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Beware Hospital Compare? New Measures Highlight Questions Surrounding Healthcare Quality Report Cards
—Anne-Marie J. Audet, MD, MSc, SM, vice president, Health System Quality and Efficiency, Commonwealth Fund
The Centers for Medicare & Medicaid Services (CMS) has been publicly reporting performance measures on its Hospital Compare website (www.hospitalcompare.hhs.gov) since 2005, focusing on processes of care, patient outcomes, patient satisfaction, patient safety, and other measures. A recent addition of patient-safety metrics has rekindled skeptical questions about the validity, purpose, and effectiveness of public healthcare quality report cards, while highlighting the need for hospitalists and their institutions to remain vigilant in the struggle to ensure that they are compared and rewarded fairly and appropriately.
Provocative Measures
Last fall, CMS began posting “Serious Complications and Deaths” measures, developed by the Agency for Healthcare Research and Quality (AHRQ). The measures score individual hospitals according to the rates at which their patients suffer from:
- Pneumothorax due to medical treatment;
- Post-operative VTE;
- Post-operative abdominal or pelvic dehiscence; and
- Accidental lacerations from medical treatment.
Four other serious complication measures (pressure ulcers, catheter and bloodstream infections, and hip fractures from falling after surgery) are folded into a separate composite score for each hospital, while another composite score for “Deaths for Certain Conditions” is based on a hospital’s post-admission mortality rate for hip fractures, acute MI, heart failure, stroke, GI bleed, and pneumonia.
National and local media reports have thrust these dramatic metrics into the public eye, putting many hospitals on the spot to explain their putative breaches of patient safety. A closer inspection of the metrics, however, reveals plausible criticisms of their shortcomings.
Methodological Weakness
The new metrics are derived from Medicare claims data instead of medical chart abstractions, which experts say weakens their validity significantly and makes their use for provider profiling questionable. Moreover, claims data are based on records that were never designed to capture the sort of clinical nuances needed for valid and equitable risk adjustment (see “Methodological Challenges to Quality Metrics,” below). “Serious Complications and Deaths” rates based on these data, critics maintain, lack validity for meaningful hospital comparisons because they can exaggerate problems at hospitals that treat a high volume of complicated patients and use more invasive procedures to do so, such as teaching hospitals in academic medical centers.1
The ante gets upped when CMS eventually begins adding patient-safety measures to the Hospital Value-Based Purchasing (HVBP) program, which rewards or punishes hospitals financially, depending on their performance on the metrics. CMS is considering adding the Serious Complications and Deaths measures to the HVPB program in the near future.
As the science of documenting and reporting patient harm struggles to find its footing, physicians and hospitals have to be more vigilant than ever to adopt a unified, organized approach to advocate the most appropriate processes and outcomes for which they will be held accountable, and avoid being cast in a reactive mode when metrics are imposed on them, says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Shreveport, La.
Last year, SHM sent comments to then-CMS administrator Don Berwick, expressing concern that the patient-safety measures CMS proposes to include in the HVBP program in fiscal-year 2014 are not endorsed by the National Quality Forum (NQF), that they are derived from billing and payment data that are not intended to be used primarily for clinical purposes, that the outcome measures are not entirely preventable even with the best of care, and that they are not adequately risk-adjusted.
“While it’s easy to agree with the experts that Hospital Compare’s patient-safety measures are not ready for prime time, it’s no longer acceptable simply to say, ‘These metrics are irrelevant,’” Dr. Torcson cautions. “We also must be aware of the evolution and inexorable movement of the nation’s healthcare quality and safety agenda. SHM embraces the triple aim of providing better care to our patients, promoting better health of patient populations, and doing so at a lower cost.”
The Power of “Why?”
Despite its imperfections, Hospital Compare’s greatest value is the power of its transparency, which fosters healthy discussion among providers, patients, and payors, according to Anne-Marie J. Audet, MD, MSc, SM, vice president for Health System Quality and Efficiency for the Commonwealth Fund. “That transparency gets providers’ attention and leads them to make changes that can translate into better performance,” she says, noting how hospital care for patients with heart attack, heart failure, and pneumonia has steadily improved in recent years, with the worst performers in 2009 doing as well or better than the best performers in 2004.
“There are also examples of hospitals that have gone from a median of four central line-associated bloodstream infections (CLABSI) per 1,000 line-days to zero because they decided not to take the status quo as acceptable,” says Stephen C. Schoenbaum, MD, MPH, special advisor to the president of the Josiah Macy Jr. Foundation. Dr. Schoenbaum played a significant role in the development of the Healthcare Effectiveness Data and Information Set, or HEDIS.
“There is no such thing as a perfect measure in which some adjustment or better collection method would not affect the numbers,” he notes. “Ideally, you want any publicly reported measure to get the poorer performers to come up with a way to explain their result. Or, even better, to improve their result.”
Methodological criticisms of CMS’ new “Serious Complications and Deaths” measures may be justified, Dr. Audet concedes, but she also notes that rigorous validation and reliability testing of quality measures is an expensive process. “To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure,” she says.
“In the meantime, providers will be probing the implications of their numbers, asking why they got the numbers they did, and what can be done about it. This attention can only lead to improvement, both in the measures themselves and in the care delivered.”
Indeed, one of the hospitals that was listed as having a high rate of accidental cuts and lacerations in the new measures found most of those cuts had been intended by the surgeon but erroneously billed to Medicare under the code for an accidental cut. Even with its methodological flaws, the Hospital Compare data led to root-cause analysis and improvement in coding.
Hospitalists’ Role
Hospitalists, according to Dr. Torcson, will be critical to the successful performance of hospitals under the HVPB program, as experts in quality and quality-measurement adherence. Hospitalists care for more hospitalized patients than any other physician group, and many believe they are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be required.
“Hospitalists and their hospitals, practicing in alignment, become champions for their patients,” Dr. Torcson says. “SHM supported the HVBP program, and we foresee that the alignment of performance and payment within the program will inevitably result in better clinical outcomes for our patients.”
Chris Guadagnino is a freelance writer in Philadelphia.
References
- Experts question Medicare’s effort to rate hospitals’ patient safety records. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/Stories/2012/February/13/medicare-hospital-patient-safety-records.aspx. Accessed March 12, 2012.
- Shahian DM, Iezzoni LI, Meyer GS, Kirle L, Normand ST. Hospital-wide mortality as a quality metric: conceptual and methodological challenges. Am J Med Qual. 2012;27:112.
—Anne-Marie J. Audet, MD, MSc, SM, vice president, Health System Quality and Efficiency, Commonwealth Fund
The Centers for Medicare & Medicaid Services (CMS) has been publicly reporting performance measures on its Hospital Compare website (www.hospitalcompare.hhs.gov) since 2005, focusing on processes of care, patient outcomes, patient satisfaction, patient safety, and other measures. A recent addition of patient-safety metrics has rekindled skeptical questions about the validity, purpose, and effectiveness of public healthcare quality report cards, while highlighting the need for hospitalists and their institutions to remain vigilant in the struggle to ensure that they are compared and rewarded fairly and appropriately.
Provocative Measures
Last fall, CMS began posting “Serious Complications and Deaths” measures, developed by the Agency for Healthcare Research and Quality (AHRQ). The measures score individual hospitals according to the rates at which their patients suffer from:
- Pneumothorax due to medical treatment;
- Post-operative VTE;
- Post-operative abdominal or pelvic dehiscence; and
- Accidental lacerations from medical treatment.
Four other serious complication measures (pressure ulcers, catheter and bloodstream infections, and hip fractures from falling after surgery) are folded into a separate composite score for each hospital, while another composite score for “Deaths for Certain Conditions” is based on a hospital’s post-admission mortality rate for hip fractures, acute MI, heart failure, stroke, GI bleed, and pneumonia.
National and local media reports have thrust these dramatic metrics into the public eye, putting many hospitals on the spot to explain their putative breaches of patient safety. A closer inspection of the metrics, however, reveals plausible criticisms of their shortcomings.
Methodological Weakness
The new metrics are derived from Medicare claims data instead of medical chart abstractions, which experts say weakens their validity significantly and makes their use for provider profiling questionable. Moreover, claims data are based on records that were never designed to capture the sort of clinical nuances needed for valid and equitable risk adjustment (see “Methodological Challenges to Quality Metrics,” below). “Serious Complications and Deaths” rates based on these data, critics maintain, lack validity for meaningful hospital comparisons because they can exaggerate problems at hospitals that treat a high volume of complicated patients and use more invasive procedures to do so, such as teaching hospitals in academic medical centers.1
The ante gets upped when CMS eventually begins adding patient-safety measures to the Hospital Value-Based Purchasing (HVBP) program, which rewards or punishes hospitals financially, depending on their performance on the metrics. CMS is considering adding the Serious Complications and Deaths measures to the HVPB program in the near future.
As the science of documenting and reporting patient harm struggles to find its footing, physicians and hospitals have to be more vigilant than ever to adopt a unified, organized approach to advocate the most appropriate processes and outcomes for which they will be held accountable, and avoid being cast in a reactive mode when metrics are imposed on them, says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Shreveport, La.
Last year, SHM sent comments to then-CMS administrator Don Berwick, expressing concern that the patient-safety measures CMS proposes to include in the HVBP program in fiscal-year 2014 are not endorsed by the National Quality Forum (NQF), that they are derived from billing and payment data that are not intended to be used primarily for clinical purposes, that the outcome measures are not entirely preventable even with the best of care, and that they are not adequately risk-adjusted.
“While it’s easy to agree with the experts that Hospital Compare’s patient-safety measures are not ready for prime time, it’s no longer acceptable simply to say, ‘These metrics are irrelevant,’” Dr. Torcson cautions. “We also must be aware of the evolution and inexorable movement of the nation’s healthcare quality and safety agenda. SHM embraces the triple aim of providing better care to our patients, promoting better health of patient populations, and doing so at a lower cost.”
The Power of “Why?”
Despite its imperfections, Hospital Compare’s greatest value is the power of its transparency, which fosters healthy discussion among providers, patients, and payors, according to Anne-Marie J. Audet, MD, MSc, SM, vice president for Health System Quality and Efficiency for the Commonwealth Fund. “That transparency gets providers’ attention and leads them to make changes that can translate into better performance,” she says, noting how hospital care for patients with heart attack, heart failure, and pneumonia has steadily improved in recent years, with the worst performers in 2009 doing as well or better than the best performers in 2004.
“There are also examples of hospitals that have gone from a median of four central line-associated bloodstream infections (CLABSI) per 1,000 line-days to zero because they decided not to take the status quo as acceptable,” says Stephen C. Schoenbaum, MD, MPH, special advisor to the president of the Josiah Macy Jr. Foundation. Dr. Schoenbaum played a significant role in the development of the Healthcare Effectiveness Data and Information Set, or HEDIS.
“There is no such thing as a perfect measure in which some adjustment or better collection method would not affect the numbers,” he notes. “Ideally, you want any publicly reported measure to get the poorer performers to come up with a way to explain their result. Or, even better, to improve their result.”
Methodological criticisms of CMS’ new “Serious Complications and Deaths” measures may be justified, Dr. Audet concedes, but she also notes that rigorous validation and reliability testing of quality measures is an expensive process. “To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure,” she says.
“In the meantime, providers will be probing the implications of their numbers, asking why they got the numbers they did, and what can be done about it. This attention can only lead to improvement, both in the measures themselves and in the care delivered.”
Indeed, one of the hospitals that was listed as having a high rate of accidental cuts and lacerations in the new measures found most of those cuts had been intended by the surgeon but erroneously billed to Medicare under the code for an accidental cut. Even with its methodological flaws, the Hospital Compare data led to root-cause analysis and improvement in coding.
Hospitalists’ Role
Hospitalists, according to Dr. Torcson, will be critical to the successful performance of hospitals under the HVPB program, as experts in quality and quality-measurement adherence. Hospitalists care for more hospitalized patients than any other physician group, and many believe they are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be required.
“Hospitalists and their hospitals, practicing in alignment, become champions for their patients,” Dr. Torcson says. “SHM supported the HVBP program, and we foresee that the alignment of performance and payment within the program will inevitably result in better clinical outcomes for our patients.”
Chris Guadagnino is a freelance writer in Philadelphia.
References
- Experts question Medicare’s effort to rate hospitals’ patient safety records. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/Stories/2012/February/13/medicare-hospital-patient-safety-records.aspx. Accessed March 12, 2012.
- Shahian DM, Iezzoni LI, Meyer GS, Kirle L, Normand ST. Hospital-wide mortality as a quality metric: conceptual and methodological challenges. Am J Med Qual. 2012;27:112.
—Anne-Marie J. Audet, MD, MSc, SM, vice president, Health System Quality and Efficiency, Commonwealth Fund
The Centers for Medicare & Medicaid Services (CMS) has been publicly reporting performance measures on its Hospital Compare website (www.hospitalcompare.hhs.gov) since 2005, focusing on processes of care, patient outcomes, patient satisfaction, patient safety, and other measures. A recent addition of patient-safety metrics has rekindled skeptical questions about the validity, purpose, and effectiveness of public healthcare quality report cards, while highlighting the need for hospitalists and their institutions to remain vigilant in the struggle to ensure that they are compared and rewarded fairly and appropriately.
Provocative Measures
Last fall, CMS began posting “Serious Complications and Deaths” measures, developed by the Agency for Healthcare Research and Quality (AHRQ). The measures score individual hospitals according to the rates at which their patients suffer from:
- Pneumothorax due to medical treatment;
- Post-operative VTE;
- Post-operative abdominal or pelvic dehiscence; and
- Accidental lacerations from medical treatment.
Four other serious complication measures (pressure ulcers, catheter and bloodstream infections, and hip fractures from falling after surgery) are folded into a separate composite score for each hospital, while another composite score for “Deaths for Certain Conditions” is based on a hospital’s post-admission mortality rate for hip fractures, acute MI, heart failure, stroke, GI bleed, and pneumonia.
National and local media reports have thrust these dramatic metrics into the public eye, putting many hospitals on the spot to explain their putative breaches of patient safety. A closer inspection of the metrics, however, reveals plausible criticisms of their shortcomings.
Methodological Weakness
The new metrics are derived from Medicare claims data instead of medical chart abstractions, which experts say weakens their validity significantly and makes their use for provider profiling questionable. Moreover, claims data are based on records that were never designed to capture the sort of clinical nuances needed for valid and equitable risk adjustment (see “Methodological Challenges to Quality Metrics,” below). “Serious Complications and Deaths” rates based on these data, critics maintain, lack validity for meaningful hospital comparisons because they can exaggerate problems at hospitals that treat a high volume of complicated patients and use more invasive procedures to do so, such as teaching hospitals in academic medical centers.1
The ante gets upped when CMS eventually begins adding patient-safety measures to the Hospital Value-Based Purchasing (HVBP) program, which rewards or punishes hospitals financially, depending on their performance on the metrics. CMS is considering adding the Serious Complications and Deaths measures to the HVPB program in the near future.
As the science of documenting and reporting patient harm struggles to find its footing, physicians and hospitals have to be more vigilant than ever to adopt a unified, organized approach to advocate the most appropriate processes and outcomes for which they will be held accountable, and avoid being cast in a reactive mode when metrics are imposed on them, says Patrick J. Torcson, MD, MMM, FACP, SFHM, chair of SHM’s Performance Measurement and Reporting Committee, and director of hospital medicine at St. Tammany Parish Hospital in Shreveport, La.
Last year, SHM sent comments to then-CMS administrator Don Berwick, expressing concern that the patient-safety measures CMS proposes to include in the HVBP program in fiscal-year 2014 are not endorsed by the National Quality Forum (NQF), that they are derived from billing and payment data that are not intended to be used primarily for clinical purposes, that the outcome measures are not entirely preventable even with the best of care, and that they are not adequately risk-adjusted.
“While it’s easy to agree with the experts that Hospital Compare’s patient-safety measures are not ready for prime time, it’s no longer acceptable simply to say, ‘These metrics are irrelevant,’” Dr. Torcson cautions. “We also must be aware of the evolution and inexorable movement of the nation’s healthcare quality and safety agenda. SHM embraces the triple aim of providing better care to our patients, promoting better health of patient populations, and doing so at a lower cost.”
The Power of “Why?”
Despite its imperfections, Hospital Compare’s greatest value is the power of its transparency, which fosters healthy discussion among providers, patients, and payors, according to Anne-Marie J. Audet, MD, MSc, SM, vice president for Health System Quality and Efficiency for the Commonwealth Fund. “That transparency gets providers’ attention and leads them to make changes that can translate into better performance,” she says, noting how hospital care for patients with heart attack, heart failure, and pneumonia has steadily improved in recent years, with the worst performers in 2009 doing as well or better than the best performers in 2004.
“There are also examples of hospitals that have gone from a median of four central line-associated bloodstream infections (CLABSI) per 1,000 line-days to zero because they decided not to take the status quo as acceptable,” says Stephen C. Schoenbaum, MD, MPH, special advisor to the president of the Josiah Macy Jr. Foundation. Dr. Schoenbaum played a significant role in the development of the Healthcare Effectiveness Data and Information Set, or HEDIS.
“There is no such thing as a perfect measure in which some adjustment or better collection method would not affect the numbers,” he notes. “Ideally, you want any publicly reported measure to get the poorer performers to come up with a way to explain their result. Or, even better, to improve their result.”
Methodological criticisms of CMS’ new “Serious Complications and Deaths” measures may be justified, Dr. Audet concedes, but she also notes that rigorous validation and reliability testing of quality measures is an expensive process. “To get where we want to go in American healthcare, we need a more thoroughly supported measure development infrastructure,” she says.
“In the meantime, providers will be probing the implications of their numbers, asking why they got the numbers they did, and what can be done about it. This attention can only lead to improvement, both in the measures themselves and in the care delivered.”
Indeed, one of the hospitals that was listed as having a high rate of accidental cuts and lacerations in the new measures found most of those cuts had been intended by the surgeon but erroneously billed to Medicare under the code for an accidental cut. Even with its methodological flaws, the Hospital Compare data led to root-cause analysis and improvement in coding.
Hospitalists’ Role
Hospitalists, according to Dr. Torcson, will be critical to the successful performance of hospitals under the HVPB program, as experts in quality and quality-measurement adherence. Hospitalists care for more hospitalized patients than any other physician group, and many believe they are uniquely positioned to lead the system-level changes and quality-improvement (QI) efforts that will be required.
“Hospitalists and their hospitals, practicing in alignment, become champions for their patients,” Dr. Torcson says. “SHM supported the HVBP program, and we foresee that the alignment of performance and payment within the program will inevitably result in better clinical outcomes for our patients.”
Chris Guadagnino is a freelance writer in Philadelphia.
References
- Experts question Medicare’s effort to rate hospitals’ patient safety records. Kaiser Health News website. Available at: http://www.kaiserhealthnews.org/Stories/2012/February/13/medicare-hospital-patient-safety-records.aspx. Accessed March 12, 2012.
- Shahian DM, Iezzoni LI, Meyer GS, Kirle L, Normand ST. Hospital-wide mortality as a quality metric: conceptual and methodological challenges. Am J Med Qual. 2012;27:112.
Cleveland Clinic Builds Urgency around Patient Experiences
Efforts to create a greater sense of urgency over patient satisfaction within the hospitalist service at the Cleveland Clinic using an eight-step model for changing organizational culture were outlined in an abstract presented at HM11.
“Attention to the doctor-patient experience should be our guiding principle,” explains lead author and hospitalist Vicente Velez, MD. “No matter how complex the science of medicine gets, the art is equally important.” Physicians can be taught skills in effective communication with their patients and families, Dr. Velez adds.
The initiative began four years ago after the department identified low patient satisfaction scores as a “credibility crisis.” Leadership sprung into action, promoting a vision that HM should be known for its ability to communicate. “Regardless of individual communication style, a proper self-introduction, eliciting the patient’s perspective, and an explanation of the daily plan of care were things we all had to develop as habits,” he says.
Individual projects to advance the agenda included:
- Communication training offered to all physicians at the Cleveland Clinic;
- New business cards with the hospitalists’ pictures on them;
- A pre-discharge “fly-by” visit from the hospitalist;
- Post-discharge callbacks to patients; and
- Joint physician-nurse rounding.
The service now shares its Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) satisfaction scores for individual physicians in small groups or one-on-one meetings. The department recognizes high performers. Overall satisfaction scores rose to between 76% and 86%, up from 69% at the start of the project, Dr. Velez says.
Reference
Efforts to create a greater sense of urgency over patient satisfaction within the hospitalist service at the Cleveland Clinic using an eight-step model for changing organizational culture were outlined in an abstract presented at HM11.
“Attention to the doctor-patient experience should be our guiding principle,” explains lead author and hospitalist Vicente Velez, MD. “No matter how complex the science of medicine gets, the art is equally important.” Physicians can be taught skills in effective communication with their patients and families, Dr. Velez adds.
The initiative began four years ago after the department identified low patient satisfaction scores as a “credibility crisis.” Leadership sprung into action, promoting a vision that HM should be known for its ability to communicate. “Regardless of individual communication style, a proper self-introduction, eliciting the patient’s perspective, and an explanation of the daily plan of care were things we all had to develop as habits,” he says.
Individual projects to advance the agenda included:
- Communication training offered to all physicians at the Cleveland Clinic;
- New business cards with the hospitalists’ pictures on them;
- A pre-discharge “fly-by” visit from the hospitalist;
- Post-discharge callbacks to patients; and
- Joint physician-nurse rounding.
The service now shares its Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) satisfaction scores for individual physicians in small groups or one-on-one meetings. The department recognizes high performers. Overall satisfaction scores rose to between 76% and 86%, up from 69% at the start of the project, Dr. Velez says.
Reference
Efforts to create a greater sense of urgency over patient satisfaction within the hospitalist service at the Cleveland Clinic using an eight-step model for changing organizational culture were outlined in an abstract presented at HM11.
“Attention to the doctor-patient experience should be our guiding principle,” explains lead author and hospitalist Vicente Velez, MD. “No matter how complex the science of medicine gets, the art is equally important.” Physicians can be taught skills in effective communication with their patients and families, Dr. Velez adds.
The initiative began four years ago after the department identified low patient satisfaction scores as a “credibility crisis.” Leadership sprung into action, promoting a vision that HM should be known for its ability to communicate. “Regardless of individual communication style, a proper self-introduction, eliciting the patient’s perspective, and an explanation of the daily plan of care were things we all had to develop as habits,” he says.
Individual projects to advance the agenda included:
- Communication training offered to all physicians at the Cleveland Clinic;
- New business cards with the hospitalists’ pictures on them;
- A pre-discharge “fly-by” visit from the hospitalist;
- Post-discharge callbacks to patients; and
- Joint physician-nurse rounding.
The service now shares its Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) satisfaction scores for individual physicians in small groups or one-on-one meetings. The department recognizes high performers. Overall satisfaction scores rose to between 76% and 86%, up from 69% at the start of the project, Dr. Velez says.
Reference
By the Numbers: 3,000
Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.1 More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.
Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.
Reference
Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.1 More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.
Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.
Reference
Approximate number of million-dollar hospitalization bills in Northern California hospitals in 2010, up from 430 a decade earlier, according to statistics from the Office of Statewide Health Planning and Development.1 More than 20% of the giant bills—typically for complicated, life-saving procedures and lengthy hospital stays following critical illness or trauma—went to the parents of newborn babies with catastrophic illnesses. Organ transplants were also associated with extended hospital stays and million-dollar price tags.
Medical bills are a major factor in two-thirds of personal bankruptcy cases, although most of the largest bills will be lowered significantly, as much as 80%, after negotiations between hospitals and insurers.
Reference
C. Diff Deaths at All-Time High
Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.
L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.1 Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.
Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.2
A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.
“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.
References
- Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
- Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.
Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.
L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.1 Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.
Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.2
A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.
“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.
References
- Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
- Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.
Both incidence and deaths related to the bacterial infection Clostridium difficile have reached an all-time high, according to the federal Centers for Disease Control and Prevention (CDC), which calls C. diff “a formidable opponent” and a widespread safety issue. A total of 14,000 deaths related to C. diff were reported during the period of 2006-2007, compared with 3,000 in 1999-2000. A quarter of infections now appear first in hospitalized patients, with the rest in nursing home residents or patients in doctors’ offices.
L. Clifford McDonald, MD, CDC epidemiologist and lead author of a recent CDC Vital Signs report on the subject, recommended several steps for reducing C. diff infections, starting with better antibiotic stewardship, early detection and isolation for those who test positive, use of gloves and gowns when treating them, and informing the receiving medical team when those patients are transferred.1 Dr. McDonald also noted that state-led hospital collaboratives in Illinois, Massachusetts, and New York have reduced infection rates by 20%.
Another recent example of successful antibiotic stewardship comes from the University of Maryland Medical Center (UMMC) and Health Day News, summarizing a study in the journal Infection Control and Hospital Epidemiology.2
A seven-year stewardship program using an anti-microbial monitoring team generated a $3 million reduction in the hospital’s annual budget for antibiotics by its third year, with no increase in death rates, hospital readmissions, or length of stay. After seven years, antibiotic spending per patient per day had been cut by nearly half. The antibiotic stewardship program was canceled in 2008 in favor of providing more infectious-disease consulting as an alternative mode of stewardship. Over the subsequent two years, antibiotic costs went back up 32%, reports lead author Harold Standiford, MD.
“Our results clearly show that an antimicrobial stewardship program like the one at UMMC is safe, effective, and makes good financial sense,” he says, adding physicians should eliminate wasteful healthcare spending.
References
- Centers for Disease Control and Prevention. Vital signs: preventing Clostridium difficile infections. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6109a3.htm. Accessed March 29, 2012.
- Standiford HC, Chan S, Tripoli M, Weekes E, Forrest GN. Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program. Infect Control Hosp Epidemiol. 2012;33(4);338-345.
AMA Microsite Offers New Practice-Management Resources
In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.
An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.
One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.
In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.
An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.
One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.
In January, the American Medical Association (AMA) announced a redesigned website for its Practice Management Center (PMC), a resource designed to help physicians manage their practice more effectively. The PMC includes an online library of tools to help physicians streamline their administrative and business practices, with new sections on practice operations, claims revenue cycle management, and health insurer relations.
An estimated 7,000 visitors access the center each month. Physicians can sign up for practice management alerts or join an online community.
One particular resource that might be useful to hospitalists is a sample hospital-physician employment agreement.
Hospital Quality Reporting Fails to Impact Death Rates
A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.1 The data were inconclusive on the impact of reporting on heart failure.
The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.
Reference
A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.1 The data were inconclusive on the impact of reporting on heart failure.
The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.
Reference
A study in the March issue of Health Affairs concludes that Hospital Compare, the government’s national hospital quality data reporting system, has produced no reductions in 30-day mortality rates for heart attacks and pneumonia, beyond what would be expected due to existing trends and ongoing innovations in care.1 The data were inconclusive on the impact of reporting on heart failure.
The survey covers Medicare claims data from 2000 to 2008. Its authors say it is one of the strongest studies yet, suggesting that Medicare’s public reporting has little or no impact on actual hospital quality—at least according to current metrics. The jury is still out on Medicare’s efforts to improve hospital quality of care with public reporting, with more study needed, according to lead author Andrew Ryan, MD, of Weill Cornell Medical College in New York City.
Reference
Win Whitcomb: Hospitalists, PCPs, and Population Health
Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.
In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.
In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.
SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:
- Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
- Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
- PCPs should be more involved in the inpatient care of the complex medically ill; and
- There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.
As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:
- Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
- Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
- Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
- Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.
SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.
Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.
While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.
Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.
Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.
In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.
In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.
SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:
- Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
- Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
- PCPs should be more involved in the inpatient care of the complex medically ill; and
- There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.
As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:
- Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
- Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
- Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
- Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.
SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.
Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.
While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.
Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.
Jan. 1 marked the official start of the Accountable Care Organization (ACO) era, with 32 Pioneer ACOs across the country beginning a three-year program embracing the “three-part aim” of improving the health of the population, enhancing patient experience, and making costs sustainable. Later this year, many more ACOs will come on line around the country under the Medicare Shared Savings Program. Perhaps the biggest challenge to ACOs will be the management of the complex medically ill, or those individuals with two or more concurrent chronic conditions that require ongoing medical attention and/or limit activities of daily living.
In 2011, SHM embarked on a groundbreaking project to improve care coordination between hospitalists and primary-care physicians (PCPs). The Complex Medically Ill Project is being carried out at three health systems and has already had a positive impact. As part of the project, SHM is working with a mobile and online physician community, QuantiaMD, to both learn and teach during the one-year project. Parenthetically, in a short time, the collaboration has yielded glimpses of the potential of mobile technology to improve healthcare, or at least learn about physician attitudes and preferences.
In November 2011, SHM queried hospitalists and PCPs about communication and care coordination between the two specialties regarding treatment of the complex medically ill patient. Remarkably, 4,000 PCPs and hospitalists responded to the survey. In less than a month, we collected more information on this crucial topic than at any other time in the past.
SHM has prepared a white paper that will provide a full picture of what we learned. Here is a preview of the survey findings:
- Improvement efforts in hospitalist-PCP communication should focus on 1) the hospital discharge and 2) the “black hole” —the time between hospital discharge and first follow-up with a PCP;
- Hospitalists and PCPs feel that the telephone currently is the best communication tool, but both groups agree that technology solutions will improve care coordination more than human resources (e.g. a transitions coach) or process improvement (e.g. checklists or discharge bundles);
- PCPs should be more involved in the inpatient care of the complex medically ill; and
- There is a high degree of alignment between PCPs and hospitalists regarding the importance of robust communication for complex medically ill patients.
As ACOs and other approaches to payment innovation expand to effectively manage the health of a population, HM must evolve its focus away from just managing the individual patient during an acute hospitalization and toward a true collaboration with PCPs and the medical home. What will this look like? In pockets across the country, there are hospitalist systems that have enabled 1990s-style managed care to survive and thrive under Medicare Advantage programs (physician groups and hospitals that have aligned incentives under capitated or global payments). They provide some of the best insight into how HM can embrace population health management. The key elements of these hospitalist programs include:
- Aligned incentives with PCPs (and in some cases specialists) and the hospital under a global payment for a population of patients;
- Active participation in disease-management programs for patients, especially the complex medically ill, across the care continuum, including the home and post-acute-care venues;
- Use of “front-end” technology to coordinate care with the PCP and other members of the care team; and
- Use of “back-end” technology to 1) track key measures of healthcare quality and population health, 2) measure and manage utilization of resources, and 3) accurately capture severity of population illness.
SHM’s Complex Medically Ill Project will be one of a number of “test tubes” for care coordination in HM as it transitions from fee-for-service to global payment and population health management. The coming months will see the start of the ACO voyage for a few hundred health systems and their hospitalist programs.
Additionally, Medicare Advantage programs continue to grow, fueling efforts at better coordination and disease management, with hospitalists squarely in the mix. Surely, each of these will represent an experiment in the design of systems for population health management.
While it is anyone’s guess as to whether these policy initiatives will have a major impact on cost containment while maintaining quality and access, it is hard to imagine the brave new world without a retooled hospitalist model that plays an integral role in population health.
Win Whitcomb, MD, MHM is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is a co-founder and past president of SHM. Email him at wfwhit@comcast.net.
Shaun Frost: Accountability Is Key to Hospital Medicine's Success
As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.
The Accountability Imperative
If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”
Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.1 The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.
Accountability and Autonomy
Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.2 He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.
Failure to Perform Not an Option
It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.
References
As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.
The Accountability Imperative
If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”
Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.1 The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.
Accountability and Autonomy
Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.2 He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.
Failure to Perform Not an Option
It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.
References
As the train of healthcare reform has undeniably left the station and presently is barreling down the tracks with unstoppable momentum, the need for the specialty of hospital medicine to truly perform as an agent of high-quality, cost-effective care delivery is of paramount importance. By perform, I mean deliver measurable results, and truly realize expectations that we have set for ourselves as a profession—a profession that has claimed since its infancy that a core justification for its existence is the ability for it to realize the goals of healthcare quality improvement (QI).
We have done much in our short history to position ourselves to realize these goals, and in many of our hospitals and communities, we are delivering tangible results. In some settings, however, we could do more. Essential to capitalizing on these performance-improvement opportunities is ensuring every hospitalist and every HM professional commits personally to making high-quality care delivery a non-negotiable proposition.
Accountability is at issue here. We all must strive to consistently hold ourselves, and each other, personally accountable for embracing the work necessary to realize HM’s potential to be a true healthcare reform effector. We have to “put our money where our mouth is” by delivering tangible performance results.
The Accountability Imperative
If there are any doubts about the need for accountability to drive performance in today’s healthcare climate, one need not look further than work ongoing to redesign the manner in which healthcare is delivered through the creation of Accountable Care Organizations (ACOs). The ACO concept is complicated and confusing, and it is doubtful that anyone knows with certainty how it will work. One thing though that should be clear is that ACOs will not be successful unless each of their members is accountable for delivering high-value healthcare—the “A” in the acronym, after all, stands for “accountable.”
Advancing the accountability imperative further is a New England Journal of Medicine sounding board article by Wachter and Pronovost, where it is eloquently argued that the time has come to hold individuals accountable for sub-optimal performance on those quality imperatives for which broken systems have been successfully redesigned.1 The authors propose that it is no longer appropriate to blame systems failures as the reason for inadequate performance, because clinicians who fail to hold themselves accountable for working within the context of successfully redesigned systems is often the relevant problem.
The authors use hand hygiene as an example, noting that despite such efforts as extensive education, increased access to hand-washing materials, and creative auditing efforts to measure performance, hospitals continue to have unacceptably low hand hygiene rates. They argue that “low hand hygiene rates are generally not a systems problem anymore; they are largely an accountability problem.” They also cite “following an institution’s guidelines regarding provider-to-provider signout at the end of a shift” as an issue of unique importance to hospitalist practice.
Emphasizing that disciplinary action is in order for poor-performing individuals, Wachter and Pronovost conclude that it is time for us to place accountability for the delivery of high-quality care at the top of our agenda. If we do not, the authors believe, regulators “are likely to judge” our lack of accountability “as an example of guild behavior,” that will result in “further intrusion on the practice of medicine.” They go on to suggest that “having our own profession unblinkingly deem some behaviors as unacceptable, with clear consequences, will serve as a vivid example of our professionalism, and thus represent our best protection against such outside intrusions.”1
Avoiding outside intrusions, however, should not be the primary motivator. We should hold ourselves accountable for high-quality care delivery because it is the right thing to do, and our patients deserve nothing less. It is time for HM to get serious by not tolerating performance failures due to accountability lapses. We must define clear, non-negotiable performance imperatives (e.g. hand hygiene and adequate end-of-shift signouts), and demand accountability by not being afraid to enforce penalties for habitual failure to meet expectations.
Accountability and Autonomy
Accountability is hard, and in healthcare it is tempting to avoid responsibility by invoking myriad excuses as to why we cannot or should not be held individually accountable. An oft-cited excuse for why physicians should not be expected to comply with QI initiatives is that doing so threatens a physician’s ability to customize care in situations in which unique circumstances necessitate customization. The argument advanced is that “medicine is an art,” and as such physicians must be permitted to act autonomously. Inevitably, these arguments proceed by invoking problems created by a decline in the degree of physician decision-making independence, and further lament a loss of autonomy.
Reinertsen has written about why the medical profession has witnessed a decline in autonomy over the past decades.2 He notes that physicians have done a poor job in holding themselves accountable for consistently practicing the science of medicine, thus necessitating the imposition of rules and regulations to ensure that every patient always receives the best care. While calling this out, Reinertsen acknowledges a place for autonomy in the practice of medicine by writing: “If clinical autonomy is good for the art of medicine … we should do a better job of policing our profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity.”
Reinertsen’s argument is beautiful in its simplicity. Furthermore, it emphasizes the accountability imperative considered above by Wachter and Pronovost. We cannot ignore that accountability failures by some of our physician predecessors are directly responsible for the quality problems that we currently face, and we must accept this as a legitimate reason for our diminishing professional autonomy. To correct this going forward, we have to hold each other and ourselves accountable for doing what is right, for it is only then that we will regain our autonomy by earning the trust and respect of the patients and the system that we serve.
Failure to Perform Not an Option
It is undeniable that in its brief history, HM has done fabulous things for patients through redesigning faulty healthcare systems that compromise our ability to consistently deliver high-quality care. It also is true, however, that we have made promises that we have yet to decisively deliver on. The time is now to definitively perform by delivering tangible results that realize those promises.
Former Notre Dame University football coach Lou Holtz once said, “When all is said and done, a lot more is said than done.” Unfortunately, this is often true in our society, and should cause hospitalists to pause and reflect on how to prevent this from happening. After national healthcare reform is complete, we must be able to say “it has been said and done, and we did it all.”
Our legacy and the future success of HM depend on this. To guarantee we reach our full potential tomorrow, we must hold ourselves accountable today for executing on what is expected of us as agents of high-quality, cost-effective care delivery.
Dr. Frost is president of SHM.
References
Why Hospitalists are Important, Integral, and Irreplaceable
As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.
I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.
Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:
Healthcare Can’t Live without Us
Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.
We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.
We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.
We Now Own Some Very Tough Problems
Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.
Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.
We Are Shaping the Pipeline
Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.
It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.
We Have Incredible Leadership
I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.
We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.
SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.
We Are a Bargain
One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.
But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.
My Mission
So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.
Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.
Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to scheured@musc.edu.
As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.
I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.
Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:
Healthcare Can’t Live without Us
Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.
We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.
We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.
We Now Own Some Very Tough Problems
Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.
Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.
We Are Shaping the Pipeline
Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.
It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.
We Have Incredible Leadership
I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.
We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.
SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.
We Are a Bargain
One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.
But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.
My Mission
So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.
Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.
Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to scheured@musc.edu.
As an introduction to my new role as physician editor, I should explain why I took this on. Simply stated: I drank the Kool-Aid. As most of you know, drinking brightly colored sugar water is a metaphor for a sincere and dedicated belief in a philosophy (though the basis of the term resides in the Jonestown massacre of 1978, let’s put that aside for now). The philosophy to which I am referring is that which defines our field. I firmly believe in the power and the future of hospital medicine, now 30,000 strong.
I am not exactly sure when I first drank the Kool-Aid. I suspect that, like for many hospitalists, it was a slow progression in the beginning, a sip or two here and there, interspersed with 7-Eleven-sized gulps at SHM annual meetings. But I do know HM, as a specialty, is firmly ingrained in me, the super-sweet beverage running deep in my veins.
Our specialty has borne monumental accomplishments in a very short sprint, and we are well on our way to dozens more in the near future. Here are a few reasons I believe in our future:
Healthcare Can’t Live without Us
Of hospitals with more than 200 beds, hospitalists practice in more than 80% of them. I would venture the same is not true of dermatologists or neurosurgeons. We have extended our tentacles into most every area of the hospital, from the ED to post-operative holding, from the blood bank to the C-suite.
We are integral to the success of almost every area under the hospital roof. The surgeons need sharp and skillful partners. The ED physicians need reliable receivers. The quality department needs informed observers. The admitting department needs sensible triagers. The utilization review department needs thorough documenters. The primary-care doctor needs discharge coordinators.
We have been all of those things and more. Hospitalists will continue to forge into new terrain, to fill the needed voids, to bridge the gap between the seamless hospital system patients deserve and the disjointed hospital system patients often traverse through. No other specialty is doing this with such remarkable flexibility and affability.
We Now Own Some Very Tough Problems
Value, efficiency, throughput, care transitions: These are not exactly issues with effortless solutions. But through ingenuity, innovation, and elbow grease, we are chiseling away at reliable solutions for each of these areas.
Few other specialties have tackled such nebulous and multifaceted problems. We have gone so far as to build them into our core competencies and maintenance of certification. This is testimony to our dedication and willingness to create a better system.
We Are Shaping the Pipeline
Hospitalists have an immense influence over trainees in many specialties; virtually all major academic medical centers employ hospitalists for the majority of their teaching services. We likely have more face time with medical students than any other specialty. We define for them what it means to be a doctor in the 21st century.
It is certainly no longer as simple as knowing facts and figures, and possessing adequate beside rapport. Those competencies constitute less than half of what we now need to seamlessly perform. With our visibility, we are defining for the pipeline what modern doctors “look” like. Much more than think tanks, we are communicators, coordinators, and patient advocates, maneuvering them through the maze of what we currently call healthcare.
We Have Incredible Leadership
I have been repeatedly awestruck with the volume and quality of leaders within SHM and the larger hospital medicine community. Hospitalist leaders have energized all aspects of the healthcare industry, including the Centers for Medicare & Medicaid Services, the American Board of Internal Medicine, and innumerable other professional societies and medical organizations.
We routinely occupy leadership seats among residency and fellowship programs, quality and safety structures, and C-suites around the country, within hospitals of all shapes, sizes, and structures. We are leading multi-million-dollar research teams at local, regional, state, and national levels.
SHM has been instrumental in providing training opportunities for hospitalists yearning for the skill set needed to take them and their organizations to the next level. There is no doubt hospitalists will continue to expand in leadership positions around the country—and beyond.
We Are a Bargain
One of the continually unsettling statistics that gets bantered around is how “expensive” we are to hospitals. That annual sum, when last surveyed, topped out at well over $100,000 per year per full-time equivalent hospitalist. That sure sounds like a lot of money—worth a few reliable vehicles, a few years of college education, or a sizable medical school loan repayment.
But I would counter that if a hospitalist is really being a hospitalist, by diligently operating within all those facets listed above, then administrators should consider us a heap of cheap dates. This would not include hospitalists with a truncated vision of their role in the hospital, which starts and ends in sharply demarcated 12-hour shifts. The latter approach, the limited perch, could certainly be perceived as a lavish investment. In the current cost-conscious healthcare environment, it’s better to be viewed as a cheap date.
My Mission
So that is a bit about why I am here: to discourse, praise, and evangelize about hospital medicine, past, present, and future; to summarize and speculate, why we are here, and where we are going next; to regularly shower each of you with the Kool-Aid; to buffer you from the daily difficulties of a very laborious yet very rewarding career. It will be an honor and a challenge to maintain this momentum, but I do believe I can execute.
Let me end with a few words about my predecessor, Jeffrey Glasheen, MD, SFHM, who successfully shepherded the previous four-plus years of The Hospitalist. Jeff is intelligent, witty, thoughtful, and an exceptional writer. He has graciously transitioned me into the publication, and I owe him my gratitude. Jeff, just don’t go too far away, in case I ever need a sprinkle of Kool-Aid myself.
Dr. Scheurer is physician editor for The Hospitalist, and is a hospitalist and chief quality officer at the Medical University of South Carolina, Charleston, S.C. Send your comments and questions to scheured@musc.edu.
John Nelson: Your Hospital Should Use Scripts to Describe Hospitalists to Patients
My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:
- Why is my usual doctor (PCP) not going to be in charge of my hospital care?
- Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
- Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
- How will the hospitalist know my medical history, and will she communicate with my PCP?
Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.
Unintentional Undermining of Patient Confidence
Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.
To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.
Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.
Scripts for Nurses and Non-Hospitalist Physicians
Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.
Or:
Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.
The Two Most Valuable Things For A Patient To Hear Are...
- That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
- That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.
My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.
It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.
Ensure Others Know the Hospitalist’s Name
Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”
Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course
.
My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:
- Why is my usual doctor (PCP) not going to be in charge of my hospital care?
- Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
- Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
- How will the hospitalist know my medical history, and will she communicate with my PCP?
Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.
Unintentional Undermining of Patient Confidence
Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.
To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.
Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.
Scripts for Nurses and Non-Hospitalist Physicians
Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.
Or:
Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.
The Two Most Valuable Things For A Patient To Hear Are...
- That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
- That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.
My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.
It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.
Ensure Others Know the Hospitalist’s Name
Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”
Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course
.
My anecdotal experience (no scientific research data) has convinced me that nearly every patient has some or all of the following questions or concerns when admitted by a hospitalist for the first time:
- Why is my usual doctor (PCP) not going to be in charge of my hospital care?
- Is the hospitalist a “real” doctor or someone in training, and whatdoes my regular doctor think of the hospitalist?
- Does the arrival of the hospitalist mean my long-term relationship with my PCP has been severed and I’ll see the hospitalist for all care (inpatient and outpatient) from now on?
- How will the hospitalist know my medical history, and will she communicate with my PCP?
Ideally, all communication about the hospitalist as an individual and the whole system of hospitalist care should help answer these questions and reassure the patient. Sadly, many people at the hospital unwittingly do the opposite.
Unintentional Undermining of Patient Confidence
Despite good intentions, doctors and nurses at the hospital often describe hospitalists to patients in a way that undermines the patients’ satisfaction and confidence in the hospitalist. They may say something like: Your doctor (PCP) doesn’t come to the hospital anymore and we have these doctors who are here all the time called hospitalists. I’ll ask one of them to see you.
To a patient, this might sound like he’s getting just any old doctor who happens to be around with nothing to do, rather than someone who specializes in the care of hospital patients and comes highly recommended by his PCP. The patient is left wondering why their “regular doctor” isn’t in charge of the hospital care, and often suspects the PCP has terminated their relationship or has been forced to refer by an insurance company when, in fact, the PCP chose to refer. Misunderstandings like these are a recipe for less satisfied and less confident patients.
Most hospitalist groups have a brochure explaining their practice, which addresses all of these points. (A simple Internet search for “hospitalist brochure patient information” or similar terms will reveal a number of good samples.) However, some patients never get a copy, and many won’t read it. So just having a brochure isn’t enough; there needs to be a way to ensure that all verbal communication serves to enlighten and reassure the patient.
Scripts for Nurses and Non-Hospitalist Physicians
Nurses and non-hospitalist doctors might not realize they’re sowing seeds of unhappiness in how they describe the hospitalist. Targeted education usually is necessary and can provide them with a new way of talking about the hospitalist. In most cases, it will be most effective to provide them with a script to use. For example, they could say: Your doctor has decided to focus her practice on the office to be more available to you there. As a result, she has decided to refer you to Dr. Bonamassa, a doctor who specializes in the care of hospitalized patients with problems like yours. Dr. Bonamassa will communicate with your primary doctor, and you should plan to follow up with her when you are discharged.
Or:
Your doctor has asked Dr. Trucks to take care of you while you are in the hospital. He is a specialist in the care of hospitalized patients and works with a team of doctors who are in the hospital 24 hours a day. Dr. Trucks will be your main doctor while you are in the hospital.
The Two Most Valuable Things For A Patient To Hear Are...
- That their PCP is in favor of the referral to a hospitalist, and that the patient’s relationship with the PCP will remain intact. Many patients worry that the arrival of the hospitalist means they won’t see their PCP ever again. Hence, the value in mentioning the patient will follow up with their usual PCP after discharge.
- That the hospitalist is a doctor devoted to the care of hospitalized patients, or a specialist in hospital care, rather than just a doctor who happens to be available.
My experience is that some PCPs worry that their patients might think less of them if they don’t provide hospital care. So despite good intentions, these PCPs’ words, demeanor, or body language could communicate unhappiness in, or something other than enthusiasm for, the hospitalist. The PCP may tell the patient something like, “I’m sending you to the hospital where you’ll be seen by a hospitalist, but I’ll be involved or overseeing everything.” This might be said with the intention of reassuring the patient, but it has the effect of undermining the patient’s confidence in the hospitalist. Such PCPs would benefit from adopting a better script.
It takes a reasonable amount of encouragement and cajoling to get others to adopt a script like I’ve suggested above, and requires periodic remedial education to ensure it isn’t abandoned in favor of old habits. But it is worth the effort.
Ensure Others Know the Hospitalist’s Name
Using the above scripts will have limited value if others don’t have a way of knowing the name of the hospitalist who will actually see the patient. If a worried family walks out of a room and asks the nurse, “Who is taking care of my father?” it is a lot better for the nurse to respond with the hospitalist’s name rather than “Your father is on the gold service, and the gold team doctor will be around later. I’m not sure which doctor has the gold service today.”
Try to ensure that everyone at the hospital knows which hospitalist is caring for every patient every day.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is course co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course
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