poised to work with all our partner organizations to do our part to create the hospital of the future. Our patients are counting on all of us.

Why measure hospital quality? One popular premise is that measurement and transparency will inform consumer decision making and drive volume to high‐quality programs, providing incentives for improvement and raising the bar nationally. In this issue of the Journal of Hospital Medicine, Halasyamani and Davis report that there is relatively poor correlation between the Hospital Compare scores of the Centers for Medicare and Medicaid Services (CMS) and U.S. News and World Report's Best Hospitals rankings.1 The authors note that this is not necessarily surprising, as the methodologies of these rating systems are quite different, although their purposes are functionally similar.

Clearly, these 2 popular quality evaluation systems reflect different underlying constructs (which may or may not actually describe quality). And therein lies a central dilemma for health care professionals and academics: we haven't agreed among ourselves on reliable and meaningful quality metrics; so how can we, or even should we, expect the public to use available data to make health care decisions?

The 2 constructs in this particular comparison are certainly divergent in design. For the Hospital Compare ratings, the CMS used detailed process‐of‐care measures, expensively abstracted from the medical record, for just 3 medical conditions: acute myocardial infarction, congestive heart failure, and community‐acquired pneumonia. The U.S. News Best Hospitals rankings used reputation (based on a survey of physicians), severity‐adjusted mortality rate, staffing ratio, and key technologies offered by hospitals. Halasyamani and Davis conclude that consumers may be left to wonder how to reconcile these discordant rating systems. At the same time, they acknowledge that it is not yet clear whether public reporting will affect consumers' health care choices. Available evidence suggests that when making choices about health care, patients are much more likely to consult family and friends than an Internet site that posts quality information.2 There is as yet no conclusive evidence that quality data drive consumer decision making. Furthermore, acute myocardial infarction patients rarely have the opportunity to choose a hospital, even if they had access to the data.

The assessment of hospital quality is not only a challenge for patients, it's still perplexing for those of us immersed in health care. The scope of measures of quality is both broad and incomplete. At the microsystem and individual clinical syndrome level, we have a plethora of process measures that are evidence based (such as the CMS Hospital Compare measures) but appear to move meaningful outcomes only slightly, if at all. The evidence linking the pneumonia measures, for instance, to significant outcomes such as lower mortality or (rarely studied) better functional outcomes is extremely limited or nonexistent.3, 4

At the other end of the continuum are sweeping metrics such as risk‐adjusted in‐hospital mortality, which may be important and yet has 2 significant limitations. First, mortality rates in acute care are generally so low that this is not a useful outcome of interest for most clinical conditions. Its utility is really limited to well‐studied procedures such as cardiac surgery. Second, mortality rate reduction is extraordinarily difficult to link meaningfully to specific process interventions with available information and tools. For high‐volume complex medical conditions, such as pneumonia, nonsurgically‐managed cardiac disease, and oncology, we cannot as yet reliably use in‐hospital mortality rate as a descriptor for quality of care because the populations are so diverse and the statistical tools so crude. The public reporting of these data is even more complex because it often lags behind current data by years and may be significantly affected by sample size.

Even when we settle on a few, well‐defined process metrics, we have problems with complete and accurate reporting of data. In Halasyamani and Davis's study, only 2.9% of hospitals reported all 14 Hospital Compare core performance measures used in their analysis.1 Evidence suggests that poor performance is a strong disincentive to voluntarily report quality measures to the public.5 And because there is no evidence that this type of transparency initiative will drive volume to higher‐quality programs, publicly reporting quality measures may not provide a strong enough incentive for hospitals to allocate resources to the improvement of the quality of care they deliver in these specific areas.

The CMS has introduced financial incentives to encourage hospitals to report performance measures (regardless of the actual level of performance which is reported), providing financial rewards to top‐performing hospitals and/or to hospitals that actually demonstrate that strong performance may have a greater impact. The results of early studies suggested that that pay‐for‐performance did improve the quality of health care.6 Lindenauer et al. recently published the results of a large study evaluating adherence to quality measures in hospitals that voluntarily reported measures compared with those participating in a pay‐for‐performance demonstration project funded by the CMS. Hospitals engaged in both public reporting and pay‐for‐performance achieved modestly greater improvements in quality compared with those that only did public reporting.7 It is notable that this demonstration project generally produced modest financial rewards to those hospitals that improved performance.8 The optimal model to reward performance remains to be determined.7, 9, 10

There are a number of potentially harmful unintended consequences of poorly designed quality measures and associated transparency and incentive programs. The most obvious is opportunity cost. As the incentives become more tangible and meaningful, hospital quality leaders will be expected to step up efforts to improve performance in the specific process of care measures for which they are rewarded. Without caution, however, hospital quality leaders may develop a narrow focus in deciding where to apply their limited resources and may become distracted from other areas in dire need of improvement. Their boards of directors might appropriately argue that it is their fiduciary responsibility to focus on improving those aspects of quality that the payer community has highlighted as most important. If the metrics are excellent and the underlying constructs are in fact the right ones to advance quality in American acute care, this is a direction to be applauded. If the metrics are flawed and limited, which is the case today, then the risk is that resources will be wasted and diverted from more important priorities.

Even worse, an overly narrow focus may have unintended adverse clinical consequences. Recently, Wachter discussed several real‐world examples of unintended consequences of quality improvement efforts, including giving patients multiple doses of pneumococcal vaccines and inappropriately treating patients with symptoms that might indicate community‐acquired pneumonia with antibiotics.11 As hospitals attempt to improve their report cards, a significant risk exists that patients will receive excessive or unnecessary care in an attempt to meet specified timeliness goals.

The most important issue that has still not been completely addressed is whether improvements in process‐of‐care measures will actually improve patient outcomes. In a recent issue of this journal, Seymann concluded that there is strong evidence for influenza vaccination and the use of appropriate antibiotics for community‐acquired pneumonia12 but that other pneumonia quality measures were of less obvious clinical benefit. Controversy continues over whether the optimal timing of the initial treatment of community‐acquired pneumonia with antibiotics is 4 hours, as it currently stands, or 8 hours. Patients hospitalized with pneumonia may be motivated to quit smoking, but CMS requirements for smoking cessation advice/counseling can be satisfied with a simple pamphlet or a video, rather than interventions that involve counseling by specifically trained professionals and the use of pharmacotherapy, which are more likely to succeed. Although smoking cessation is an admirable goal, whether this is performed will not affect the quality of care that a patient with pneumonia receives during the index admission. In fact, it would be more important to counsel all patients about the hazards of smoking in an attempt to prevent pneumonia and acute myocardial infarction as well as a host of other smoking‐related illnesses.

In another example, Fonarow and colleagues examined the association between heart failure clinical outcomes and performance measures in a large observational cohort.13 The study found that current heart failure performance measures, aside from prescribing angiotensin‐converting inhibitor or angiotensin receptor blocker at discharge, had little relationship to mortality in the first 60‐90 days following discharge. On the other hand, the team found that being discharged on a beta blocker was associated with a significant reduction in mortality; however, beta blocker use is not part of the current CMS core measures. In addition, many patients hospitalized for heart failure may benefit from implantable cardioverter‐defibrillator therapy and/or cardiac resynchronization therapy,14 yet referral to a cardiologist to evaluate patients who may be suitable for these therapies is not a CMS core measure.

A similar, more comprehensive study recently evaluated whether performance on CMS quality measures for acute myocardial infarction, heart failure, and pneumonia correlated with condition‐specific inpatient, 30‐day, and 1‐year risk‐adjusted mortality rates.15 The study found that the best hospitals, those performing at the 75th percentile on quality measures, did have lower mortality rates than did hospitals performing at the 25th percentile, but the absolute risk reduction was small. Specifically, the absolute risk reduction for 30‐day mortality was 0.6%, 0.1%, and 0.1% for acute myocardial infarction, heart failure, and pneumonia, respectively. In attempting to explain their findings, the authors noted that current quality measures include only a subset of activities involved in the care of hospitalized patients. In addition, mortality rates are likely influenced by factors not included in current quality measures, such as the use of electronic health records, staffing levels, and other activities of quality oversight committees.

The era of measurement and accountability for providing high‐quality health care is upon us. Public reporting may lead to improvement in quality measures, but it is incumbent on the academic and provider communities as well as the payer community to ensure that the metrics are meaningful, reliable, and reproducible and, equally important, that they make a difference in essential clinical outcomes such as mortality, return to function, and avoidance of adverse events.10 Emerging evidence suggests the measures may need to be linked to meaningful financial incentives to the provider in order to accelerate change. Incentives directed at patients appear to be ineffective, clumsy, and slow to produce results.16

The time is right to revisit the quality measures currently used for transparency and incentives. We need a tighter, more reliable set of metrics that actually correlate with meaningful outcomes. Some evidence‐based measures appear to be missing from the current leading lists and some remain inadequately defined with regard to compliance. As a system, the measurement program contains poorly understood risks of unintended consequences. Above all else, local and national quality leaders need to be mindful that improving patient outcomes must be the central goal in our efforts to improve performance on process‐of‐care measures.

Why measure hospital quality? One popular premise is that measurement and transparency will inform consumer decision making and drive volume to high‐quality programs, providing incentives for improvement and raising the bar nationally. In this issue of the Journal of Hospital Medicine, Halasyamani and Davis report that there is relatively poor correlation between the Hospital Compare scores of the Centers for Medicare and Medicaid Services (CMS) and U.S. News and World Report's Best Hospitals rankings.1 The authors note that this is not necessarily surprising, as the methodologies of these rating systems are quite different, although their purposes are functionally similar.

Clearly, these 2 popular quality evaluation systems reflect different underlying constructs (which may or may not actually describe quality). And therein lies a central dilemma for health care professionals and academics: we haven't agreed among ourselves on reliable and meaningful quality metrics; so how can we, or even should we, expect the public to use available data to make health care decisions?

The 2 constructs in this particular comparison are certainly divergent in design. For the Hospital Compare ratings, the CMS used detailed process‐of‐care measures, expensively abstracted from the medical record, for just 3 medical conditions: acute myocardial infarction, congestive heart failure, and community‐acquired pneumonia. The U.S. News Best Hospitals rankings used reputation (based on a survey of physicians), severity‐adjusted mortality rate, staffing ratio, and key technologies offered by hospitals. Halasyamani and Davis conclude that consumers may be left to wonder how to reconcile these discordant rating systems. At the same time, they acknowledge that it is not yet clear whether public reporting will affect consumers' health care choices. Available evidence suggests that when making choices about health care, patients are much more likely to consult family and friends than an Internet site that posts quality information.2 There is as yet no conclusive evidence that quality data drive consumer decision making. Furthermore, acute myocardial infarction patients rarely have the opportunity to choose a hospital, even if they had access to the data.

The assessment of hospital quality is not only a challenge for patients, it's still perplexing for those of us immersed in health care. The scope of measures of quality is both broad and incomplete. At the microsystem and individual clinical syndrome level, we have a plethora of process measures that are evidence based (such as the CMS Hospital Compare measures) but appear to move meaningful outcomes only slightly, if at all. The evidence linking the pneumonia measures, for instance, to significant outcomes such as lower mortality or (rarely studied) better functional outcomes is extremely limited or nonexistent.3, 4

At the other end of the continuum are sweeping metrics such as risk‐adjusted in‐hospital mortality, which may be important and yet has 2 significant limitations. First, mortality rates in acute care are generally so low that this is not a useful outcome of interest for most clinical conditions. Its utility is really limited to well‐studied procedures such as cardiac surgery. Second, mortality rate reduction is extraordinarily difficult to link meaningfully to specific process interventions with available information and tools. For high‐volume complex medical conditions, such as pneumonia, nonsurgically‐managed cardiac disease, and oncology, we cannot as yet reliably use in‐hospital mortality rate as a descriptor for quality of care because the populations are so diverse and the statistical tools so crude. The public reporting of these data is even more complex because it often lags behind current data by years and may be significantly affected by sample size.

Even when we settle on a few, well‐defined process metrics, we have problems with complete and accurate reporting of data. In Halasyamani and Davis's study, only 2.9% of hospitals reported all 14 Hospital Compare core performance measures used in their analysis.1 Evidence suggests that poor performance is a strong disincentive to voluntarily report quality measures to the public.5 And because there is no evidence that this type of transparency initiative will drive volume to higher‐quality programs, publicly reporting quality measures may not provide a strong enough incentive for hospitals to allocate resources to the improvement of the quality of care they deliver in these specific areas.

The CMS has introduced financial incentives to encourage hospitals to report performance measures (regardless of the actual level of performance which is reported), providing financial rewards to top‐performing hospitals and/or to hospitals that actually demonstrate that strong performance may have a greater impact. The results of early studies suggested that that pay‐for‐performance did improve the quality of health care.6 Lindenauer et al. recently published the results of a large study evaluating adherence to quality measures in hospitals that voluntarily reported measures compared with those participating in a pay‐for‐performance demonstration project funded by the CMS. Hospitals engaged in both public reporting and pay‐for‐performance achieved modestly greater improvements in quality compared with those that only did public reporting.7 It is notable that this demonstration project generally produced modest financial rewards to those hospitals that improved performance.8 The optimal model to reward performance remains to be determined.7, 9, 10

There are a number of potentially harmful unintended consequences of poorly designed quality measures and associated transparency and incentive programs. The most obvious is opportunity cost. As the incentives become more tangible and meaningful, hospital quality leaders will be expected to step up efforts to improve performance in the specific process of care measures for which they are rewarded. Without caution, however, hospital quality leaders may develop a narrow focus in deciding where to apply their limited resources and may become distracted from other areas in dire need of improvement. Their boards of directors might appropriately argue that it is their fiduciary responsibility to focus on improving those aspects of quality that the payer community has highlighted as most important. If the metrics are excellent and the underlying constructs are in fact the right ones to advance quality in American acute care, this is a direction to be applauded. If the metrics are flawed and limited, which is the case today, then the risk is that resources will be wasted and diverted from more important priorities.

Even worse, an overly narrow focus may have unintended adverse clinical consequences. Recently, Wachter discussed several real‐world examples of unintended consequences of quality improvement efforts, including giving patients multiple doses of pneumococcal vaccines and inappropriately treating patients with symptoms that might indicate community‐acquired pneumonia with antibiotics.11 As hospitals attempt to improve their report cards, a significant risk exists that patients will receive excessive or unnecessary care in an attempt to meet specified timeliness goals.

The most important issue that has still not been completely addressed is whether improvements in process‐of‐care measures will actually improve patient outcomes. In a recent issue of this journal, Seymann concluded that there is strong evidence for influenza vaccination and the use of appropriate antibiotics for community‐acquired pneumonia12 but that other pneumonia quality measures were of less obvious clinical benefit. Controversy continues over whether the optimal timing of the initial treatment of community‐acquired pneumonia with antibiotics is 4 hours, as it currently stands, or 8 hours. Patients hospitalized with pneumonia may be motivated to quit smoking, but CMS requirements for smoking cessation advice/counseling can be satisfied with a simple pamphlet or a video, rather than interventions that involve counseling by specifically trained professionals and the use of pharmacotherapy, which are more likely to succeed. Although smoking cessation is an admirable goal, whether this is performed will not affect the quality of care that a patient with pneumonia receives during the index admission. In fact, it would be more important to counsel all patients about the hazards of smoking in an attempt to prevent pneumonia and acute myocardial infarction as well as a host of other smoking‐related illnesses.

In another example, Fonarow and colleagues examined the association between heart failure clinical outcomes and performance measures in a large observational cohort.13 The study found that current heart failure performance measures, aside from prescribing angiotensin‐converting inhibitor or angiotensin receptor blocker at discharge, had little relationship to mortality in the first 60‐90 days following discharge. On the other hand, the team found that being discharged on a beta blocker was associated with a significant reduction in mortality; however, beta blocker use is not part of the current CMS core measures. In addition, many patients hospitalized for heart failure may benefit from implantable cardioverter‐defibrillator therapy and/or cardiac resynchronization therapy,14 yet referral to a cardiologist to evaluate patients who may be suitable for these therapies is not a CMS core measure.

A similar, more comprehensive study recently evaluated whether performance on CMS quality measures for acute myocardial infarction, heart failure, and pneumonia correlated with condition‐specific inpatient, 30‐day, and 1‐year risk‐adjusted mortality rates.15 The study found that the best hospitals, those performing at the 75th percentile on quality measures, did have lower mortality rates than did hospitals performing at the 25th percentile, but the absolute risk reduction was small. Specifically, the absolute risk reduction for 30‐day mortality was 0.6%, 0.1%, and 0.1% for acute myocardial infarction, heart failure, and pneumonia, respectively. In attempting to explain their findings, the authors noted that current quality measures include only a subset of activities involved in the care of hospitalized patients. In addition, mortality rates are likely influenced by factors not included in current quality measures, such as the use of electronic health records, staffing levels, and other activities of quality oversight committees.

The era of measurement and accountability for providing high‐quality health care is upon us. Public reporting may lead to improvement in quality measures, but it is incumbent on the academic and provider communities as well as the payer community to ensure that the metrics are meaningful, reliable, and reproducible and, equally important, that they make a difference in essential clinical outcomes such as mortality, return to function, and avoidance of adverse events.10 Emerging evidence suggests the measures may need to be linked to meaningful financial incentives to the provider in order to accelerate change. Incentives directed at patients appear to be ineffective, clumsy, and slow to produce results.16

The time is right to revisit the quality measures currently used for transparency and incentives. We need a tighter, more reliable set of metrics that actually correlate with meaningful outcomes. Some evidence‐based measures appear to be missing from the current leading lists and some remain inadequately defined with regard to compliance. As a system, the measurement program contains poorly understood risks of unintended consequences. Above all else, local and national quality leaders need to be mindful that improving patient outcomes must be the central goal in our efforts to improve performance on process‐of‐care measures.

Why measure hospital quality? One popular premise is that measurement and transparency will inform consumer decision making and drive volume to high‐quality programs, providing incentives for improvement and raising the bar nationally. In this issue of the Journal of Hospital Medicine, Halasyamani and Davis report that there is relatively poor correlation between the Hospital Compare scores of the Centers for Medicare and Medicaid Services (CMS) and U.S. News and World Report's Best Hospitals rankings.1 The authors note that this is not necessarily surprising, as the methodologies of these rating systems are quite different, although their purposes are functionally similar.

Clearly, these 2 popular quality evaluation systems reflect different underlying constructs (which may or may not actually describe quality). And therein lies a central dilemma for health care professionals and academics: we haven't agreed among ourselves on reliable and meaningful quality metrics; so how can we, or even should we, expect the public to use available data to make health care decisions?

The 2 constructs in this particular comparison are certainly divergent in design. For the Hospital Compare ratings, the CMS used detailed process‐of‐care measures, expensively abstracted from the medical record, for just 3 medical conditions: acute myocardial infarction, congestive heart failure, and community‐acquired pneumonia. The U.S. News Best Hospitals rankings used reputation (based on a survey of physicians), severity‐adjusted mortality rate, staffing ratio, and key technologies offered by hospitals. Halasyamani and Davis conclude that consumers may be left to wonder how to reconcile these discordant rating systems. At the same time, they acknowledge that it is not yet clear whether public reporting will affect consumers' health care choices. Available evidence suggests that when making choices about health care, patients are much more likely to consult family and friends than an Internet site that posts quality information.2 There is as yet no conclusive evidence that quality data drive consumer decision making. Furthermore, acute myocardial infarction patients rarely have the opportunity to choose a hospital, even if they had access to the data.

The assessment of hospital quality is not only a challenge for patients, it's still perplexing for those of us immersed in health care. The scope of measures of quality is both broad and incomplete. At the microsystem and individual clinical syndrome level, we have a plethora of process measures that are evidence based (such as the CMS Hospital Compare measures) but appear to move meaningful outcomes only slightly, if at all. The evidence linking the pneumonia measures, for instance, to significant outcomes such as lower mortality or (rarely studied) better functional outcomes is extremely limited or nonexistent.3, 4

At the other end of the continuum are sweeping metrics such as risk‐adjusted in‐hospital mortality, which may be important and yet has 2 significant limitations. First, mortality rates in acute care are generally so low that this is not a useful outcome of interest for most clinical conditions. Its utility is really limited to well‐studied procedures such as cardiac surgery. Second, mortality rate reduction is extraordinarily difficult to link meaningfully to specific process interventions with available information and tools. For high‐volume complex medical conditions, such as pneumonia, nonsurgically‐managed cardiac disease, and oncology, we cannot as yet reliably use in‐hospital mortality rate as a descriptor for quality of care because the populations are so diverse and the statistical tools so crude. The public reporting of these data is even more complex because it often lags behind current data by years and may be significantly affected by sample size.

Even when we settle on a few, well‐defined process metrics, we have problems with complete and accurate reporting of data. In Halasyamani and Davis's study, only 2.9% of hospitals reported all 14 Hospital Compare core performance measures used in their analysis.1 Evidence suggests that poor performance is a strong disincentive to voluntarily report quality measures to the public.5 And because there is no evidence that this type of transparency initiative will drive volume to higher‐quality programs, publicly reporting quality measures may not provide a strong enough incentive for hospitals to allocate resources to the improvement of the quality of care they deliver in these specific areas.

The CMS has introduced financial incentives to encourage hospitals to report performance measures (regardless of the actual level of performance which is reported), providing financial rewards to top‐performing hospitals and/or to hospitals that actually demonstrate that strong performance may have a greater impact. The results of early studies suggested that that pay‐for‐performance did improve the quality of health care.6 Lindenauer et al. recently published the results of a large study evaluating adherence to quality measures in hospitals that voluntarily reported measures compared with those participating in a pay‐for‐performance demonstration project funded by the CMS. Hospitals engaged in both public reporting and pay‐for‐performance achieved modestly greater improvements in quality compared with those that only did public reporting.7 It is notable that this demonstration project generally produced modest financial rewards to those hospitals that improved performance.8 The optimal model to reward performance remains to be determined.7, 9, 10

There are a number of potentially harmful unintended consequences of poorly designed quality measures and associated transparency and incentive programs. The most obvious is opportunity cost. As the incentives become more tangible and meaningful, hospital quality leaders will be expected to step up efforts to improve performance in the specific process of care measures for which they are rewarded. Without caution, however, hospital quality leaders may develop a narrow focus in deciding where to apply their limited resources and may become distracted from other areas in dire need of improvement. Their boards of directors might appropriately argue that it is their fiduciary responsibility to focus on improving those aspects of quality that the payer community has highlighted as most important. If the metrics are excellent and the underlying constructs are in fact the right ones to advance quality in American acute care, this is a direction to be applauded. If the metrics are flawed and limited, which is the case today, then the risk is that resources will be wasted and diverted from more important priorities.

Even worse, an overly narrow focus may have unintended adverse clinical consequences. Recently, Wachter discussed several real‐world examples of unintended consequences of quality improvement efforts, including giving patients multiple doses of pneumococcal vaccines and inappropriately treating patients with symptoms that might indicate community‐acquired pneumonia with antibiotics.11 As hospitals attempt to improve their report cards, a significant risk exists that patients will receive excessive or unnecessary care in an attempt to meet specified timeliness goals.

The most important issue that has still not been completely addressed is whether improvements in process‐of‐care measures will actually improve patient outcomes. In a recent issue of this journal, Seymann concluded that there is strong evidence for influenza vaccination and the use of appropriate antibiotics for community‐acquired pneumonia12 but that other pneumonia quality measures were of less obvious clinical benefit. Controversy continues over whether the optimal timing of the initial treatment of community‐acquired pneumonia with antibiotics is 4 hours, as it currently stands, or 8 hours. Patients hospitalized with pneumonia may be motivated to quit smoking, but CMS requirements for smoking cessation advice/counseling can be satisfied with a simple pamphlet or a video, rather than interventions that involve counseling by specifically trained professionals and the use of pharmacotherapy, which are more likely to succeed. Although smoking cessation is an admirable goal, whether this is performed will not affect the quality of care that a patient with pneumonia receives during the index admission. In fact, it would be more important to counsel all patients about the hazards of smoking in an attempt to prevent pneumonia and acute myocardial infarction as well as a host of other smoking‐related illnesses.

In another example, Fonarow and colleagues examined the association between heart failure clinical outcomes and performance measures in a large observational cohort.13 The study found that current heart failure performance measures, aside from prescribing angiotensin‐converting inhibitor or angiotensin receptor blocker at discharge, had little relationship to mortality in the first 60‐90 days following discharge. On the other hand, the team found that being discharged on a beta blocker was associated with a significant reduction in mortality; however, beta blocker use is not part of the current CMS core measures. In addition, many patients hospitalized for heart failure may benefit from implantable cardioverter‐defibrillator therapy and/or cardiac resynchronization therapy,14 yet referral to a cardiologist to evaluate patients who may be suitable for these therapies is not a CMS core measure.

A similar, more comprehensive study recently evaluated whether performance on CMS quality measures for acute myocardial infarction, heart failure, and pneumonia correlated with condition‐specific inpatient, 30‐day, and 1‐year risk‐adjusted mortality rates.15 The study found that the best hospitals, those performing at the 75th percentile on quality measures, did have lower mortality rates than did hospitals performing at the 25th percentile, but the absolute risk reduction was small. Specifically, the absolute risk reduction for 30‐day mortality was 0.6%, 0.1%, and 0.1% for acute myocardial infarction, heart failure, and pneumonia, respectively. In attempting to explain their findings, the authors noted that current quality measures include only a subset of activities involved in the care of hospitalized patients. In addition, mortality rates are likely influenced by factors not included in current quality measures, such as the use of electronic health records, staffing levels, and other activities of quality oversight committees.

The era of measurement and accountability for providing high‐quality health care is upon us. Public reporting may lead to improvement in quality measures, but it is incumbent on the academic and provider communities as well as the payer community to ensure that the metrics are meaningful, reliable, and reproducible and, equally important, that they make a difference in essential clinical outcomes such as mortality, return to function, and avoidance of adverse events.10 Emerging evidence suggests the measures may need to be linked to meaningful financial incentives to the provider in order to accelerate change. Incentives directed at patients appear to be ineffective, clumsy, and slow to produce results.16

The time is right to revisit the quality measures currently used for transparency and incentives. We need a tighter, more reliable set of metrics that actually correlate with meaningful outcomes. Some evidence‐based measures appear to be missing from the current leading lists and some remain inadequately defined with regard to compliance. As a system, the measurement program contains poorly understood risks of unintended consequences. Above all else, local and national quality leaders need to be mindful that improving patient outcomes must be the central goal in our efforts to improve performance on process‐of‐care measures.