The continuity of care for older patients decreased substantially from 1996 to 2006, according to a study published last month in the Journal of the American Medical Association (2009;301(16):1671-1680). And while the study period syncs up with the birth and development of HM, the study’s authors attribute only one-third of the decrease to the growth in hospitalist activity.

“In terms of the forces behind the phenomenon, I would not think hospitalists are the fundamental force behind decreasing continuity of care,” says James S. Goodwin, MD, who serves as director of the Sealy Center on Aging at the University of Texas Medical Branch in Galveston. The decrease, Dr. Goodwin says, can be better explained by a push from hospitals for more efficient and effective care at the lowest price possible.

Dr. Goodwin and other researchers analyzed Medicare records for more than 3 million hospital admissions, and concluded that outpatient-to-inpatient continuity with outpatient physicians decreased to 39.8% in 2006 from 50.5% in 1996. Accordingly, the study also found continuity to a primary-care physician (PCP) dropped to 31.9% from 44.3%. Patients with coexisting illnesses and the oldest patients were more likely to have continuity with their outpatient physicians and with their PCPs during hospitalization because of the severity and intricacies of their conditions.

Dr. Goodwin emphasizes that the study was based on a statistical analysis of Medicare data and doesn’t address quality of care issues or how the HM movement has tried to address efficiency concerns. He also acknowledges SHM and group leaders have been pushing quality initiatives in the past several years to improve the care continuum.

“Future research should explore whether the lack of continuity contributes to suboptimal care and whether interventions might ameliorate any detrimental effects of discontinuities,” the authors report.

To learn more about SHM’s quality initiative Project BOOST (Better Outcomes for Older Adults through Safe Transitions), visit www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm.

The continuity of care for older patients decreased substantially from 1996 to 2006, according to a study published last month in the Journal of the American Medical Association (2009;301(16):1671-1680). And while the study period syncs up with the birth and development of HM, the study’s authors attribute only one-third of the decrease to the growth in hospitalist activity.

“In terms of the forces behind the phenomenon, I would not think hospitalists are the fundamental force behind decreasing continuity of care,” says James S. Goodwin, MD, who serves as director of the Sealy Center on Aging at the University of Texas Medical Branch in Galveston. The decrease, Dr. Goodwin says, can be better explained by a push from hospitals for more efficient and effective care at the lowest price possible.

Dr. Goodwin and other researchers analyzed Medicare records for more than 3 million hospital admissions, and concluded that outpatient-to-inpatient continuity with outpatient physicians decreased to 39.8% in 2006 from 50.5% in 1996. Accordingly, the study also found continuity to a primary-care physician (PCP) dropped to 31.9% from 44.3%. Patients with coexisting illnesses and the oldest patients were more likely to have continuity with their outpatient physicians and with their PCPs during hospitalization because of the severity and intricacies of their conditions.

Dr. Goodwin emphasizes that the study was based on a statistical analysis of Medicare data and doesn’t address quality of care issues or how the HM movement has tried to address efficiency concerns. He also acknowledges SHM and group leaders have been pushing quality initiatives in the past several years to improve the care continuum.

“Future research should explore whether the lack of continuity contributes to suboptimal care and whether interventions might ameliorate any detrimental effects of discontinuities,” the authors report.

To learn more about SHM’s quality initiative Project BOOST (Better Outcomes for Older Adults through Safe Transitions), visit www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm.

The continuity of care for older patients decreased substantially from 1996 to 2006, according to a study published last month in the Journal of the American Medical Association (2009;301(16):1671-1680). And while the study period syncs up with the birth and development of HM, the study’s authors attribute only one-third of the decrease to the growth in hospitalist activity.

“In terms of the forces behind the phenomenon, I would not think hospitalists are the fundamental force behind decreasing continuity of care,” says James S. Goodwin, MD, who serves as director of the Sealy Center on Aging at the University of Texas Medical Branch in Galveston. The decrease, Dr. Goodwin says, can be better explained by a push from hospitals for more efficient and effective care at the lowest price possible.

Dr. Goodwin and other researchers analyzed Medicare records for more than 3 million hospital admissions, and concluded that outpatient-to-inpatient continuity with outpatient physicians decreased to 39.8% in 2006 from 50.5% in 1996. Accordingly, the study also found continuity to a primary-care physician (PCP) dropped to 31.9% from 44.3%. Patients with coexisting illnesses and the oldest patients were more likely to have continuity with their outpatient physicians and with their PCPs during hospitalization because of the severity and intricacies of their conditions.

Dr. Goodwin emphasizes that the study was based on a statistical analysis of Medicare data and doesn’t address quality of care issues or how the HM movement has tried to address efficiency concerns. He also acknowledges SHM and group leaders have been pushing quality initiatives in the past several years to improve the care continuum.

“Future research should explore whether the lack of continuity contributes to suboptimal care and whether interventions might ameliorate any detrimental effects of discontinuities,” the authors report.

To learn more about SHM’s quality initiative Project BOOST (Better Outcomes for Older Adults through Safe Transitions), visit www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm.

With all the healthcare policy changes President Obama is hoping to usher in over the next few years, it might be comforting to know that a hospitalist will be leading at least one of these initiatives. Patrick Conway, MD, has been selected to serve as executive director of the Department of Health and Human Services’ (HHS) Federal Coordinating Council for Comparative Effectiveness Research. Authorized by the American Recovery and Reinvestment Act, the council is responsible for allocating $1.1 billion for research that will compare various medical interventions.

Dr. Conway, a pediatric hospitalist who also is chief medical officer in the policy division of the Office of Secretary at HHS and does weekend rounds at Children’s National Medical Center in Washington, D.C., spoke with the TH eWire about his new role.

Some physicians are concerned the Centers for Medicare & Medicaid Services (CMS) will use the council’s findings to make payment decisions. Is this a valid worry?

They specifically put in the Recovery Act that this information should not be construed as mandates or clinical guidelines for coverage or payment. Our purview now is to fund the research that provides the information.

Is there a lack of comparative effectiveness research?

Yes. The reason this is important is there are so many common clinical decisions that as a clinician or patient we don’t know the answer to. I’ll give you one concrete example from last week when I was on service. A mother’s child who is neurologically impaired and therefore [has gastroesophageal reflux disease] asked me if [her child] should have surgery or medical management for this problem. So I have to have the painful conversation with her that there’s not good evidence to inform or start to point to whether for her child or the specific circumstances of her child she should get surgery or medical treatment.

How can get hospitalists get involved in this project?

Hospitalists should try to be on the agenda for public listening sessions to share their viewpoints. There will be spots for people to publicly read their testimony. There’ll also likely be the ability to submit comments online.

For more information or to sign up for the council’s Listening Sessions, visit www.hhs.gov/recovery/programs/cer/index.html.

With all the healthcare policy changes President Obama is hoping to usher in over the next few years, it might be comforting to know that a hospitalist will be leading at least one of these initiatives. Patrick Conway, MD, has been selected to serve as executive director of the Department of Health and Human Services’ (HHS) Federal Coordinating Council for Comparative Effectiveness Research. Authorized by the American Recovery and Reinvestment Act, the council is responsible for allocating $1.1 billion for research that will compare various medical interventions.

Dr. Conway, a pediatric hospitalist who also is chief medical officer in the policy division of the Office of Secretary at HHS and does weekend rounds at Children’s National Medical Center in Washington, D.C., spoke with the TH eWire about his new role.

Some physicians are concerned the Centers for Medicare & Medicaid Services (CMS) will use the council’s findings to make payment decisions. Is this a valid worry?

They specifically put in the Recovery Act that this information should not be construed as mandates or clinical guidelines for coverage or payment. Our purview now is to fund the research that provides the information.

Is there a lack of comparative effectiveness research?

Yes. The reason this is important is there are so many common clinical decisions that as a clinician or patient we don’t know the answer to. I’ll give you one concrete example from last week when I was on service. A mother’s child who is neurologically impaired and therefore [has gastroesophageal reflux disease] asked me if [her child] should have surgery or medical management for this problem. So I have to have the painful conversation with her that there’s not good evidence to inform or start to point to whether for her child or the specific circumstances of her child she should get surgery or medical treatment.

How can get hospitalists get involved in this project?

Hospitalists should try to be on the agenda for public listening sessions to share their viewpoints. There will be spots for people to publicly read their testimony. There’ll also likely be the ability to submit comments online.

For more information or to sign up for the council’s Listening Sessions, visit www.hhs.gov/recovery/programs/cer/index.html.

With all the healthcare policy changes President Obama is hoping to usher in over the next few years, it might be comforting to know that a hospitalist will be leading at least one of these initiatives. Patrick Conway, MD, has been selected to serve as executive director of the Department of Health and Human Services’ (HHS) Federal Coordinating Council for Comparative Effectiveness Research. Authorized by the American Recovery and Reinvestment Act, the council is responsible for allocating $1.1 billion for research that will compare various medical interventions.

Dr. Conway, a pediatric hospitalist who also is chief medical officer in the policy division of the Office of Secretary at HHS and does weekend rounds at Children’s National Medical Center in Washington, D.C., spoke with the TH eWire about his new role.

Some physicians are concerned the Centers for Medicare & Medicaid Services (CMS) will use the council’s findings to make payment decisions. Is this a valid worry?

They specifically put in the Recovery Act that this information should not be construed as mandates or clinical guidelines for coverage or payment. Our purview now is to fund the research that provides the information.

Is there a lack of comparative effectiveness research?

Yes. The reason this is important is there are so many common clinical decisions that as a clinician or patient we don’t know the answer to. I’ll give you one concrete example from last week when I was on service. A mother’s child who is neurologically impaired and therefore [has gastroesophageal reflux disease] asked me if [her child] should have surgery or medical management for this problem. So I have to have the painful conversation with her that there’s not good evidence to inform or start to point to whether for her child or the specific circumstances of her child she should get surgery or medical treatment.

How can get hospitalists get involved in this project?

Hospitalists should try to be on the agenda for public listening sessions to share their viewpoints. There will be spots for people to publicly read their testimony. There’ll also likely be the ability to submit comments online.

For more information or to sign up for the council’s Listening Sessions, visit www.hhs.gov/recovery/programs/cer/index.html.

In a survey distributed to 50 member hospitals by Allen Rosenstein, MD, and his colleagues at VHA Inc. (an alliance of 2,400 nonprofit health care organizations) more than 1,500 participants responded to questions pertaining to their colleagues’ behavior.1 Of the 965 respondents to the question Have you ever witnessed disruptive behavior from a physician at your hospital?, nearly 68% said yes. Of the 675 nurses who responded to the question, 86% said they had witnessed it; almost half of the 249 physician respondents said they had witnessed it from their peers. Most respondents estimated the number of either nurses or physicians who exhibited disruptive behavior to be 1%-3%.

Of the 1,416 respondents who answered the question How often does physician disruptive behavior occur at your hospital?, 22% answered “weekly,” 26% answered “1 to 2 times per month,” and 33% answered “1 to 5 times per year.” Interestingly, 11% of the respondents said that such behavior by physicians never occurs, but 8% said it’s a daily occurrence.

Disruptive Behavior Defined

Disruptive behavior includes anything that interferes with the ability of a healthcare professional to effectively perform his or her duties or any behavior that undermines confidence in the hospital or its workers.2-4 In general, “disruptive” refers to behaviors that are abusive, disrespectful, sexual, angry, critical, negative, inappropriate, or unethical.2 (See “What Is Disruptive Behavior?” p. 40.) Individuals termed “impaired” are those who have active addictions or psychiatric problems and who exhibit the disruptive, intimidating, or abusive behavior.

Most respondents to the above-mentioned survey reported that disruptive behavior had negative or worsening effects on stress, frustration, concentration, communication, collaboration, information transfer, and workplace relationships. (See Figure 1, p. 41.)

“Physicians whose performance persistently falters pose a substantial threat to patient safety that is often unrecognized or unsatisfactorily addressed in hospitals and other healthcare organizations,” writes Lucian Leape, MD, adjunct professor of health policy in the Department of Health Policy and Management at the Harvard School of Public Health.2

“Whoever tells you that they have not experienced any kind of disruptive behavior is either lying or … in neglect, because there are always certain types of disruptive behaviors [among healthcare workers],” says Martin Izakovic, MD, medical director, Hospitalist Program, Mercy Hospital, Iowa City, Iowa.

Effects of Disruptive Behavior

Can we go so far as to say disruptive behavior affects clinical outcomes?

“It has to,” says Scott Flanders, MD, associate professor of medicine at the University of Michigan and director of the hospitalist program, Ann Arbor, and member of SHM’s board of directors. “People clearly understand the importance of teamwork in hospital medicine. If one member of the team is dysfunctional from an emotional intelligence/behavioral standpoint, that drags down the team in its entirety and impacts patient care.”

Providing safe and effective care should be the first priority of all healthcare professionals. Excellent outcomes have been associated with procedural efficiency and the use of evidence-based standards and tools designed to reduce the likelihood of medical error. The effects of work relationships on clinical outcomes are less well documented, but attention to the matter is increasing in parallel with the focus on patient safety.3,5

Dr. Leape, one of the founders of the National Patient Safety Foundation, devotes concerted energy to making organizations aware of the need to upgrade systems to diagnose and treat this problem.2 “Physician performance failures are not rare and pose substantial threats to patient welfare and safety,” he writes. “Few hospitals respond to such failures promptly or effectively. Failure to ensure the quality and safety of the performance of colleagues is a breach of medicine’s fiduciary responsibility to the public.”6

When it comes to the issues of behavior, besides monitoring their own performance, what do hospitalists do when they come up against colleagues whose shortcomings require correction in order for the entire institution to uphold its legal obligation to each patient?

Physician, Heal Thyself

A study published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported that 24% of sentinel events could be attributed to problems referred to as human factors, including communication gaps, staffing issues, and lack of teamwork.2, 5 The March 2004 issue of the Institute for Safe Medication Practice’s (ISMP) Medication Safety Alert reported that 7% of medication errors could be attributed to nurses feeling intimidated by physicians.4 And, as a response to this growing problem, the Institute of Medicine’s groundbreaking report on medical errors and patient safety, To Err is Human, shifted the focus from individual blame to that of preventing errors through efforts to “design safety into systems.”7

Dr. Flanders, who is also associate chief for the Division of General Internal Medicine for Inpatient Programs at the University of Michigan Medical Center (Ann Arbor), certainly understands the need to grapple with these types of issues. He is a member of his institution’s interdisciplinary Medical Staff Quality Committee (MSQC), which works to get a better handle on individual physician-level quality and performance.

“A lot stems from JCAHO’s increased focus on institutions doing a better job of trying to figure out, in short, who’s a good doctor and who’s a bad doctor,” he says, “And having medical staff appointments, privileging, and assessment of clinical skills be something a little more robust than just asking four of your friends if they think you’re a good doctor.”

One of the charges of the MSQC is developing a better system of tracking physicians’ clinical skills down to the individual level, which Dr. Flanders says is a difficult task. But their second charge is even more elusive to track: examining “the range of daily activities, behaviors, and actions that encompass being a physician.” As part of that, the committee deals with interpersonal relations: interactions with other staff and behavioral issues.

Make the Diagnosis, Initiate Treatment

As with most academic medical centers, when someone at MSQC observes a behavioral issue, that person’s supervisor (often a department chair) is the next place for the buck to stop. There are clearly defined lines of communication and “very robust systems” to deal with these kinds of things, says Dr. Flanders.

MSQC is assisting department chairs in dealing with a particular behavior or problem. “It is a venue to vet particular problems and solutions,” he says. Ultimately, if there are repeated transgressions and administration is not satisfied that their directives have been followed, the committee can recommend revoking a physician’s medical staff privileges and implementing a remediation plan.

Those robust systems have not differed in medical institutions for the last 50 years. “I think what has changed is people are less willing to tolerate this persistently,” says Dr. Flanders. “People used to put up with the disruptive physician, the badly behaving physician, and if he was bringing in lots of research dollars or if he was a great scientist, [they’d be more likely to] accept bad behavior.”

With the increased risk of litigation and the increasing scrutiny on patient safety, these offenses can no longer be tolerated.8

At a community hospital, the hierarchies and channels of communication for handling behavioral issues are different. Because of the different atmosphere and mood of a hospitalist department, says Dr. Izakovic, who is also adjunct clinical assistant professor, Department of Internal Medicine, University of Iowa–Carver College of Medicine, Iowa City, “plus word of mouth, it is easier to either enforce or, even more, lead by example [such that] certain behaviors are [encouraged] and certain behavior types are suppressed.”

click for large version

Michael Zavarin, MD, director of the hospitalist group at Jordan Hospital in Plymouth, Mass., agrees that the environment of a community hospital may be different enough so that handling disruptive behavior also occurs differently than it does in an academic medical center.

Dr. Zavarin’s group is composed of 6.5 full-time day hospitalists and one full-time night hospitalist, as well as two nurse practitioners. Disruptive behavior in his group “really hasn’t been an issue, so I guess it is [dealt with] on an as-needed basis,” he says, and he can only speculate that the proper channel for dealing with situations involving disruptive behavior would be his institution’s medical executive committee.

When Dr. Izakovic faces situations involving disruptive behavior, he says, it is generally an instance in which a hospitalist has “a good intention, but feels pressured by overwork or patient care circumstances, or [has] difficulty communicating or handling the nursing staff … who perceive [the physician’s behavior] as being either threatening or disrespectful or just not called for.”9

He estimates that these instances occur most often when a physician’s expectations are not met regarding duties being performed in a timely manner. Formal complaints are rarely made in his group—maybe two or three times a year. In those cases, he is responsible for formal follow-up, which requires having a one-on-one conversation with the physician and reporting back to the risk management department. But he prefers doing what is necessary to avoid a situation getting to that stage. Informal behavior-related events happen at least monthly, he estimates. “I’d rather hear earlier than later, with no formal complaint, no formal channel,” says Dr. Izakovic.

Blow the Whistle

What are the political ramifications of blowing the whistle on a disruptive colleague? The University of Michigan’s MSQC was created largely to help get at that issue and to create a place where such subjects can be brought up anonymously. [It can be done] if the reporting person wishes. In most situations, there has been a concerted effort against backlash just as there is when incidents and errors are reported to improve or maintain patient safety.

“As the patient safety culture changes, and I think it is changing, it’s going to facilitate culture change on this issue, too,” says Dr. Flanders, “because I think people are beginning to recognize, appropriately so, that some of these behavioral issues are safety issues.”

Do nurses feel comfortable reporting such instances? “I think it depends on the personality,” says Dr. Izakovic. “Some do, and some feel less comfortable; there are nurses who never complain and nurses who always complain, like doctors and everybody else. But I think that the climate is changing [so] that raising your voice and pointing toward deficiency and/or imperfection is becoming, if not [socially] acceptable, then [at least] a standard of behavior.”

Behavior, Safety, and Quality

“Communication is the key to success in today’s medicine,” says Dr. Izakovic. “Specifically among hospitalists: You communicate with the family physician, the patient, the referring specialist, or specialist that you called, the family, nurses, and patients all around the hospital.” And although communication is the most important part of the hospitalist’s practice, he says, “it sometimes leads to tension, and it’s not as much the message that you want to convey as the form [you use] and how it is transferred.”

Nurses are key stakeholders in reporting these behaviors, just as they are encouraged to report errors as an expression of their professionalism. Certainly, Dr. Flanders says, reporting a behavioral incident is “a lot more personal and less tangible than reporting a wrong dose on a medication.”

He has noticed a dramatic increase in the number of messages he receives about inappropriate or dangerous behavior among physicians. Everyone has a bad day from time to time, he says, but at the end of the year, “if I have one physician who has been mentioned 15 times, that helps me assess that person overall as a professional and be able to say, ‘Listen, there may be some red flags here’ and [then we can] begin to intervene and try to change that behavior.”

Effective systems employed to adequately address performance problems should be fair, objective, and responsive, writes Dr. Leape.2,6 Strategies available to handle incidents of disruptive behavior include adopting performance standards for behavior as well as competence. All physicians should be required to acknowledge in writing that they have read and understood these standards and that persistent failure to uphold them will result in loss of clinical privileges. Adherence to standards should be monitored annually and provided confidentially to each individual. Finally, assessment and treatment programs must be available to manage all the underlying causes of sub-par performance. The long-term objective is to enable physicians to continue to practice, as opposed to attempting to “weed them out.”

Prevention

According to Balazs Zsenits, MD, director, Division of Hospital Medicine at Rochester General Hospital, Rochester, N.Y., two mechanisms should be applied when discussing the prevention of disruptive behavior.

“First, physician selection should be conducted by a thorough interview process,” he says, “including at least a full-day face-to-face interview, discussion with previous employers, assessment of team-participation experience, and communication skills.”

Also, you need to clarify your expectations by means of “written policies, leading by example, promoting this culture in meetings, etc., and proactively monitoring performance,” says Dr. Zsenits. That means talking with doctors, nurses, and families and actively looking for feedback. “This process is time-intensive and may be under-recognized during resource allocation, but I believe it is a tool that may prevent this and many other common problems from growing out of control.”

A director of a hospital medicine group may have to deal with the perception of an escalating number of complaints about physician behaviors. “The growth of a hospitalist program that goes from seeing a small fraction of patients within a hospital to seeing the majority of medical admissions creates challenges beyond just simply managing the increased number of doctors and complaints,” says Dr. Zsenits. “Our co-workers and stakeholders might develop an impression that ‘most doctor problems’ in the hospital are related to the hospitalists. Even if this is [because] the hospitalists actually take care of most patients in house, and each hospitalist takes care of many more patients than private attendings used to, avoiding the perception that this single group is associated with most complaints is a difficult task.”

Although hospitalists’ focus on teamwork and quality of care may improve the actual statistics, he adds, “some factors may create more feedback, including more complaints; for example, being new docs to patients and relatives at times of stress, and having a closer working relationship with nurses, which may [be problematic] by creating heightened expectations or [because you are working with] a young workforce … .”

Conclusion

Hospitalists can increase their capacities to observe, document, address, consult on, and refer instances of disruptive behavior appropriately. Although incidents of disruption may be relatively infrequent and may involve a few perpetrators, when they occur they should be addressed promptly and appropriately. Strategies to address the issue of disruptive behavior include conducting an organizational assessment; opening up lines of communication, including inviting nurses as well as physicians to submit anonymous notes or suggestions; and increasing staff awareness of the nature and severity of the issue.

As Dr. Flanders and colleagues have written, hospitalists should be the “fulcrum” we use to improve patient safety.10 The advantage of having just a few hospitalists influencing the healthcare of many patients can be a detriment if a colleague is a “problem doctor.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006 Jul;203(1):96-105. Epub 2006 Jun 5.
2. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006 Jan 17;144(2):107-115.
3. Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Safety Qual Healthcare. 2006 Jul-Aug;3:16-24.
4. Institute for Safe Medication Practice. Intimidation: practitioners speak up about this unresolved problem (Part I) ISMP Medication Safety Alert. Available at: www.ismp.org/MSAarticles/intimidation.htm. Accessed on October 16, 2006.
5. Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005 Jan;105(1):54-64; quiz 64-55.
6. Leape LL. Physician self-examination. Int J Qual Health Care. 1998;10(4):289-290.
7. Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press; 2000.
8. Linney BJ. Confronting the disruptive physician. Physician Exec. 1997 Sep-Oct;23(7):55-58.
9. Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
10. Flanders SA, Kaufman SR, Saint S. Hospitalists as emerging leaders in patient safety: targeting a few to affect many. J Patient Safety. 2005 Jun;1(2):78-82.

In a survey distributed to 50 member hospitals by Allen Rosenstein, MD, and his colleagues at VHA Inc. (an alliance of 2,400 nonprofit health care organizations) more than 1,500 participants responded to questions pertaining to their colleagues’ behavior.1 Of the 965 respondents to the question Have you ever witnessed disruptive behavior from a physician at your hospital?, nearly 68% said yes. Of the 675 nurses who responded to the question, 86% said they had witnessed it; almost half of the 249 physician respondents said they had witnessed it from their peers. Most respondents estimated the number of either nurses or physicians who exhibited disruptive behavior to be 1%-3%.

Of the 1,416 respondents who answered the question How often does physician disruptive behavior occur at your hospital?, 22% answered “weekly,” 26% answered “1 to 2 times per month,” and 33% answered “1 to 5 times per year.” Interestingly, 11% of the respondents said that such behavior by physicians never occurs, but 8% said it’s a daily occurrence.

Disruptive Behavior Defined

Disruptive behavior includes anything that interferes with the ability of a healthcare professional to effectively perform his or her duties or any behavior that undermines confidence in the hospital or its workers.2-4 In general, “disruptive” refers to behaviors that are abusive, disrespectful, sexual, angry, critical, negative, inappropriate, or unethical.2 (See “What Is Disruptive Behavior?” p. 40.) Individuals termed “impaired” are those who have active addictions or psychiatric problems and who exhibit the disruptive, intimidating, or abusive behavior.

Most respondents to the above-mentioned survey reported that disruptive behavior had negative or worsening effects on stress, frustration, concentration, communication, collaboration, information transfer, and workplace relationships. (See Figure 1, p. 41.)

“Physicians whose performance persistently falters pose a substantial threat to patient safety that is often unrecognized or unsatisfactorily addressed in hospitals and other healthcare organizations,” writes Lucian Leape, MD, adjunct professor of health policy in the Department of Health Policy and Management at the Harvard School of Public Health.2

“Whoever tells you that they have not experienced any kind of disruptive behavior is either lying or … in neglect, because there are always certain types of disruptive behaviors [among healthcare workers],” says Martin Izakovic, MD, medical director, Hospitalist Program, Mercy Hospital, Iowa City, Iowa.

Effects of Disruptive Behavior

Can we go so far as to say disruptive behavior affects clinical outcomes?

“It has to,” says Scott Flanders, MD, associate professor of medicine at the University of Michigan and director of the hospitalist program, Ann Arbor, and member of SHM’s board of directors. “People clearly understand the importance of teamwork in hospital medicine. If one member of the team is dysfunctional from an emotional intelligence/behavioral standpoint, that drags down the team in its entirety and impacts patient care.”

Providing safe and effective care should be the first priority of all healthcare professionals. Excellent outcomes have been associated with procedural efficiency and the use of evidence-based standards and tools designed to reduce the likelihood of medical error. The effects of work relationships on clinical outcomes are less well documented, but attention to the matter is increasing in parallel with the focus on patient safety.3,5

Dr. Leape, one of the founders of the National Patient Safety Foundation, devotes concerted energy to making organizations aware of the need to upgrade systems to diagnose and treat this problem.2 “Physician performance failures are not rare and pose substantial threats to patient welfare and safety,” he writes. “Few hospitals respond to such failures promptly or effectively. Failure to ensure the quality and safety of the performance of colleagues is a breach of medicine’s fiduciary responsibility to the public.”6

When it comes to the issues of behavior, besides monitoring their own performance, what do hospitalists do when they come up against colleagues whose shortcomings require correction in order for the entire institution to uphold its legal obligation to each patient?

Physician, Heal Thyself

A study published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported that 24% of sentinel events could be attributed to problems referred to as human factors, including communication gaps, staffing issues, and lack of teamwork.2, 5 The March 2004 issue of the Institute for Safe Medication Practice’s (ISMP) Medication Safety Alert reported that 7% of medication errors could be attributed to nurses feeling intimidated by physicians.4 And, as a response to this growing problem, the Institute of Medicine’s groundbreaking report on medical errors and patient safety, To Err is Human, shifted the focus from individual blame to that of preventing errors through efforts to “design safety into systems.”7

Dr. Flanders, who is also associate chief for the Division of General Internal Medicine for Inpatient Programs at the University of Michigan Medical Center (Ann Arbor), certainly understands the need to grapple with these types of issues. He is a member of his institution’s interdisciplinary Medical Staff Quality Committee (MSQC), which works to get a better handle on individual physician-level quality and performance.

“A lot stems from JCAHO’s increased focus on institutions doing a better job of trying to figure out, in short, who’s a good doctor and who’s a bad doctor,” he says, “And having medical staff appointments, privileging, and assessment of clinical skills be something a little more robust than just asking four of your friends if they think you’re a good doctor.”

One of the charges of the MSQC is developing a better system of tracking physicians’ clinical skills down to the individual level, which Dr. Flanders says is a difficult task. But their second charge is even more elusive to track: examining “the range of daily activities, behaviors, and actions that encompass being a physician.” As part of that, the committee deals with interpersonal relations: interactions with other staff and behavioral issues.

Make the Diagnosis, Initiate Treatment

As with most academic medical centers, when someone at MSQC observes a behavioral issue, that person’s supervisor (often a department chair) is the next place for the buck to stop. There are clearly defined lines of communication and “very robust systems” to deal with these kinds of things, says Dr. Flanders.

MSQC is assisting department chairs in dealing with a particular behavior or problem. “It is a venue to vet particular problems and solutions,” he says. Ultimately, if there are repeated transgressions and administration is not satisfied that their directives have been followed, the committee can recommend revoking a physician’s medical staff privileges and implementing a remediation plan.

Those robust systems have not differed in medical institutions for the last 50 years. “I think what has changed is people are less willing to tolerate this persistently,” says Dr. Flanders. “People used to put up with the disruptive physician, the badly behaving physician, and if he was bringing in lots of research dollars or if he was a great scientist, [they’d be more likely to] accept bad behavior.”

With the increased risk of litigation and the increasing scrutiny on patient safety, these offenses can no longer be tolerated.8

At a community hospital, the hierarchies and channels of communication for handling behavioral issues are different. Because of the different atmosphere and mood of a hospitalist department, says Dr. Izakovic, who is also adjunct clinical assistant professor, Department of Internal Medicine, University of Iowa–Carver College of Medicine, Iowa City, “plus word of mouth, it is easier to either enforce or, even more, lead by example [such that] certain behaviors are [encouraged] and certain behavior types are suppressed.”

click for large version

Michael Zavarin, MD, director of the hospitalist group at Jordan Hospital in Plymouth, Mass., agrees that the environment of a community hospital may be different enough so that handling disruptive behavior also occurs differently than it does in an academic medical center.

Dr. Zavarin’s group is composed of 6.5 full-time day hospitalists and one full-time night hospitalist, as well as two nurse practitioners. Disruptive behavior in his group “really hasn’t been an issue, so I guess it is [dealt with] on an as-needed basis,” he says, and he can only speculate that the proper channel for dealing with situations involving disruptive behavior would be his institution’s medical executive committee.

When Dr. Izakovic faces situations involving disruptive behavior, he says, it is generally an instance in which a hospitalist has “a good intention, but feels pressured by overwork or patient care circumstances, or [has] difficulty communicating or handling the nursing staff … who perceive [the physician’s behavior] as being either threatening or disrespectful or just not called for.”9

He estimates that these instances occur most often when a physician’s expectations are not met regarding duties being performed in a timely manner. Formal complaints are rarely made in his group—maybe two or three times a year. In those cases, he is responsible for formal follow-up, which requires having a one-on-one conversation with the physician and reporting back to the risk management department. But he prefers doing what is necessary to avoid a situation getting to that stage. Informal behavior-related events happen at least monthly, he estimates. “I’d rather hear earlier than later, with no formal complaint, no formal channel,” says Dr. Izakovic.

Blow the Whistle

What are the political ramifications of blowing the whistle on a disruptive colleague? The University of Michigan’s MSQC was created largely to help get at that issue and to create a place where such subjects can be brought up anonymously. [It can be done] if the reporting person wishes. In most situations, there has been a concerted effort against backlash just as there is when incidents and errors are reported to improve or maintain patient safety.

“As the patient safety culture changes, and I think it is changing, it’s going to facilitate culture change on this issue, too,” says Dr. Flanders, “because I think people are beginning to recognize, appropriately so, that some of these behavioral issues are safety issues.”

Do nurses feel comfortable reporting such instances? “I think it depends on the personality,” says Dr. Izakovic. “Some do, and some feel less comfortable; there are nurses who never complain and nurses who always complain, like doctors and everybody else. But I think that the climate is changing [so] that raising your voice and pointing toward deficiency and/or imperfection is becoming, if not [socially] acceptable, then [at least] a standard of behavior.”

Behavior, Safety, and Quality

“Communication is the key to success in today’s medicine,” says Dr. Izakovic. “Specifically among hospitalists: You communicate with the family physician, the patient, the referring specialist, or specialist that you called, the family, nurses, and patients all around the hospital.” And although communication is the most important part of the hospitalist’s practice, he says, “it sometimes leads to tension, and it’s not as much the message that you want to convey as the form [you use] and how it is transferred.”

Nurses are key stakeholders in reporting these behaviors, just as they are encouraged to report errors as an expression of their professionalism. Certainly, Dr. Flanders says, reporting a behavioral incident is “a lot more personal and less tangible than reporting a wrong dose on a medication.”

He has noticed a dramatic increase in the number of messages he receives about inappropriate or dangerous behavior among physicians. Everyone has a bad day from time to time, he says, but at the end of the year, “if I have one physician who has been mentioned 15 times, that helps me assess that person overall as a professional and be able to say, ‘Listen, there may be some red flags here’ and [then we can] begin to intervene and try to change that behavior.”

Effective systems employed to adequately address performance problems should be fair, objective, and responsive, writes Dr. Leape.2,6 Strategies available to handle incidents of disruptive behavior include adopting performance standards for behavior as well as competence. All physicians should be required to acknowledge in writing that they have read and understood these standards and that persistent failure to uphold them will result in loss of clinical privileges. Adherence to standards should be monitored annually and provided confidentially to each individual. Finally, assessment and treatment programs must be available to manage all the underlying causes of sub-par performance. The long-term objective is to enable physicians to continue to practice, as opposed to attempting to “weed them out.”

Prevention

According to Balazs Zsenits, MD, director, Division of Hospital Medicine at Rochester General Hospital, Rochester, N.Y., two mechanisms should be applied when discussing the prevention of disruptive behavior.

“First, physician selection should be conducted by a thorough interview process,” he says, “including at least a full-day face-to-face interview, discussion with previous employers, assessment of team-participation experience, and communication skills.”

Also, you need to clarify your expectations by means of “written policies, leading by example, promoting this culture in meetings, etc., and proactively monitoring performance,” says Dr. Zsenits. That means talking with doctors, nurses, and families and actively looking for feedback. “This process is time-intensive and may be under-recognized during resource allocation, but I believe it is a tool that may prevent this and many other common problems from growing out of control.”

A director of a hospital medicine group may have to deal with the perception of an escalating number of complaints about physician behaviors. “The growth of a hospitalist program that goes from seeing a small fraction of patients within a hospital to seeing the majority of medical admissions creates challenges beyond just simply managing the increased number of doctors and complaints,” says Dr. Zsenits. “Our co-workers and stakeholders might develop an impression that ‘most doctor problems’ in the hospital are related to the hospitalists. Even if this is [because] the hospitalists actually take care of most patients in house, and each hospitalist takes care of many more patients than private attendings used to, avoiding the perception that this single group is associated with most complaints is a difficult task.”

Although hospitalists’ focus on teamwork and quality of care may improve the actual statistics, he adds, “some factors may create more feedback, including more complaints; for example, being new docs to patients and relatives at times of stress, and having a closer working relationship with nurses, which may [be problematic] by creating heightened expectations or [because you are working with] a young workforce … .”

Conclusion

Hospitalists can increase their capacities to observe, document, address, consult on, and refer instances of disruptive behavior appropriately. Although incidents of disruption may be relatively infrequent and may involve a few perpetrators, when they occur they should be addressed promptly and appropriately. Strategies to address the issue of disruptive behavior include conducting an organizational assessment; opening up lines of communication, including inviting nurses as well as physicians to submit anonymous notes or suggestions; and increasing staff awareness of the nature and severity of the issue.

As Dr. Flanders and colleagues have written, hospitalists should be the “fulcrum” we use to improve patient safety.10 The advantage of having just a few hospitalists influencing the healthcare of many patients can be a detriment if a colleague is a “problem doctor.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006 Jul;203(1):96-105. Epub 2006 Jun 5.
2. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006 Jan 17;144(2):107-115.
3. Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Safety Qual Healthcare. 2006 Jul-Aug;3:16-24.
4. Institute for Safe Medication Practice. Intimidation: practitioners speak up about this unresolved problem (Part I) ISMP Medication Safety Alert. Available at: www.ismp.org/MSAarticles/intimidation.htm. Accessed on October 16, 2006.
5. Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005 Jan;105(1):54-64; quiz 64-55.
6. Leape LL. Physician self-examination. Int J Qual Health Care. 1998;10(4):289-290.
7. Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press; 2000.
8. Linney BJ. Confronting the disruptive physician. Physician Exec. 1997 Sep-Oct;23(7):55-58.
9. Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
10. Flanders SA, Kaufman SR, Saint S. Hospitalists as emerging leaders in patient safety: targeting a few to affect many. J Patient Safety. 2005 Jun;1(2):78-82.

In a survey distributed to 50 member hospitals by Allen Rosenstein, MD, and his colleagues at VHA Inc. (an alliance of 2,400 nonprofit health care organizations) more than 1,500 participants responded to questions pertaining to their colleagues’ behavior.1 Of the 965 respondents to the question Have you ever witnessed disruptive behavior from a physician at your hospital?, nearly 68% said yes. Of the 675 nurses who responded to the question, 86% said they had witnessed it; almost half of the 249 physician respondents said they had witnessed it from their peers. Most respondents estimated the number of either nurses or physicians who exhibited disruptive behavior to be 1%-3%.

Of the 1,416 respondents who answered the question How often does physician disruptive behavior occur at your hospital?, 22% answered “weekly,” 26% answered “1 to 2 times per month,” and 33% answered “1 to 5 times per year.” Interestingly, 11% of the respondents said that such behavior by physicians never occurs, but 8% said it’s a daily occurrence.

Disruptive Behavior Defined

Disruptive behavior includes anything that interferes with the ability of a healthcare professional to effectively perform his or her duties or any behavior that undermines confidence in the hospital or its workers.2-4 In general, “disruptive” refers to behaviors that are abusive, disrespectful, sexual, angry, critical, negative, inappropriate, or unethical.2 (See “What Is Disruptive Behavior?” p. 40.) Individuals termed “impaired” are those who have active addictions or psychiatric problems and who exhibit the disruptive, intimidating, or abusive behavior.

Most respondents to the above-mentioned survey reported that disruptive behavior had negative or worsening effects on stress, frustration, concentration, communication, collaboration, information transfer, and workplace relationships. (See Figure 1, p. 41.)

“Physicians whose performance persistently falters pose a substantial threat to patient safety that is often unrecognized or unsatisfactorily addressed in hospitals and other healthcare organizations,” writes Lucian Leape, MD, adjunct professor of health policy in the Department of Health Policy and Management at the Harvard School of Public Health.2

“Whoever tells you that they have not experienced any kind of disruptive behavior is either lying or … in neglect, because there are always certain types of disruptive behaviors [among healthcare workers],” says Martin Izakovic, MD, medical director, Hospitalist Program, Mercy Hospital, Iowa City, Iowa.

Effects of Disruptive Behavior

Can we go so far as to say disruptive behavior affects clinical outcomes?

“It has to,” says Scott Flanders, MD, associate professor of medicine at the University of Michigan and director of the hospitalist program, Ann Arbor, and member of SHM’s board of directors. “People clearly understand the importance of teamwork in hospital medicine. If one member of the team is dysfunctional from an emotional intelligence/behavioral standpoint, that drags down the team in its entirety and impacts patient care.”

Providing safe and effective care should be the first priority of all healthcare professionals. Excellent outcomes have been associated with procedural efficiency and the use of evidence-based standards and tools designed to reduce the likelihood of medical error. The effects of work relationships on clinical outcomes are less well documented, but attention to the matter is increasing in parallel with the focus on patient safety.3,5

Dr. Leape, one of the founders of the National Patient Safety Foundation, devotes concerted energy to making organizations aware of the need to upgrade systems to diagnose and treat this problem.2 “Physician performance failures are not rare and pose substantial threats to patient welfare and safety,” he writes. “Few hospitals respond to such failures promptly or effectively. Failure to ensure the quality and safety of the performance of colleagues is a breach of medicine’s fiduciary responsibility to the public.”6

When it comes to the issues of behavior, besides monitoring their own performance, what do hospitalists do when they come up against colleagues whose shortcomings require correction in order for the entire institution to uphold its legal obligation to each patient?

Physician, Heal Thyself

A study published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reported that 24% of sentinel events could be attributed to problems referred to as human factors, including communication gaps, staffing issues, and lack of teamwork.2, 5 The March 2004 issue of the Institute for Safe Medication Practice’s (ISMP) Medication Safety Alert reported that 7% of medication errors could be attributed to nurses feeling intimidated by physicians.4 And, as a response to this growing problem, the Institute of Medicine’s groundbreaking report on medical errors and patient safety, To Err is Human, shifted the focus from individual blame to that of preventing errors through efforts to “design safety into systems.”7

Dr. Flanders, who is also associate chief for the Division of General Internal Medicine for Inpatient Programs at the University of Michigan Medical Center (Ann Arbor), certainly understands the need to grapple with these types of issues. He is a member of his institution’s interdisciplinary Medical Staff Quality Committee (MSQC), which works to get a better handle on individual physician-level quality and performance.

“A lot stems from JCAHO’s increased focus on institutions doing a better job of trying to figure out, in short, who’s a good doctor and who’s a bad doctor,” he says, “And having medical staff appointments, privileging, and assessment of clinical skills be something a little more robust than just asking four of your friends if they think you’re a good doctor.”

One of the charges of the MSQC is developing a better system of tracking physicians’ clinical skills down to the individual level, which Dr. Flanders says is a difficult task. But their second charge is even more elusive to track: examining “the range of daily activities, behaviors, and actions that encompass being a physician.” As part of that, the committee deals with interpersonal relations: interactions with other staff and behavioral issues.

Make the Diagnosis, Initiate Treatment

As with most academic medical centers, when someone at MSQC observes a behavioral issue, that person’s supervisor (often a department chair) is the next place for the buck to stop. There are clearly defined lines of communication and “very robust systems” to deal with these kinds of things, says Dr. Flanders.

MSQC is assisting department chairs in dealing with a particular behavior or problem. “It is a venue to vet particular problems and solutions,” he says. Ultimately, if there are repeated transgressions and administration is not satisfied that their directives have been followed, the committee can recommend revoking a physician’s medical staff privileges and implementing a remediation plan.

Those robust systems have not differed in medical institutions for the last 50 years. “I think what has changed is people are less willing to tolerate this persistently,” says Dr. Flanders. “People used to put up with the disruptive physician, the badly behaving physician, and if he was bringing in lots of research dollars or if he was a great scientist, [they’d be more likely to] accept bad behavior.”

With the increased risk of litigation and the increasing scrutiny on patient safety, these offenses can no longer be tolerated.8

At a community hospital, the hierarchies and channels of communication for handling behavioral issues are different. Because of the different atmosphere and mood of a hospitalist department, says Dr. Izakovic, who is also adjunct clinical assistant professor, Department of Internal Medicine, University of Iowa–Carver College of Medicine, Iowa City, “plus word of mouth, it is easier to either enforce or, even more, lead by example [such that] certain behaviors are [encouraged] and certain behavior types are suppressed.”

click for large version

Michael Zavarin, MD, director of the hospitalist group at Jordan Hospital in Plymouth, Mass., agrees that the environment of a community hospital may be different enough so that handling disruptive behavior also occurs differently than it does in an academic medical center.

Dr. Zavarin’s group is composed of 6.5 full-time day hospitalists and one full-time night hospitalist, as well as two nurse practitioners. Disruptive behavior in his group “really hasn’t been an issue, so I guess it is [dealt with] on an as-needed basis,” he says, and he can only speculate that the proper channel for dealing with situations involving disruptive behavior would be his institution’s medical executive committee.

When Dr. Izakovic faces situations involving disruptive behavior, he says, it is generally an instance in which a hospitalist has “a good intention, but feels pressured by overwork or patient care circumstances, or [has] difficulty communicating or handling the nursing staff … who perceive [the physician’s behavior] as being either threatening or disrespectful or just not called for.”9

He estimates that these instances occur most often when a physician’s expectations are not met regarding duties being performed in a timely manner. Formal complaints are rarely made in his group—maybe two or three times a year. In those cases, he is responsible for formal follow-up, which requires having a one-on-one conversation with the physician and reporting back to the risk management department. But he prefers doing what is necessary to avoid a situation getting to that stage. Informal behavior-related events happen at least monthly, he estimates. “I’d rather hear earlier than later, with no formal complaint, no formal channel,” says Dr. Izakovic.

Blow the Whistle

What are the political ramifications of blowing the whistle on a disruptive colleague? The University of Michigan’s MSQC was created largely to help get at that issue and to create a place where such subjects can be brought up anonymously. [It can be done] if the reporting person wishes. In most situations, there has been a concerted effort against backlash just as there is when incidents and errors are reported to improve or maintain patient safety.

“As the patient safety culture changes, and I think it is changing, it’s going to facilitate culture change on this issue, too,” says Dr. Flanders, “because I think people are beginning to recognize, appropriately so, that some of these behavioral issues are safety issues.”

Do nurses feel comfortable reporting such instances? “I think it depends on the personality,” says Dr. Izakovic. “Some do, and some feel less comfortable; there are nurses who never complain and nurses who always complain, like doctors and everybody else. But I think that the climate is changing [so] that raising your voice and pointing toward deficiency and/or imperfection is becoming, if not [socially] acceptable, then [at least] a standard of behavior.”

Behavior, Safety, and Quality

“Communication is the key to success in today’s medicine,” says Dr. Izakovic. “Specifically among hospitalists: You communicate with the family physician, the patient, the referring specialist, or specialist that you called, the family, nurses, and patients all around the hospital.” And although communication is the most important part of the hospitalist’s practice, he says, “it sometimes leads to tension, and it’s not as much the message that you want to convey as the form [you use] and how it is transferred.”

Nurses are key stakeholders in reporting these behaviors, just as they are encouraged to report errors as an expression of their professionalism. Certainly, Dr. Flanders says, reporting a behavioral incident is “a lot more personal and less tangible than reporting a wrong dose on a medication.”

He has noticed a dramatic increase in the number of messages he receives about inappropriate or dangerous behavior among physicians. Everyone has a bad day from time to time, he says, but at the end of the year, “if I have one physician who has been mentioned 15 times, that helps me assess that person overall as a professional and be able to say, ‘Listen, there may be some red flags here’ and [then we can] begin to intervene and try to change that behavior.”

Effective systems employed to adequately address performance problems should be fair, objective, and responsive, writes Dr. Leape.2,6 Strategies available to handle incidents of disruptive behavior include adopting performance standards for behavior as well as competence. All physicians should be required to acknowledge in writing that they have read and understood these standards and that persistent failure to uphold them will result in loss of clinical privileges. Adherence to standards should be monitored annually and provided confidentially to each individual. Finally, assessment and treatment programs must be available to manage all the underlying causes of sub-par performance. The long-term objective is to enable physicians to continue to practice, as opposed to attempting to “weed them out.”

Prevention

According to Balazs Zsenits, MD, director, Division of Hospital Medicine at Rochester General Hospital, Rochester, N.Y., two mechanisms should be applied when discussing the prevention of disruptive behavior.

“First, physician selection should be conducted by a thorough interview process,” he says, “including at least a full-day face-to-face interview, discussion with previous employers, assessment of team-participation experience, and communication skills.”

Also, you need to clarify your expectations by means of “written policies, leading by example, promoting this culture in meetings, etc., and proactively monitoring performance,” says Dr. Zsenits. That means talking with doctors, nurses, and families and actively looking for feedback. “This process is time-intensive and may be under-recognized during resource allocation, but I believe it is a tool that may prevent this and many other common problems from growing out of control.”

A director of a hospital medicine group may have to deal with the perception of an escalating number of complaints about physician behaviors. “The growth of a hospitalist program that goes from seeing a small fraction of patients within a hospital to seeing the majority of medical admissions creates challenges beyond just simply managing the increased number of doctors and complaints,” says Dr. Zsenits. “Our co-workers and stakeholders might develop an impression that ‘most doctor problems’ in the hospital are related to the hospitalists. Even if this is [because] the hospitalists actually take care of most patients in house, and each hospitalist takes care of many more patients than private attendings used to, avoiding the perception that this single group is associated with most complaints is a difficult task.”

Although hospitalists’ focus on teamwork and quality of care may improve the actual statistics, he adds, “some factors may create more feedback, including more complaints; for example, being new docs to patients and relatives at times of stress, and having a closer working relationship with nurses, which may [be problematic] by creating heightened expectations or [because you are working with] a young workforce … .”

Conclusion

Hospitalists can increase their capacities to observe, document, address, consult on, and refer instances of disruptive behavior appropriately. Although incidents of disruption may be relatively infrequent and may involve a few perpetrators, when they occur they should be addressed promptly and appropriately. Strategies to address the issue of disruptive behavior include conducting an organizational assessment; opening up lines of communication, including inviting nurses as well as physicians to submit anonymous notes or suggestions; and increasing staff awareness of the nature and severity of the issue.

As Dr. Flanders and colleagues have written, hospitalists should be the “fulcrum” we use to improve patient safety.10 The advantage of having just a few hospitalists influencing the healthcare of many patients can be a detriment if a colleague is a “problem doctor.” TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Rosenstein AH, O'Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006 Jul;203(1):96-105. Epub 2006 Jun 5.
2. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006 Jan 17;144(2):107-115.
3. Porto G, Lauve R. Disruptive clinician behavior: a persistent threat to patient safety. Patient Safety Qual Healthcare. 2006 Jul-Aug;3:16-24.
4. Institute for Safe Medication Practice. Intimidation: practitioners speak up about this unresolved problem (Part I) ISMP Medication Safety Alert. Available at: www.ismp.org/MSAarticles/intimidation.htm. Accessed on October 16, 2006.
5. Rosenstein AH, O'Daniel M. Disruptive behavior and clinical outcomes: perceptions of nurses and physicians. Am J Nurs. 2005 Jan;105(1):54-64; quiz 64-55.
6. Leape LL. Physician self-examination. Int J Qual Health Care. 1998;10(4):289-290.
7. Kohn L, Corrigan J, Donaldson M, eds. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press; 2000.
8. Linney BJ. Confronting the disruptive physician. Physician Exec. 1997 Sep-Oct;23(7):55-58.
9. Localio AR, Lawthers AG, Brennan TA, et al. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. N Engl J Med. 1991 Jul 25;325(4):245-251.
10. Flanders SA, Kaufman SR, Saint S. Hospitalists as emerging leaders in patient safety: targeting a few to affect many. J Patient Safety. 2005 Jun;1(2):78-82.

Mark Chassin, MD, isn’t quite sure what he’ll say when he steps to the podium to deliver the keynote address at sold-out HM09.

“At the pace everything is changing, it’s hard to know exactly what I’ll want to talk about,” says Chassin, president of The Joint Commission.

He is certain about one thing, however: the importance of reaching out to and connecting with hospital-based physicians. “Accreditation alone is not enough,” Dr. Chassin says. “We need active engagement of the hospital medicine practitioners in all of the quality and safety initiatives The Joint Commission has set in motion.

“It’s also important," he continues, "for us to hear from physicians on the front lines ... about how our efforts are working and where we need to fill in gaps.”

Since taking over as president of The Joint Commission in January 2008, Dr. Chassin has pushed for the organization to adopt business management strategies like Six Sigma and the Toyota Production System. The goal is to work with hospitals and health systems that also use these strategies to rectify recurring safety and quality problems, such as medication reconciliation, infection control breakdown, and wrong-site/wrong-side surgery.

His ultimate goal is to make sure the commission and organizations that deliver care work together to transform healthcare into a high-reliability industry.

“The legacy of what The Joint Commission used to be sometimes gets caricatured as a bunch of silly rules and hoops people have to jump through that have nothing to do with patient care,” Dr. Chassin says. “That caricature really is a thing of the past.”

To read an in-depth interview with Dr. Chassin, see the June issue of The Hospitalist.

HM 2009 will take place May 14-17 in Chicago. For more information, visit SHM's Web site.

Mark Chassin, MD, isn’t quite sure what he’ll say when he steps to the podium to deliver the keynote address at sold-out HM09.

“At the pace everything is changing, it’s hard to know exactly what I’ll want to talk about,” says Chassin, president of The Joint Commission.

He is certain about one thing, however: the importance of reaching out to and connecting with hospital-based physicians. “Accreditation alone is not enough,” Dr. Chassin says. “We need active engagement of the hospital medicine practitioners in all of the quality and safety initiatives The Joint Commission has set in motion.

“It’s also important," he continues, "for us to hear from physicians on the front lines ... about how our efforts are working and where we need to fill in gaps.”

Since taking over as president of The Joint Commission in January 2008, Dr. Chassin has pushed for the organization to adopt business management strategies like Six Sigma and the Toyota Production System. The goal is to work with hospitals and health systems that also use these strategies to rectify recurring safety and quality problems, such as medication reconciliation, infection control breakdown, and wrong-site/wrong-side surgery.

His ultimate goal is to make sure the commission and organizations that deliver care work together to transform healthcare into a high-reliability industry.

“The legacy of what The Joint Commission used to be sometimes gets caricatured as a bunch of silly rules and hoops people have to jump through that have nothing to do with patient care,” Dr. Chassin says. “That caricature really is a thing of the past.”

To read an in-depth interview with Dr. Chassin, see the June issue of The Hospitalist.

HM 2009 will take place May 14-17 in Chicago. For more information, visit SHM's Web site.

Mark Chassin, MD, isn’t quite sure what he’ll say when he steps to the podium to deliver the keynote address at sold-out HM09.

“At the pace everything is changing, it’s hard to know exactly what I’ll want to talk about,” says Chassin, president of The Joint Commission.

He is certain about one thing, however: the importance of reaching out to and connecting with hospital-based physicians. “Accreditation alone is not enough,” Dr. Chassin says. “We need active engagement of the hospital medicine practitioners in all of the quality and safety initiatives The Joint Commission has set in motion.

“It’s also important," he continues, "for us to hear from physicians on the front lines ... about how our efforts are working and where we need to fill in gaps.”

Since taking over as president of The Joint Commission in January 2008, Dr. Chassin has pushed for the organization to adopt business management strategies like Six Sigma and the Toyota Production System. The goal is to work with hospitals and health systems that also use these strategies to rectify recurring safety and quality problems, such as medication reconciliation, infection control breakdown, and wrong-site/wrong-side surgery.

His ultimate goal is to make sure the commission and organizations that deliver care work together to transform healthcare into a high-reliability industry.

“The legacy of what The Joint Commission used to be sometimes gets caricatured as a bunch of silly rules and hoops people have to jump through that have nothing to do with patient care,” Dr. Chassin says. “That caricature really is a thing of the past.”

To read an in-depth interview with Dr. Chassin, see the June issue of The Hospitalist.

HM 2009 will take place May 14-17 in Chicago. For more information, visit SHM's Web site.

Sutharsanam Veerappan, MD, a pediatric hospitalist, learned while on a family vacation to India that his New Jersey hospital had chosen him as 2008's Physician of the Year. So he did what anyone 7,000 miles from work would do: He cut short the family time to receive an honor from his other family.

"Dr. Veerappan just gets it," says Jeanne Whaley, RN, manager of the Maternity and Newborn Care Center at Hunterdon Medical Center (HMC) in Raritan Township, N.J. "He understands what it means to be a team."

HMC nurses say honoring a hospitalist is a testament to how comfortable the staff is with having a full-time hospitalist to rely on, as opposed to the pre-HM model of private-practice doctors making rounds.

Dr. Veerappan, medical director for newborn and pediatric services, is a familiar face in the maternity ward, as well as the pediatrics and emergency departments. He's known for bringing in coffee cake in the mornings, pizza on busy days, and even making accommodations for nursing staff to attend conferences.

Hospitalists aren't "always dashing out to the office," says Ardath Youngblood, RN, MN, a perinatal educator at HMC. "There's a depth of relationship that develops sometimes with a hospitalist because they're around more and available more. It definitely builds teamwork."

For his part, Dr. Veerappan shies away from the attention he's been given for receiving the award. He is proud of the accomplishment, but he still views HM as a team sport that involves nurses and physicians from other departments. Still, he acknowledges his constant presence in the hospital affords him advantages in working with both staff and patients.

"The communication is the key part here," Dr. Veerappan says. "When [nurses or patients] have questions, we just show up in the room and answer them."

Sutharsanam Veerappan, MD, a pediatric hospitalist, learned while on a family vacation to India that his New Jersey hospital had chosen him as 2008's Physician of the Year. So he did what anyone 7,000 miles from work would do: He cut short the family time to receive an honor from his other family.

"Dr. Veerappan just gets it," says Jeanne Whaley, RN, manager of the Maternity and Newborn Care Center at Hunterdon Medical Center (HMC) in Raritan Township, N.J. "He understands what it means to be a team."

HMC nurses say honoring a hospitalist is a testament to how comfortable the staff is with having a full-time hospitalist to rely on, as opposed to the pre-HM model of private-practice doctors making rounds.

Dr. Veerappan, medical director for newborn and pediatric services, is a familiar face in the maternity ward, as well as the pediatrics and emergency departments. He's known for bringing in coffee cake in the mornings, pizza on busy days, and even making accommodations for nursing staff to attend conferences.

Hospitalists aren't "always dashing out to the office," says Ardath Youngblood, RN, MN, a perinatal educator at HMC. "There's a depth of relationship that develops sometimes with a hospitalist because they're around more and available more. It definitely builds teamwork."

For his part, Dr. Veerappan shies away from the attention he's been given for receiving the award. He is proud of the accomplishment, but he still views HM as a team sport that involves nurses and physicians from other departments. Still, he acknowledges his constant presence in the hospital affords him advantages in working with both staff and patients.

"The communication is the key part here," Dr. Veerappan says. "When [nurses or patients] have questions, we just show up in the room and answer them."

Sutharsanam Veerappan, MD, a pediatric hospitalist, learned while on a family vacation to India that his New Jersey hospital had chosen him as 2008's Physician of the Year. So he did what anyone 7,000 miles from work would do: He cut short the family time to receive an honor from his other family.

"Dr. Veerappan just gets it," says Jeanne Whaley, RN, manager of the Maternity and Newborn Care Center at Hunterdon Medical Center (HMC) in Raritan Township, N.J. "He understands what it means to be a team."

HMC nurses say honoring a hospitalist is a testament to how comfortable the staff is with having a full-time hospitalist to rely on, as opposed to the pre-HM model of private-practice doctors making rounds.

Dr. Veerappan, medical director for newborn and pediatric services, is a familiar face in the maternity ward, as well as the pediatrics and emergency departments. He's known for bringing in coffee cake in the mornings, pizza on busy days, and even making accommodations for nursing staff to attend conferences.

Hospitalists aren't "always dashing out to the office," says Ardath Youngblood, RN, MN, a perinatal educator at HMC. "There's a depth of relationship that develops sometimes with a hospitalist because they're around more and available more. It definitely builds teamwork."

For his part, Dr. Veerappan shies away from the attention he's been given for receiving the award. He is proud of the accomplishment, but he still views HM as a team sport that involves nurses and physicians from other departments. Still, he acknowledges his constant presence in the hospital affords him advantages in working with both staff and patients.

"The communication is the key part here," Dr. Veerappan says. "When [nurses or patients] have questions, we just show up in the room and answer them."

Like many family medicine practices, Chris Heck, MD’s, group in Waynesboro, Va., made the tough decision two years ago to limit their practice to outpatient services. According to Dr. Heck, one partner, Tom McNamara, DO, MMM, CPE, was reluctant to give up hospital work.

So, maybe it’s not surprising Dr. McNamara now fills a unique dual role, as president and chief executive officer and a working hospitalist at Carilion Stonewall Jackson Hospital in Lexington, Va. Dr. McNamara is the first physician CEO at Stonewall Jackson, and the first doctor of osteopathic medicine CEO at one of the hospitals in the Carilion Clinic, a Virginia-based multispecialty organization with more than 400 doctors and eight hospitals.

Serving double duty as CEO and a hospitalist at a critical-access, 25-bed hospital seems to suit Dr. McNamara. “It has allowed me to quickly and thoroughly learn about our staff and our patients,” he says. “And it has given me insight into quality, cost, and feedback programs from both sides, so that I can make informed decisions.”

Both Perspectives

When Dr. McNamara first agreed to be CEO and work shifts, he feared he might have difficulty considering doctors’ requests impartially, or that physicians might feel uneasy working with their boss during patient encounters.

Neither fear has panned out. He says the physicians and recruits he works with generally feel they have an advocate in the executive suite. In addition, when they come to him with suggestions and requests, “they bring very thorough arguments because they know I know exactly where they’re coming from,” he adds.

Dr. McNamara already has put this unique perspective to use several times since taking the jobs in April. For example, when he started the staff was experiencing glitches when filing lab reports in patients’ electronic health records. “They were changing the process when I came in, but since I had broad experiences,” he says, “I was able to help make the changes smoother.”

Dr. McNamara also improved the hospital’s hand-washing practices by having dispensers placed in hallways, where their use could be more readily observed. The idea was to increase documentation of hand washing. “I had this thought because I had used the dispensers [at another hospital] myself,” he says.

Dr. McNamara’s hands-on experience also has made the hospitalist recruiting process easier, according to Howard Graman, MD, medical director of Carilion. “[Dr. McNamara] knows the profile of the job and the kind of person who would like it,” Dr. Graman says. “He’s a savvy judge of character.”

Double-Duty Accolades

Dr. McNamara’s bosses are happy with how he has handled the juggling act, so far. Dr. Graman says Dr. McNamara has helped him to better understand the institution, how to make improvements, and how to respond to staff. “It’s great for employees to see the head of the hospital working,” he says.

The man Dr. McNamara replaced, Steve Arner, now vice president of cardiac and vascular services for a larger Carilion hospital, agrees there are advantages to having the hospital’s CEO also be a working physician. “On the floor or in the emergency department, [Tom] can test the processes, especially new ones,” Arner says, “and see first hand the impact on practitioners and patients.”

Dr. McNamara peers think he’s effective in both of his roles. “As CEO, Tom may touch a dozen topics in a given day,” Arner says. “The boiler breaks, he does a community lecture, talks to unhappy cafeteria workers. It’s so many different things.” Because Dr. McNamara is a working physician, his words greatly affect the groups he lectures. “The fact that he is still treating patients builds confidence, especially in a small community, that the hospital is a high-quality institution,” Dr. Arner adds.

Even the nursing department is in Dr. McNamara’s corner. Shelia Hatmaker, Stonewall Jackson’s director of nursing for more than two years, appreciates the fact Dr. McNamara respects the role of nurses and understands how to address nurse-specific issues. “Tom values the partnership with nurses who are with the patients all day,” Hatmaker says. “He is my boss, but he respects and seeks out opinions from a nursing point of view.”

As CEO, “Tom can create an environment where the staff feels safe to practice and speak up when something is wrong,” she says. “They have to feel comfortable saying they almost made a mistake, because it’s often the system that needs changing.”

Agent of Change

Those system changes are now Dr. McNamara’s problem, but he’s well prepared, having earned a master’s degree in medical management from Carnegie Mellon University in 2006, 19 years after finishing his residency in family practice at McKeesport Hospital in Pennsylvania, and receiving certifications from the American College of Physician Executives.

Nevertheless, Dr. McNamara had serious reservations about leaving clinical medicine. “Clinical medicine is why I became a doctor in the first place,” he says.

Working as a hospitalist and serving as the hospital’s chief executive allows Dr. McNamara to provide patient care and lead at the same time, setting an example for admission-time standards, physician-to-physician communication, and relationships with specialists, nurses, and ancillary staff, says Dennis Means, MD, also a member of the Carilion management team. From a practical point of view, it also gives the regularly rotating doctors a break. Dr. McNamara works weekend shifts every few weeks.

Still, the new CEO has more than patient care to consider. “I’ve really been struck by how high costs are and how much reimbursements are being cut back,” he says. “I was always aware of cost issues, but now I have to figure out the best way to use our scarce resources. It doesn’t change what I do for patients, but I’m even more aware that money is very tight and I have to recognize that we can’t meet every need.”

It helps to be part of the larger Carilion system, as Stonewall Jackson is in the process of integrating with the other Carilion facilities. “We are a very small facility providing basic services, but we can tap into the capabilities of much larger Carilion institutions and people to serve this community,” Dr. McNamara says.

Hatmaker, the nursing director, isn’t surprised to hear that’s how Dr. McNamara the new CEO feels. “That’s Tom,” she says. “He wants to take care of this community. And the patients just might have the head of the hospital as their doctor. How cool.” TH

Like many family medicine practices, Chris Heck, MD’s, group in Waynesboro, Va., made the tough decision two years ago to limit their practice to outpatient services. According to Dr. Heck, one partner, Tom McNamara, DO, MMM, CPE, was reluctant to give up hospital work.

So, maybe it’s not surprising Dr. McNamara now fills a unique dual role, as president and chief executive officer and a working hospitalist at Carilion Stonewall Jackson Hospital in Lexington, Va. Dr. McNamara is the first physician CEO at Stonewall Jackson, and the first doctor of osteopathic medicine CEO at one of the hospitals in the Carilion Clinic, a Virginia-based multispecialty organization with more than 400 doctors and eight hospitals.

Serving double duty as CEO and a hospitalist at a critical-access, 25-bed hospital seems to suit Dr. McNamara. “It has allowed me to quickly and thoroughly learn about our staff and our patients,” he says. “And it has given me insight into quality, cost, and feedback programs from both sides, so that I can make informed decisions.”

Both Perspectives

When Dr. McNamara first agreed to be CEO and work shifts, he feared he might have difficulty considering doctors’ requests impartially, or that physicians might feel uneasy working with their boss during patient encounters.

Neither fear has panned out. He says the physicians and recruits he works with generally feel they have an advocate in the executive suite. In addition, when they come to him with suggestions and requests, “they bring very thorough arguments because they know I know exactly where they’re coming from,” he adds.

Dr. McNamara already has put this unique perspective to use several times since taking the jobs in April. For example, when he started the staff was experiencing glitches when filing lab reports in patients’ electronic health records. “They were changing the process when I came in, but since I had broad experiences,” he says, “I was able to help make the changes smoother.”

Dr. McNamara also improved the hospital’s hand-washing practices by having dispensers placed in hallways, where their use could be more readily observed. The idea was to increase documentation of hand washing. “I had this thought because I had used the dispensers [at another hospital] myself,” he says.

Dr. McNamara’s hands-on experience also has made the hospitalist recruiting process easier, according to Howard Graman, MD, medical director of Carilion. “[Dr. McNamara] knows the profile of the job and the kind of person who would like it,” Dr. Graman says. “He’s a savvy judge of character.”

Double-Duty Accolades

Dr. McNamara’s bosses are happy with how he has handled the juggling act, so far. Dr. Graman says Dr. McNamara has helped him to better understand the institution, how to make improvements, and how to respond to staff. “It’s great for employees to see the head of the hospital working,” he says.

The man Dr. McNamara replaced, Steve Arner, now vice president of cardiac and vascular services for a larger Carilion hospital, agrees there are advantages to having the hospital’s CEO also be a working physician. “On the floor or in the emergency department, [Tom] can test the processes, especially new ones,” Arner says, “and see first hand the impact on practitioners and patients.”

Dr. McNamara peers think he’s effective in both of his roles. “As CEO, Tom may touch a dozen topics in a given day,” Arner says. “The boiler breaks, he does a community lecture, talks to unhappy cafeteria workers. It’s so many different things.” Because Dr. McNamara is a working physician, his words greatly affect the groups he lectures. “The fact that he is still treating patients builds confidence, especially in a small community, that the hospital is a high-quality institution,” Dr. Arner adds.

Even the nursing department is in Dr. McNamara’s corner. Shelia Hatmaker, Stonewall Jackson’s director of nursing for more than two years, appreciates the fact Dr. McNamara respects the role of nurses and understands how to address nurse-specific issues. “Tom values the partnership with nurses who are with the patients all day,” Hatmaker says. “He is my boss, but he respects and seeks out opinions from a nursing point of view.”

As CEO, “Tom can create an environment where the staff feels safe to practice and speak up when something is wrong,” she says. “They have to feel comfortable saying they almost made a mistake, because it’s often the system that needs changing.”

Agent of Change

Those system changes are now Dr. McNamara’s problem, but he’s well prepared, having earned a master’s degree in medical management from Carnegie Mellon University in 2006, 19 years after finishing his residency in family practice at McKeesport Hospital in Pennsylvania, and receiving certifications from the American College of Physician Executives.

Nevertheless, Dr. McNamara had serious reservations about leaving clinical medicine. “Clinical medicine is why I became a doctor in the first place,” he says.

Working as a hospitalist and serving as the hospital’s chief executive allows Dr. McNamara to provide patient care and lead at the same time, setting an example for admission-time standards, physician-to-physician communication, and relationships with specialists, nurses, and ancillary staff, says Dennis Means, MD, also a member of the Carilion management team. From a practical point of view, it also gives the regularly rotating doctors a break. Dr. McNamara works weekend shifts every few weeks.

Still, the new CEO has more than patient care to consider. “I’ve really been struck by how high costs are and how much reimbursements are being cut back,” he says. “I was always aware of cost issues, but now I have to figure out the best way to use our scarce resources. It doesn’t change what I do for patients, but I’m even more aware that money is very tight and I have to recognize that we can’t meet every need.”

It helps to be part of the larger Carilion system, as Stonewall Jackson is in the process of integrating with the other Carilion facilities. “We are a very small facility providing basic services, but we can tap into the capabilities of much larger Carilion institutions and people to serve this community,” Dr. McNamara says.

Hatmaker, the nursing director, isn’t surprised to hear that’s how Dr. McNamara the new CEO feels. “That’s Tom,” she says. “He wants to take care of this community. And the patients just might have the head of the hospital as their doctor. How cool.” TH

Like many family medicine practices, Chris Heck, MD’s, group in Waynesboro, Va., made the tough decision two years ago to limit their practice to outpatient services. According to Dr. Heck, one partner, Tom McNamara, DO, MMM, CPE, was reluctant to give up hospital work.

So, maybe it’s not surprising Dr. McNamara now fills a unique dual role, as president and chief executive officer and a working hospitalist at Carilion Stonewall Jackson Hospital in Lexington, Va. Dr. McNamara is the first physician CEO at Stonewall Jackson, and the first doctor of osteopathic medicine CEO at one of the hospitals in the Carilion Clinic, a Virginia-based multispecialty organization with more than 400 doctors and eight hospitals.

Serving double duty as CEO and a hospitalist at a critical-access, 25-bed hospital seems to suit Dr. McNamara. “It has allowed me to quickly and thoroughly learn about our staff and our patients,” he says. “And it has given me insight into quality, cost, and feedback programs from both sides, so that I can make informed decisions.”

Both Perspectives

When Dr. McNamara first agreed to be CEO and work shifts, he feared he might have difficulty considering doctors’ requests impartially, or that physicians might feel uneasy working with their boss during patient encounters.

Neither fear has panned out. He says the physicians and recruits he works with generally feel they have an advocate in the executive suite. In addition, when they come to him with suggestions and requests, “they bring very thorough arguments because they know I know exactly where they’re coming from,” he adds.

Dr. McNamara already has put this unique perspective to use several times since taking the jobs in April. For example, when he started the staff was experiencing glitches when filing lab reports in patients’ electronic health records. “They were changing the process when I came in, but since I had broad experiences,” he says, “I was able to help make the changes smoother.”

Dr. McNamara also improved the hospital’s hand-washing practices by having dispensers placed in hallways, where their use could be more readily observed. The idea was to increase documentation of hand washing. “I had this thought because I had used the dispensers [at another hospital] myself,” he says.

Dr. McNamara’s hands-on experience also has made the hospitalist recruiting process easier, according to Howard Graman, MD, medical director of Carilion. “[Dr. McNamara] knows the profile of the job and the kind of person who would like it,” Dr. Graman says. “He’s a savvy judge of character.”

Double-Duty Accolades

Dr. McNamara’s bosses are happy with how he has handled the juggling act, so far. Dr. Graman says Dr. McNamara has helped him to better understand the institution, how to make improvements, and how to respond to staff. “It’s great for employees to see the head of the hospital working,” he says.

The man Dr. McNamara replaced, Steve Arner, now vice president of cardiac and vascular services for a larger Carilion hospital, agrees there are advantages to having the hospital’s CEO also be a working physician. “On the floor or in the emergency department, [Tom] can test the processes, especially new ones,” Arner says, “and see first hand the impact on practitioners and patients.”

Dr. McNamara peers think he’s effective in both of his roles. “As CEO, Tom may touch a dozen topics in a given day,” Arner says. “The boiler breaks, he does a community lecture, talks to unhappy cafeteria workers. It’s so many different things.” Because Dr. McNamara is a working physician, his words greatly affect the groups he lectures. “The fact that he is still treating patients builds confidence, especially in a small community, that the hospital is a high-quality institution,” Dr. Arner adds.

Even the nursing department is in Dr. McNamara’s corner. Shelia Hatmaker, Stonewall Jackson’s director of nursing for more than two years, appreciates the fact Dr. McNamara respects the role of nurses and understands how to address nurse-specific issues. “Tom values the partnership with nurses who are with the patients all day,” Hatmaker says. “He is my boss, but he respects and seeks out opinions from a nursing point of view.”

As CEO, “Tom can create an environment where the staff feels safe to practice and speak up when something is wrong,” she says. “They have to feel comfortable saying they almost made a mistake, because it’s often the system that needs changing.”

Agent of Change

Those system changes are now Dr. McNamara’s problem, but he’s well prepared, having earned a master’s degree in medical management from Carnegie Mellon University in 2006, 19 years after finishing his residency in family practice at McKeesport Hospital in Pennsylvania, and receiving certifications from the American College of Physician Executives.

Nevertheless, Dr. McNamara had serious reservations about leaving clinical medicine. “Clinical medicine is why I became a doctor in the first place,” he says.

Working as a hospitalist and serving as the hospital’s chief executive allows Dr. McNamara to provide patient care and lead at the same time, setting an example for admission-time standards, physician-to-physician communication, and relationships with specialists, nurses, and ancillary staff, says Dennis Means, MD, also a member of the Carilion management team. From a practical point of view, it also gives the regularly rotating doctors a break. Dr. McNamara works weekend shifts every few weeks.

Still, the new CEO has more than patient care to consider. “I’ve really been struck by how high costs are and how much reimbursements are being cut back,” he says. “I was always aware of cost issues, but now I have to figure out the best way to use our scarce resources. It doesn’t change what I do for patients, but I’m even more aware that money is very tight and I have to recognize that we can’t meet every need.”

It helps to be part of the larger Carilion system, as Stonewall Jackson is in the process of integrating with the other Carilion facilities. “We are a very small facility providing basic services, but we can tap into the capabilities of much larger Carilion institutions and people to serve this community,” Dr. McNamara says.

Hatmaker, the nursing director, isn’t surprised to hear that’s how Dr. McNamara the new CEO feels. “That’s Tom,” she says. “He wants to take care of this community. And the patients just might have the head of the hospital as their doctor. How cool.” TH

Last summer, 17 infants mistakenly were given incorrect doses of the blood-thinning medication heparin during their stay at a hospital in Corpus Christi, Texas. Two of those infants died.

Thousands of medication errors, including the ordering, dispensing and monitoring of medication, occur each year in hospitals throughout the country. Several studies in recent years have shown that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions and more than two billion dollars annually in inpatient costs.

Whether a patient is an infant, child or adult, the potential for medication errors begins as soon as a patient reaches the hospital and continues well after discharge.

“Medication errors often start when the patient comes to the emergency room,” says Sandeep Sachdeva, MD, clinical assistant professor at University of Washington Medical Center in Seattle. “Patients usually don’t carry a detailed list of the drugs they’re taking. If they come in late at night, it may not be possible for us to get an alternative list.”

That’s why it’s important for drug reconciliation to begin at the time of arrival, Dr. Sachdeva says. “In my opinion, medication reconciliation is a dynamic process, and medication reconciliation is a daily process. When patients come into the hospital, certain medications automatically get changed to the medications that are available in hospitals, and anytime there is a change in medications, it’s an opportunity for an error.”

Opportunities for Error

Even if a patient arrives with a full medication list, once he or she transfers from one hospital unit to another or is discharged, the opportunity for errors increases exponentially, says Julia Wright, MD, director of hospital medicine at University of Wisconsin Hospital and associate professor of medicine at The University of Wisconsin School of Medicine and Public Health in Madison, Wis.

“What providers have to remember is that there are multiple stages at which mistakes can be made,” says William Basco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. The physician or nurse practitioner can make a mistake writing the order; a nurse can misread the order; a pharmacist can incorrectly prepare the order; and a floor nurse can make a mistake drawing up the medication or delivering it, Dr Basco explains.

What’s a Hospitalist To Do?

Although the opportunities for medication errors are many, Dr. Basco says hospitalists should take several steps to mitigate medication errors. First, he says, limit verbal orders for drugs. Instead, write the order out, print legibly and refrain from using abbreviations. He suggests writing out numbers and placing them inside parentheses after the corresponding numeral.

“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.

Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”

Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”

Computers to the Rescue

More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”

For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.

Check with the Pharmacist

More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.

“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”

Dr. Bossard says his group has a second pharmacist who provides requested educational information on a day-to-day basis, in terms of article and literature reviews. “It’s a great relationship,” he says. “They love to do that, and we love the information that they get for us.”

Work as a Team

Sondra May, PharmD, medications safety coordinator at the University of Colorado Hospital, says teamwork is the best way to avoid errors. “This would include the pharmacist who would determine appropriate in-house drug therapy, whether that would be determining dosage or specific drugs for specific patients’ needs. It would include making sure they’re providing sufficient information to the nurse at the bedside,” Dr. May says. “I think one of the biggest contributing factors to medication errors is poor communication.”

Dr. Sachdeva agrees direct communication is vital.

“I think hospitalists are in a unique position because we interact with almost everyone who cares for the patient,” Dr. Sachdeva says. “When I’m working, I’m talking continuously with the nurses. I think it’s important to have an open dialogue. I’ve learned that if I make a change, whether it’s on paper or on the computer, if I talk to the nurse, there is more chance it will happen earlier and it will happen correctly.”

When Errors Occur

Early detection of errors is imperative. “You want to make sure patient monitoring is frequent and specialized to the drugs they’re receiving,” Dr. May says.

If an overdose occurs before an error is detected, it’s important to strategize the treatment based on the error in question. Treatment depends on how much drug the patient received and what specific drug was given in error, Dr. May explains.

“Many hospitals have a rapid response team that will go to the bedside of patients who are showing signs of acute change in their condition, including overdoses,” Dr. Bossard says. ”The response team will assess that patient immediately and then contact the primary care physician or the hospitalist to address those issues. On the process management side, each sentinel event is reviewed in exceedingly fine detail, so processes can be adjusted and made safer in the future.”

In fact, more hospitals are creating an environment where it’s OK to admit that you’ve made a mistake. “We need to move away from blame and realize that these are patient safety issues about which we all need to be honest,” Dr. Basco says. “Part of that means full disclosure to the patient once you detect that an error has occurred. There’s no benefit to you or from a medical-legal standpoint of trying to keep it hush-hush. In fact, there’s a lot of evidence that disclosing [the error] early is beneficial.”

The Usual Suspects

A few classes of drugs are considered especially risky, Dr. May says, including narcotics, anticoagulants and insulin. These drugs aren’t necessarily involved in medication errors at a higher frequency, but they receive a lot of attention because, when an error does occur with these medications, the outcome tends to be more serious, she says.

Anti-epileptic agents, chemotherapeutic agents, and immuno-suppressants, especially in patients who have undergone transplants, can be risky. “What may be a therapeutic level for one patient may not be for a transplant patient,” Dr. Wright says.

Dr. Ferrance says he finds narcotics to be the riskiest class of drugs, especially in post-operative patients. “The dosing range is so wide to begin with,” he says, “Surgeons are afraid of not treating pain adequately, and they’re afraid of an overdose.”

Last but Not Least

A known-yet-underrepresented problem is medication reconciliation from inpatient to outpatient and vice versa. Studies clearly show that post-discharge telephone calls and home visits identify problems in medication dosing and compliance, according to Dr. Bossard. “Systems really need to be in place to facilitate this level of service, both when the patient comes into the hospital and after they’ve been discharged.” TH

Reference

1. The Journal of the American Medical Association. Medication errors continue even in highly computerized hospital. ScienceDaily. www.sciencedaily.com/releases/2005/05/050524101312.htm Published May 24, 2005. Accessed September 30, 2008.

Last summer, 17 infants mistakenly were given incorrect doses of the blood-thinning medication heparin during their stay at a hospital in Corpus Christi, Texas. Two of those infants died.

Thousands of medication errors, including the ordering, dispensing and monitoring of medication, occur each year in hospitals throughout the country. Several studies in recent years have shown that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions and more than two billion dollars annually in inpatient costs.

Whether a patient is an infant, child or adult, the potential for medication errors begins as soon as a patient reaches the hospital and continues well after discharge.

“Medication errors often start when the patient comes to the emergency room,” says Sandeep Sachdeva, MD, clinical assistant professor at University of Washington Medical Center in Seattle. “Patients usually don’t carry a detailed list of the drugs they’re taking. If they come in late at night, it may not be possible for us to get an alternative list.”

That’s why it’s important for drug reconciliation to begin at the time of arrival, Dr. Sachdeva says. “In my opinion, medication reconciliation is a dynamic process, and medication reconciliation is a daily process. When patients come into the hospital, certain medications automatically get changed to the medications that are available in hospitals, and anytime there is a change in medications, it’s an opportunity for an error.”

Opportunities for Error

Even if a patient arrives with a full medication list, once he or she transfers from one hospital unit to another or is discharged, the opportunity for errors increases exponentially, says Julia Wright, MD, director of hospital medicine at University of Wisconsin Hospital and associate professor of medicine at The University of Wisconsin School of Medicine and Public Health in Madison, Wis.

“What providers have to remember is that there are multiple stages at which mistakes can be made,” says William Basco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. The physician or nurse practitioner can make a mistake writing the order; a nurse can misread the order; a pharmacist can incorrectly prepare the order; and a floor nurse can make a mistake drawing up the medication or delivering it, Dr Basco explains.

What’s a Hospitalist To Do?

Although the opportunities for medication errors are many, Dr. Basco says hospitalists should take several steps to mitigate medication errors. First, he says, limit verbal orders for drugs. Instead, write the order out, print legibly and refrain from using abbreviations. He suggests writing out numbers and placing them inside parentheses after the corresponding numeral.

“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.

Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”

Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”

Computers to the Rescue

More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”

For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.

Check with the Pharmacist

More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.

“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”

Dr. Bossard says his group has a second pharmacist who provides requested educational information on a day-to-day basis, in terms of article and literature reviews. “It’s a great relationship,” he says. “They love to do that, and we love the information that they get for us.”

Work as a Team

Sondra May, PharmD, medications safety coordinator at the University of Colorado Hospital, says teamwork is the best way to avoid errors. “This would include the pharmacist who would determine appropriate in-house drug therapy, whether that would be determining dosage or specific drugs for specific patients’ needs. It would include making sure they’re providing sufficient information to the nurse at the bedside,” Dr. May says. “I think one of the biggest contributing factors to medication errors is poor communication.”

Dr. Sachdeva agrees direct communication is vital.

“I think hospitalists are in a unique position because we interact with almost everyone who cares for the patient,” Dr. Sachdeva says. “When I’m working, I’m talking continuously with the nurses. I think it’s important to have an open dialogue. I’ve learned that if I make a change, whether it’s on paper or on the computer, if I talk to the nurse, there is more chance it will happen earlier and it will happen correctly.”

When Errors Occur

Early detection of errors is imperative. “You want to make sure patient monitoring is frequent and specialized to the drugs they’re receiving,” Dr. May says.

If an overdose occurs before an error is detected, it’s important to strategize the treatment based on the error in question. Treatment depends on how much drug the patient received and what specific drug was given in error, Dr. May explains.

“Many hospitals have a rapid response team that will go to the bedside of patients who are showing signs of acute change in their condition, including overdoses,” Dr. Bossard says. ”The response team will assess that patient immediately and then contact the primary care physician or the hospitalist to address those issues. On the process management side, each sentinel event is reviewed in exceedingly fine detail, so processes can be adjusted and made safer in the future.”

In fact, more hospitals are creating an environment where it’s OK to admit that you’ve made a mistake. “We need to move away from blame and realize that these are patient safety issues about which we all need to be honest,” Dr. Basco says. “Part of that means full disclosure to the patient once you detect that an error has occurred. There’s no benefit to you or from a medical-legal standpoint of trying to keep it hush-hush. In fact, there’s a lot of evidence that disclosing [the error] early is beneficial.”

The Usual Suspects

A few classes of drugs are considered especially risky, Dr. May says, including narcotics, anticoagulants and insulin. These drugs aren’t necessarily involved in medication errors at a higher frequency, but they receive a lot of attention because, when an error does occur with these medications, the outcome tends to be more serious, she says.

Anti-epileptic agents, chemotherapeutic agents, and immuno-suppressants, especially in patients who have undergone transplants, can be risky. “What may be a therapeutic level for one patient may not be for a transplant patient,” Dr. Wright says.

Dr. Ferrance says he finds narcotics to be the riskiest class of drugs, especially in post-operative patients. “The dosing range is so wide to begin with,” he says, “Surgeons are afraid of not treating pain adequately, and they’re afraid of an overdose.”

Last but Not Least

A known-yet-underrepresented problem is medication reconciliation from inpatient to outpatient and vice versa. Studies clearly show that post-discharge telephone calls and home visits identify problems in medication dosing and compliance, according to Dr. Bossard. “Systems really need to be in place to facilitate this level of service, both when the patient comes into the hospital and after they’ve been discharged.” TH

Reference

1. The Journal of the American Medical Association. Medication errors continue even in highly computerized hospital. ScienceDaily. www.sciencedaily.com/releases/2005/05/050524101312.htm Published May 24, 2005. Accessed September 30, 2008.

Last summer, 17 infants mistakenly were given incorrect doses of the blood-thinning medication heparin during their stay at a hospital in Corpus Christi, Texas. Two of those infants died.

Thousands of medication errors, including the ordering, dispensing and monitoring of medication, occur each year in hospitals throughout the country. Several studies in recent years have shown that injuries resulting from adverse drug events (ADEs) account for up to 41 percent of all hospital admissions and more than two billion dollars annually in inpatient costs.

Whether a patient is an infant, child or adult, the potential for medication errors begins as soon as a patient reaches the hospital and continues well after discharge.

“Medication errors often start when the patient comes to the emergency room,” says Sandeep Sachdeva, MD, clinical assistant professor at University of Washington Medical Center in Seattle. “Patients usually don’t carry a detailed list of the drugs they’re taking. If they come in late at night, it may not be possible for us to get an alternative list.”

That’s why it’s important for drug reconciliation to begin at the time of arrival, Dr. Sachdeva says. “In my opinion, medication reconciliation is a dynamic process, and medication reconciliation is a daily process. When patients come into the hospital, certain medications automatically get changed to the medications that are available in hospitals, and anytime there is a change in medications, it’s an opportunity for an error.”

Opportunities for Error

Even if a patient arrives with a full medication list, once he or she transfers from one hospital unit to another or is discharged, the opportunity for errors increases exponentially, says Julia Wright, MD, director of hospital medicine at University of Wisconsin Hospital and associate professor of medicine at The University of Wisconsin School of Medicine and Public Health in Madison, Wis.

“What providers have to remember is that there are multiple stages at which mistakes can be made,” says William Basco, MD, director of general pediatrics at the Medical University of South Carolina in Charleston, S.C. The physician or nurse practitioner can make a mistake writing the order; a nurse can misread the order; a pharmacist can incorrectly prepare the order; and a floor nurse can make a mistake drawing up the medication or delivering it, Dr Basco explains.

What’s a Hospitalist To Do?

Although the opportunities for medication errors are many, Dr. Basco says hospitalists should take several steps to mitigate medication errors. First, he says, limit verbal orders for drugs. Instead, write the order out, print legibly and refrain from using abbreviations. He suggests writing out numbers and placing them inside parentheses after the corresponding numeral.

“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.

Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”

Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”

Computers to the Rescue

More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”

For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.

Check with the Pharmacist

More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.

“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”

Dr. Bossard says his group has a second pharmacist who provides requested educational information on a day-to-day basis, in terms of article and literature reviews. “It’s a great relationship,” he says. “They love to do that, and we love the information that they get for us.”

Work as a Team

Sondra May, PharmD, medications safety coordinator at the University of Colorado Hospital, says teamwork is the best way to avoid errors. “This would include the pharmacist who would determine appropriate in-house drug therapy, whether that would be determining dosage or specific drugs for specific patients’ needs. It would include making sure they’re providing sufficient information to the nurse at the bedside,” Dr. May says. “I think one of the biggest contributing factors to medication errors is poor communication.”

Dr. Sachdeva agrees direct communication is vital.

“I think hospitalists are in a unique position because we interact with almost everyone who cares for the patient,” Dr. Sachdeva says. “When I’m working, I’m talking continuously with the nurses. I think it’s important to have an open dialogue. I’ve learned that if I make a change, whether it’s on paper or on the computer, if I talk to the nurse, there is more chance it will happen earlier and it will happen correctly.”

When Errors Occur

Early detection of errors is imperative. “You want to make sure patient monitoring is frequent and specialized to the drugs they’re receiving,” Dr. May says.

If an overdose occurs before an error is detected, it’s important to strategize the treatment based on the error in question. Treatment depends on how much drug the patient received and what specific drug was given in error, Dr. May explains.

“Many hospitals have a rapid response team that will go to the bedside of patients who are showing signs of acute change in their condition, including overdoses,” Dr. Bossard says. ”The response team will assess that patient immediately and then contact the primary care physician or the hospitalist to address those issues. On the process management side, each sentinel event is reviewed in exceedingly fine detail, so processes can be adjusted and made safer in the future.”

In fact, more hospitals are creating an environment where it’s OK to admit that you’ve made a mistake. “We need to move away from blame and realize that these are patient safety issues about which we all need to be honest,” Dr. Basco says. “Part of that means full disclosure to the patient once you detect that an error has occurred. There’s no benefit to you or from a medical-legal standpoint of trying to keep it hush-hush. In fact, there’s a lot of evidence that disclosing [the error] early is beneficial.”

The Usual Suspects

A few classes of drugs are considered especially risky, Dr. May says, including narcotics, anticoagulants and insulin. These drugs aren’t necessarily involved in medication errors at a higher frequency, but they receive a lot of attention because, when an error does occur with these medications, the outcome tends to be more serious, she says.

Anti-epileptic agents, chemotherapeutic agents, and immuno-suppressants, especially in patients who have undergone transplants, can be risky. “What may be a therapeutic level for one patient may not be for a transplant patient,” Dr. Wright says.

Dr. Ferrance says he finds narcotics to be the riskiest class of drugs, especially in post-operative patients. “The dosing range is so wide to begin with,” he says, “Surgeons are afraid of not treating pain adequately, and they’re afraid of an overdose.”

Last but Not Least

A known-yet-underrepresented problem is medication reconciliation from inpatient to outpatient and vice versa. Studies clearly show that post-discharge telephone calls and home visits identify problems in medication dosing and compliance, according to Dr. Bossard. “Systems really need to be in place to facilitate this level of service, both when the patient comes into the hospital and after they’ve been discharged.” TH

Reference

1. The Journal of the American Medical Association. Medication errors continue even in highly computerized hospital. ScienceDaily. www.sciencedaily.com/releases/2005/05/050524101312.htm Published May 24, 2005. Accessed September 30, 2008.

At Emory University School of Medicine in Atlanta, Jason M. Stein, MD, and his team are working on a quality improvement (QI) strategy they hope will transfer to any hospital, anywhere. “That is where QI research lives right now,” says Dr. Stein, co-director of Emory’s hospital medicine quality improvement research program and co-chair of the department of medicine’s quality committee.

The Emory “blueprint” lays out what ideal care looks like and how physicians can provide that care. Dr. Stein’s team already has completed three successful pilot projects: preventing hospital-acquired venous thromboembolism (VTE); reducing catheter-related bloodstream infection; and improving management of hyperglycemia. “We are a mile down the road in the QI marathon,” Dr. Stein says.

Everywhere—not just in large academic medical centers, but in community hospitals and hospital medicine groups, as well—hospitalists are responding to an increased demand from government regulators, payers, and consumers to show demonstrated quality improvements. Even hospitalists on the sidelines are watching closely the experiences of others, in the hopes of marshaling their own resources and working collaboratively.

“The patient experience needs to improve at a pace we haven’t seen before in healthcare,” says Lakshmi Halasyamani, MD, vice president of quality and systems improvement at Saint Joseph Mercy Health System in Ann Arbor, Mich. Hospitalists, she says, are uniquely qualified to meet these demands.

The New Look of QI

The existence of hospitalists has changed the dynamic of QI research, Dr. Stein explains. “Before hospitalists, almost never was a clinician in charge of improving quality hospitalwide. Now, we have hospitalists who can generate and implement quality research.”

For hospitalists, QI research is rewarding and a good career move, he says. “If you fix something that’s broken today, it won’t be broken tomorrow. It’s doing something that makes a difference on a scale that’s way beyond what you normally do every day.” Plus, he adds, the demand for hospitalists with experience in quality improvement will continue to increase as more hospitals try to demonstrate their improvement efforts.

However, the increased demand could, in some cases, be a barrier to research, says hospitalist program consultant Ken Epstein, MD, MBA, former director of medical affairs and clinical research at IPC: The Hospitalist Company in North Hollywood, Calif. “There is more clinical work for hospitalists than there is time in the day, or that there are enough hospitalists to handle,” he explains. “Many hospitalists would like to do QI research, but are too busy clinically.”

That can change, but only with the support of employers. For example, academic medical centers build in time away from clinical duties and provide staff and information systems support. That’s harder to come by in community hospitals.

Funding is an issue, too. More medical schools are competing for a rapidly decreasing pool of research dollars, Dr. Stein says. That means it will be necessary to get more help from private foundations and drug companies to adequately fund quality improvement. Some hospitals are digging into their operating budgets to fund QI research.

Hospitalists in Action

Despite the barriers, hospitalists are changing the course of QI research in a variety of settings. Dr. Stein’s team at Emory is just one example. In Michigan, Saint Joseph Mercy Health System is creating a multidisciplinary practice council with teams established to study heart failure, acute coronary syndrome, and glycemic control—taking the first steps in its research efforts. “When we think about improving care, we need to think in teams, so you don’t have folks wanting to take care of one intervention that creates issues for another member of the team,” Dr. Halasyamani says.

IPC: The Hospitalist Company is focusing on post-discharge issues. The organization’s research has revealed patients with new or worsening symptoms after discharge were no more likely to make follow-up appointments than those who felt well, and that patients given five or more prescriptions at discharge were more likely to have trouble filling them than those who received less than five. Those with insurance or HMO coverage were more likely to fill the prescriptions than those without.

Dr. Epstein also published quality improvement research showing that patients’ hospital stays increased incrementally with the number of physicians seen at the hospital. In addition, the location of hospitalists when they spoke with patients—whether they were in the hospital round the clock or took calls from home—had little effect on patient satisfaction.

HMG Experience

At Northern Colorado Hospitalists in Fort Collins, Colo., hospitalists began their QI efforts by implementing and studying the research of the SHM VTE Collaborative. “The resource room on the SHM Web site gives you a cookbook for implementing QI research,” says Christine Lum Lung, MD, medical director of the 10-hospitalist group. “It can be implemented in any hospital, of any size, and should be.”

The key is for one hospitalist to take responsibility for seeing it through. Dr. Lum Lung did just that. Using the SHM resource room and mentors, she headed a team that developed and implemented a practice protocol for prevention of VTE for Poudre Valley Hospital in Fort Collins and Medical Center of the Rockies in Loveland, Colo. The group gathered background data and built a consensus to come up with the protocol, then measured the preliminary outcomes and improved on the process.

With the backing of hospital administration, Dr. Lum Lung and her team performed their own chart audits, created spreadsheets, and went back to naysayers with data demonstrating their progress. Early results have been impressive. The initiative has increased compliance with appropriate measures, increasing VTE prevention from 58% to 85% from November 2007 through May 2008.

Dr. Lum Lung is convinced quality initiatives are the future of hospital medicine. “We need to stop being reactive to what the government is telling us we should do,” she says. “We should be leading the quality charge because we are the ones who see what works.” She’s drawing on her experience with VTE to create an infrastructure, so other hospitalists can take on their own QI initiatives. A project on glycemic control already is underway.

Dr. Lum Lung advises hospitalists to take time to educate themselves before jumping into the lion’s den. For her, it meant reading everything she could get her hands on about quality improvement and clinical developments. She also suggests understanding what must happen for behaviors to change. In the case of the VTE QI initiative, documentation was the key.

“When you’re asking physicians to change their practice standards, you have to have incredibly good documentation—and a thick skin,” she says. If you have documentation to back up your request, she explains, most healthcare providers are willing to give it a try.

For hospital care to improve, it’s essential hospitalists take the next step. “Quality improvement is an incredibly important responsibility we have as hospitalists in taking care of patients,” Dr. Lum Lung says. “If you start with that as your foundation, then the difficulties you encounter along the way are easier. You can find the time to do anything, if you’re passionate about it.”

The First Step

The future of QI research in community hospitals may depend on several things. To start, it’s essential to set up an infrastructure for support, Dr. Halasyamani says. Though this may be more difficult for community hospitals, all hospitals have some systems in place for research, she points out. And smaller hospitals also can participate in research collaboratives to get the support they need.

Saint Joseph’s funds its QI efforts from its operating budget. Researchers also are in discussions with the hospital’s development office about possible donor funding. “There may be people who are interested in leaving as their legacy improvements in care, rather than having their name on a building,” Dr. Halasyamani says.

Partnerships with academic medical centers may advance quality improvement, says David Meltzer, MD, PhD, associate professor and chief of hospital medicine at the University of Chicago Pritzker School of Medicine. He also is director of the program on outcomes research training and chair of SHM’s research committee. “Community hospitals could share their data with academic medical centers to look at quality measurers across multiple settings,” he suggests.

SHM’s research committee is working on strategies to develop networks of institutions, starting with academic medical centers and then broadening to community hospitals, Dr. Meltzer says. The goal is collaborative research. It’s a win-win for both settings. “Academics would like data on patients in community hospitals and community hospitals would like resources to do research,” says Dr. Epstein, who founded KRE Consulting, LLC.

Some institutions are receiving funding for just this purpose. The medical school at the University of Chicago Medical, for example, received a grant from the Agency for Healthcare Research and Quality to help community hospitals develop quality improvement teams. The funds will pay for hospitalists from across the country to visit the school for a summer program in outcomes research. The hospitalists will then return to their institutions to begin QI research.

Calls for Training

Initiatives, such as the summer program at the University of Chicago, are just one aspect of the education necessary to move QI forward. Some hospitalists also see a need for increased training during residency. Dr. Stein, of Emory, is working with other academics to create a core competency in QI research for hospitalists, looking at systems issues and quality tools. “Hospitalists have to feel like they have the expertise in QI research if they are to respond to the increased QI demands,” he says.

There are several programs dedicated to making that happen. The Robert Wood Johnson Clinical Scholars Program at the University of Chicago trains physicians on health policy and outcomes research, preparing them for academic careers. Dr. Meltzer thinks a similar program could be designed for community-based hospitalists who want to conduct quality improvement research.

Intermountain Healthcare in Salt Lake City, Utah, also offers training in QI research for practicing hospitalists that “jams a lot into 12- and 20-day programs,” according to Dr. Stein.

Hospitalists have to be willing to invest in themselves to get additional training in QI research, Dr. Meltzer says. Taking a job at a lower salary in exchange for time off for QI training, or paying for their own training, will lead to advancement opportunities in the future, he says.

For patients, the QI work done by hospitalists already is paying off by raising expectations about the quality of care, Dr. Epstein says. “When hospitalists are involved with a hospital to improve the system of care, it raises the bar for all patients, whether or not they are cared for by hospitalists.” TH

At Emory University School of Medicine in Atlanta, Jason M. Stein, MD, and his team are working on a quality improvement (QI) strategy they hope will transfer to any hospital, anywhere. “That is where QI research lives right now,” says Dr. Stein, co-director of Emory’s hospital medicine quality improvement research program and co-chair of the department of medicine’s quality committee.

The Emory “blueprint” lays out what ideal care looks like and how physicians can provide that care. Dr. Stein’s team already has completed three successful pilot projects: preventing hospital-acquired venous thromboembolism (VTE); reducing catheter-related bloodstream infection; and improving management of hyperglycemia. “We are a mile down the road in the QI marathon,” Dr. Stein says.

Everywhere—not just in large academic medical centers, but in community hospitals and hospital medicine groups, as well—hospitalists are responding to an increased demand from government regulators, payers, and consumers to show demonstrated quality improvements. Even hospitalists on the sidelines are watching closely the experiences of others, in the hopes of marshaling their own resources and working collaboratively.

“The patient experience needs to improve at a pace we haven’t seen before in healthcare,” says Lakshmi Halasyamani, MD, vice president of quality and systems improvement at Saint Joseph Mercy Health System in Ann Arbor, Mich. Hospitalists, she says, are uniquely qualified to meet these demands.

The New Look of QI

The existence of hospitalists has changed the dynamic of QI research, Dr. Stein explains. “Before hospitalists, almost never was a clinician in charge of improving quality hospitalwide. Now, we have hospitalists who can generate and implement quality research.”

For hospitalists, QI research is rewarding and a good career move, he says. “If you fix something that’s broken today, it won’t be broken tomorrow. It’s doing something that makes a difference on a scale that’s way beyond what you normally do every day.” Plus, he adds, the demand for hospitalists with experience in quality improvement will continue to increase as more hospitals try to demonstrate their improvement efforts.

However, the increased demand could, in some cases, be a barrier to research, says hospitalist program consultant Ken Epstein, MD, MBA, former director of medical affairs and clinical research at IPC: The Hospitalist Company in North Hollywood, Calif. “There is more clinical work for hospitalists than there is time in the day, or that there are enough hospitalists to handle,” he explains. “Many hospitalists would like to do QI research, but are too busy clinically.”

That can change, but only with the support of employers. For example, academic medical centers build in time away from clinical duties and provide staff and information systems support. That’s harder to come by in community hospitals.

Funding is an issue, too. More medical schools are competing for a rapidly decreasing pool of research dollars, Dr. Stein says. That means it will be necessary to get more help from private foundations and drug companies to adequately fund quality improvement. Some hospitals are digging into their operating budgets to fund QI research.

Hospitalists in Action

Despite the barriers, hospitalists are changing the course of QI research in a variety of settings. Dr. Stein’s team at Emory is just one example. In Michigan, Saint Joseph Mercy Health System is creating a multidisciplinary practice council with teams established to study heart failure, acute coronary syndrome, and glycemic control—taking the first steps in its research efforts. “When we think about improving care, we need to think in teams, so you don’t have folks wanting to take care of one intervention that creates issues for another member of the team,” Dr. Halasyamani says.

IPC: The Hospitalist Company is focusing on post-discharge issues. The organization’s research has revealed patients with new or worsening symptoms after discharge were no more likely to make follow-up appointments than those who felt well, and that patients given five or more prescriptions at discharge were more likely to have trouble filling them than those who received less than five. Those with insurance or HMO coverage were more likely to fill the prescriptions than those without.

Dr. Epstein also published quality improvement research showing that patients’ hospital stays increased incrementally with the number of physicians seen at the hospital. In addition, the location of hospitalists when they spoke with patients—whether they were in the hospital round the clock or took calls from home—had little effect on patient satisfaction.

HMG Experience

At Northern Colorado Hospitalists in Fort Collins, Colo., hospitalists began their QI efforts by implementing and studying the research of the SHM VTE Collaborative. “The resource room on the SHM Web site gives you a cookbook for implementing QI research,” says Christine Lum Lung, MD, medical director of the 10-hospitalist group. “It can be implemented in any hospital, of any size, and should be.”

The key is for one hospitalist to take responsibility for seeing it through. Dr. Lum Lung did just that. Using the SHM resource room and mentors, she headed a team that developed and implemented a practice protocol for prevention of VTE for Poudre Valley Hospital in Fort Collins and Medical Center of the Rockies in Loveland, Colo. The group gathered background data and built a consensus to come up with the protocol, then measured the preliminary outcomes and improved on the process.

With the backing of hospital administration, Dr. Lum Lung and her team performed their own chart audits, created spreadsheets, and went back to naysayers with data demonstrating their progress. Early results have been impressive. The initiative has increased compliance with appropriate measures, increasing VTE prevention from 58% to 85% from November 2007 through May 2008.

Dr. Lum Lung is convinced quality initiatives are the future of hospital medicine. “We need to stop being reactive to what the government is telling us we should do,” she says. “We should be leading the quality charge because we are the ones who see what works.” She’s drawing on her experience with VTE to create an infrastructure, so other hospitalists can take on their own QI initiatives. A project on glycemic control already is underway.

Dr. Lum Lung advises hospitalists to take time to educate themselves before jumping into the lion’s den. For her, it meant reading everything she could get her hands on about quality improvement and clinical developments. She also suggests understanding what must happen for behaviors to change. In the case of the VTE QI initiative, documentation was the key.

“When you’re asking physicians to change their practice standards, you have to have incredibly good documentation—and a thick skin,” she says. If you have documentation to back up your request, she explains, most healthcare providers are willing to give it a try.

For hospital care to improve, it’s essential hospitalists take the next step. “Quality improvement is an incredibly important responsibility we have as hospitalists in taking care of patients,” Dr. Lum Lung says. “If you start with that as your foundation, then the difficulties you encounter along the way are easier. You can find the time to do anything, if you’re passionate about it.”

The First Step

The future of QI research in community hospitals may depend on several things. To start, it’s essential to set up an infrastructure for support, Dr. Halasyamani says. Though this may be more difficult for community hospitals, all hospitals have some systems in place for research, she points out. And smaller hospitals also can participate in research collaboratives to get the support they need.

Saint Joseph’s funds its QI efforts from its operating budget. Researchers also are in discussions with the hospital’s development office about possible donor funding. “There may be people who are interested in leaving as their legacy improvements in care, rather than having their name on a building,” Dr. Halasyamani says.

Partnerships with academic medical centers may advance quality improvement, says David Meltzer, MD, PhD, associate professor and chief of hospital medicine at the University of Chicago Pritzker School of Medicine. He also is director of the program on outcomes research training and chair of SHM’s research committee. “Community hospitals could share their data with academic medical centers to look at quality measurers across multiple settings,” he suggests.

SHM’s research committee is working on strategies to develop networks of institutions, starting with academic medical centers and then broadening to community hospitals, Dr. Meltzer says. The goal is collaborative research. It’s a win-win for both settings. “Academics would like data on patients in community hospitals and community hospitals would like resources to do research,” says Dr. Epstein, who founded KRE Consulting, LLC.

Some institutions are receiving funding for just this purpose. The medical school at the University of Chicago Medical, for example, received a grant from the Agency for Healthcare Research and Quality to help community hospitals develop quality improvement teams. The funds will pay for hospitalists from across the country to visit the school for a summer program in outcomes research. The hospitalists will then return to their institutions to begin QI research.

Calls for Training

Initiatives, such as the summer program at the University of Chicago, are just one aspect of the education necessary to move QI forward. Some hospitalists also see a need for increased training during residency. Dr. Stein, of Emory, is working with other academics to create a core competency in QI research for hospitalists, looking at systems issues and quality tools. “Hospitalists have to feel like they have the expertise in QI research if they are to respond to the increased QI demands,” he says.

There are several programs dedicated to making that happen. The Robert Wood Johnson Clinical Scholars Program at the University of Chicago trains physicians on health policy and outcomes research, preparing them for academic careers. Dr. Meltzer thinks a similar program could be designed for community-based hospitalists who want to conduct quality improvement research.

Intermountain Healthcare in Salt Lake City, Utah, also offers training in QI research for practicing hospitalists that “jams a lot into 12- and 20-day programs,” according to Dr. Stein.

Hospitalists have to be willing to invest in themselves to get additional training in QI research, Dr. Meltzer says. Taking a job at a lower salary in exchange for time off for QI training, or paying for their own training, will lead to advancement opportunities in the future, he says.

For patients, the QI work done by hospitalists already is paying off by raising expectations about the quality of care, Dr. Epstein says. “When hospitalists are involved with a hospital to improve the system of care, it raises the bar for all patients, whether or not they are cared for by hospitalists.” TH

At Emory University School of Medicine in Atlanta, Jason M. Stein, MD, and his team are working on a quality improvement (QI) strategy they hope will transfer to any hospital, anywhere. “That is where QI research lives right now,” says Dr. Stein, co-director of Emory’s hospital medicine quality improvement research program and co-chair of the department of medicine’s quality committee.

The Emory “blueprint” lays out what ideal care looks like and how physicians can provide that care. Dr. Stein’s team already has completed three successful pilot projects: preventing hospital-acquired venous thromboembolism (VTE); reducing catheter-related bloodstream infection; and improving management of hyperglycemia. “We are a mile down the road in the QI marathon,” Dr. Stein says.

Everywhere—not just in large academic medical centers, but in community hospitals and hospital medicine groups, as well—hospitalists are responding to an increased demand from government regulators, payers, and consumers to show demonstrated quality improvements. Even hospitalists on the sidelines are watching closely the experiences of others, in the hopes of marshaling their own resources and working collaboratively.

“The patient experience needs to improve at a pace we haven’t seen before in healthcare,” says Lakshmi Halasyamani, MD, vice president of quality and systems improvement at Saint Joseph Mercy Health System in Ann Arbor, Mich. Hospitalists, she says, are uniquely qualified to meet these demands.

The New Look of QI

The existence of hospitalists has changed the dynamic of QI research, Dr. Stein explains. “Before hospitalists, almost never was a clinician in charge of improving quality hospitalwide. Now, we have hospitalists who can generate and implement quality research.”

For hospitalists, QI research is rewarding and a good career move, he says. “If you fix something that’s broken today, it won’t be broken tomorrow. It’s doing something that makes a difference on a scale that’s way beyond what you normally do every day.” Plus, he adds, the demand for hospitalists with experience in quality improvement will continue to increase as more hospitals try to demonstrate their improvement efforts.

However, the increased demand could, in some cases, be a barrier to research, says hospitalist program consultant Ken Epstein, MD, MBA, former director of medical affairs and clinical research at IPC: The Hospitalist Company in North Hollywood, Calif. “There is more clinical work for hospitalists than there is time in the day, or that there are enough hospitalists to handle,” he explains. “Many hospitalists would like to do QI research, but are too busy clinically.”

That can change, but only with the support of employers. For example, academic medical centers build in time away from clinical duties and provide staff and information systems support. That’s harder to come by in community hospitals.

Funding is an issue, too. More medical schools are competing for a rapidly decreasing pool of research dollars, Dr. Stein says. That means it will be necessary to get more help from private foundations and drug companies to adequately fund quality improvement. Some hospitals are digging into their operating budgets to fund QI research.

Hospitalists in Action

Despite the barriers, hospitalists are changing the course of QI research in a variety of settings. Dr. Stein’s team at Emory is just one example. In Michigan, Saint Joseph Mercy Health System is creating a multidisciplinary practice council with teams established to study heart failure, acute coronary syndrome, and glycemic control—taking the first steps in its research efforts. “When we think about improving care, we need to think in teams, so you don’t have folks wanting to take care of one intervention that creates issues for another member of the team,” Dr. Halasyamani says.

IPC: The Hospitalist Company is focusing on post-discharge issues. The organization’s research has revealed patients with new or worsening symptoms after discharge were no more likely to make follow-up appointments than those who felt well, and that patients given five or more prescriptions at discharge were more likely to have trouble filling them than those who received less than five. Those with insurance or HMO coverage were more likely to fill the prescriptions than those without.

Dr. Epstein also published quality improvement research showing that patients’ hospital stays increased incrementally with the number of physicians seen at the hospital. In addition, the location of hospitalists when they spoke with patients—whether they were in the hospital round the clock or took calls from home—had little effect on patient satisfaction.

HMG Experience

At Northern Colorado Hospitalists in Fort Collins, Colo., hospitalists began their QI efforts by implementing and studying the research of the SHM VTE Collaborative. “The resource room on the SHM Web site gives you a cookbook for implementing QI research,” says Christine Lum Lung, MD, medical director of the 10-hospitalist group. “It can be implemented in any hospital, of any size, and should be.”

The key is for one hospitalist to take responsibility for seeing it through. Dr. Lum Lung did just that. Using the SHM resource room and mentors, she headed a team that developed and implemented a practice protocol for prevention of VTE for Poudre Valley Hospital in Fort Collins and Medical Center of the Rockies in Loveland, Colo. The group gathered background data and built a consensus to come up with the protocol, then measured the preliminary outcomes and improved on the process.

With the backing of hospital administration, Dr. Lum Lung and her team performed their own chart audits, created spreadsheets, and went back to naysayers with data demonstrating their progress. Early results have been impressive. The initiative has increased compliance with appropriate measures, increasing VTE prevention from 58% to 85% from November 2007 through May 2008.

Dr. Lum Lung is convinced quality initiatives are the future of hospital medicine. “We need to stop being reactive to what the government is telling us we should do,” she says. “We should be leading the quality charge because we are the ones who see what works.” She’s drawing on her experience with VTE to create an infrastructure, so other hospitalists can take on their own QI initiatives. A project on glycemic control already is underway.

Dr. Lum Lung advises hospitalists to take time to educate themselves before jumping into the lion’s den. For her, it meant reading everything she could get her hands on about quality improvement and clinical developments. She also suggests understanding what must happen for behaviors to change. In the case of the VTE QI initiative, documentation was the key.

“When you’re asking physicians to change their practice standards, you have to have incredibly good documentation—and a thick skin,” she says. If you have documentation to back up your request, she explains, most healthcare providers are willing to give it a try.

For hospital care to improve, it’s essential hospitalists take the next step. “Quality improvement is an incredibly important responsibility we have as hospitalists in taking care of patients,” Dr. Lum Lung says. “If you start with that as your foundation, then the difficulties you encounter along the way are easier. You can find the time to do anything, if you’re passionate about it.”

The First Step

The future of QI research in community hospitals may depend on several things. To start, it’s essential to set up an infrastructure for support, Dr. Halasyamani says. Though this may be more difficult for community hospitals, all hospitals have some systems in place for research, she points out. And smaller hospitals also can participate in research collaboratives to get the support they need.

Saint Joseph’s funds its QI efforts from its operating budget. Researchers also are in discussions with the hospital’s development office about possible donor funding. “There may be people who are interested in leaving as their legacy improvements in care, rather than having their name on a building,” Dr. Halasyamani says.

Partnerships with academic medical centers may advance quality improvement, says David Meltzer, MD, PhD, associate professor and chief of hospital medicine at the University of Chicago Pritzker School of Medicine. He also is director of the program on outcomes research training and chair of SHM’s research committee. “Community hospitals could share their data with academic medical centers to look at quality measurers across multiple settings,” he suggests.

SHM’s research committee is working on strategies to develop networks of institutions, starting with academic medical centers and then broadening to community hospitals, Dr. Meltzer says. The goal is collaborative research. It’s a win-win for both settings. “Academics would like data on patients in community hospitals and community hospitals would like resources to do research,” says Dr. Epstein, who founded KRE Consulting, LLC.

Some institutions are receiving funding for just this purpose. The medical school at the University of Chicago Medical, for example, received a grant from the Agency for Healthcare Research and Quality to help community hospitals develop quality improvement teams. The funds will pay for hospitalists from across the country to visit the school for a summer program in outcomes research. The hospitalists will then return to their institutions to begin QI research.

Calls for Training

Initiatives, such as the summer program at the University of Chicago, are just one aspect of the education necessary to move QI forward. Some hospitalists also see a need for increased training during residency. Dr. Stein, of Emory, is working with other academics to create a core competency in QI research for hospitalists, looking at systems issues and quality tools. “Hospitalists have to feel like they have the expertise in QI research if they are to respond to the increased QI demands,” he says.

There are several programs dedicated to making that happen. The Robert Wood Johnson Clinical Scholars Program at the University of Chicago trains physicians on health policy and outcomes research, preparing them for academic careers. Dr. Meltzer thinks a similar program could be designed for community-based hospitalists who want to conduct quality improvement research.

Intermountain Healthcare in Salt Lake City, Utah, also offers training in QI research for practicing hospitalists that “jams a lot into 12- and 20-day programs,” according to Dr. Stein.

Hospitalists have to be willing to invest in themselves to get additional training in QI research, Dr. Meltzer says. Taking a job at a lower salary in exchange for time off for QI training, or paying for their own training, will lead to advancement opportunities in the future, he says.

For patients, the QI work done by hospitalists already is paying off by raising expectations about the quality of care, Dr. Epstein says. “When hospitalists are involved with a hospital to improve the system of care, it raises the bar for all patients, whether or not they are cared for by hospitalists.” TH

Continuing medical education (CME) is changing rapidly. The descriptions of courses offered at HM09 reflect one of the more prevalent trends: Didactic lectures are being replaced by more innovative, interactive training sessions.

It’s a big reason why CME will continue to serve as “the hallmark method” to help medical professionals continue increasing their knowledge and improving their skills, says Sally Wang, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston. Dr. Wang relates the shift to a famous saying from Chinese philosopher Confucius: “Tell me and I’ll forget. Show me and I may remember. Involve me and I’ll understand.”

CME, which is required of most medical professionals to maintain licenses to practice medicine, is a rapidly growing enterprise. Since 1998, the number of accredited providers increased by 10%, while the number of activities and physician participants has increased by 40%, according to the Accreditation Council for Continuing Medical Education (ACCME).

“You can’t just sit in a lecture,” Dr. Wang emphasizes. “You’re not going to absorb anything. You need to understand how you’re going to apply what you learn in practice.”

HM09 is following suit, offering an unprecedented number of hands-on training sessions. In one course, through the use of simulator models, participants will learn how to use ultrasound for safe and accurate vascular access. They’ll also have the opportunity to practice skin biopsies and lumbar punctures.

“I think that’s a reflection of our field,” says course director Joseph Ming-Wah Li, MD, FHM, SHM board member and director of the HM group at Beth Israel Deaconess Medical Center in Boston. “Hospitalists roll up their sleeves and get to work. We don’t talk about quality; we develop and implement programs to ensure quality. We don’t talk about teaching; we do it. We really hope this meeting will always be cutting-edge and set the tone for what we do as hospitalists in this country.”

Spread the Wealth of Knowledge

In a growing field such as HM, the benefits are almost limitless, says James W. Levy, PA-C, a physician assistant and hospitalist at Munson Medical Center in Traverse City, Mich. “We have the luxury of working as a team, so it’s especially helpful when we go to CME events and bring back very current material. We can share that with the rest of the team, and that can extend the ‘bang for the buck,’ ” Levy says.

Levy acknowledges CMS isn’t the only way to keep current, but it’s an “important way,” he says. “With the hospitalist movement having caught on the way it has, we have a much bigger opportunity to standardize care and our approach from one provider to another. I think CME can play a vital role in that.”

Although CME opportunities vary, Levy prefers settings like SHM functions when interaction with colleagues complements—and often enhances—the lessons learned.

Dr. Li agrees, noting meetings such as HM09 provide an opportunity to get away from the daily grind and “get the juices flowing” in terms of thinking, learning, and sharing ideas with colleagues. He’s particularly excited about the diversity of this year’s course lineup, as well as the behind-the-scenes efforts intended to ensure participants get the most out of the experience.

The annual meeting committee provided considerable guidance to each presenter, outlining objectives for each talk and reviewing presentations to make sure those objectives were met. “More than ever, the quality of the talks are going to be very good and very consistent,” Dr. Li says.

For a complete course schedule and faculty lineup, or to register for HM09, visit www.hospitalmedicine.org/source/AM09/event.cfm?Event=AM09. TH

Mark Leiser is a freelance writer based in New Jersey.

Continuing medical education (CME) is changing rapidly. The descriptions of courses offered at HM09 reflect one of the more prevalent trends: Didactic lectures are being replaced by more innovative, interactive training sessions.

It’s a big reason why CME will continue to serve as “the hallmark method” to help medical professionals continue increasing their knowledge and improving their skills, says Sally Wang, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston. Dr. Wang relates the shift to a famous saying from Chinese philosopher Confucius: “Tell me and I’ll forget. Show me and I may remember. Involve me and I’ll understand.”

CME, which is required of most medical professionals to maintain licenses to practice medicine, is a rapidly growing enterprise. Since 1998, the number of accredited providers increased by 10%, while the number of activities and physician participants has increased by 40%, according to the Accreditation Council for Continuing Medical Education (ACCME).

“You can’t just sit in a lecture,” Dr. Wang emphasizes. “You’re not going to absorb anything. You need to understand how you’re going to apply what you learn in practice.”

HM09 is following suit, offering an unprecedented number of hands-on training sessions. In one course, through the use of simulator models, participants will learn how to use ultrasound for safe and accurate vascular access. They’ll also have the opportunity to practice skin biopsies and lumbar punctures.

“I think that’s a reflection of our field,” says course director Joseph Ming-Wah Li, MD, FHM, SHM board member and director of the HM group at Beth Israel Deaconess Medical Center in Boston. “Hospitalists roll up their sleeves and get to work. We don’t talk about quality; we develop and implement programs to ensure quality. We don’t talk about teaching; we do it. We really hope this meeting will always be cutting-edge and set the tone for what we do as hospitalists in this country.”

Spread the Wealth of Knowledge

In a growing field such as HM, the benefits are almost limitless, says James W. Levy, PA-C, a physician assistant and hospitalist at Munson Medical Center in Traverse City, Mich. “We have the luxury of working as a team, so it’s especially helpful when we go to CME events and bring back very current material. We can share that with the rest of the team, and that can extend the ‘bang for the buck,’ ” Levy says.

Levy acknowledges CMS isn’t the only way to keep current, but it’s an “important way,” he says. “With the hospitalist movement having caught on the way it has, we have a much bigger opportunity to standardize care and our approach from one provider to another. I think CME can play a vital role in that.”

Although CME opportunities vary, Levy prefers settings like SHM functions when interaction with colleagues complements—and often enhances—the lessons learned.

Dr. Li agrees, noting meetings such as HM09 provide an opportunity to get away from the daily grind and “get the juices flowing” in terms of thinking, learning, and sharing ideas with colleagues. He’s particularly excited about the diversity of this year’s course lineup, as well as the behind-the-scenes efforts intended to ensure participants get the most out of the experience.

The annual meeting committee provided considerable guidance to each presenter, outlining objectives for each talk and reviewing presentations to make sure those objectives were met. “More than ever, the quality of the talks are going to be very good and very consistent,” Dr. Li says.

For a complete course schedule and faculty lineup, or to register for HM09, visit www.hospitalmedicine.org/source/AM09/event.cfm?Event=AM09. TH

Mark Leiser is a freelance writer based in New Jersey.

Continuing medical education (CME) is changing rapidly. The descriptions of courses offered at HM09 reflect one of the more prevalent trends: Didactic lectures are being replaced by more innovative, interactive training sessions.

It’s a big reason why CME will continue to serve as “the hallmark method” to help medical professionals continue increasing their knowledge and improving their skills, says Sally Wang, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston. Dr. Wang relates the shift to a famous saying from Chinese philosopher Confucius: “Tell me and I’ll forget. Show me and I may remember. Involve me and I’ll understand.”

CME, which is required of most medical professionals to maintain licenses to practice medicine, is a rapidly growing enterprise. Since 1998, the number of accredited providers increased by 10%, while the number of activities and physician participants has increased by 40%, according to the Accreditation Council for Continuing Medical Education (ACCME).

“You can’t just sit in a lecture,” Dr. Wang emphasizes. “You’re not going to absorb anything. You need to understand how you’re going to apply what you learn in practice.”

HM09 is following suit, offering an unprecedented number of hands-on training sessions. In one course, through the use of simulator models, participants will learn how to use ultrasound for safe and accurate vascular access. They’ll also have the opportunity to practice skin biopsies and lumbar punctures.

“I think that’s a reflection of our field,” says course director Joseph Ming-Wah Li, MD, FHM, SHM board member and director of the HM group at Beth Israel Deaconess Medical Center in Boston. “Hospitalists roll up their sleeves and get to work. We don’t talk about quality; we develop and implement programs to ensure quality. We don’t talk about teaching; we do it. We really hope this meeting will always be cutting-edge and set the tone for what we do as hospitalists in this country.”

Spread the Wealth of Knowledge

In a growing field such as HM, the benefits are almost limitless, says James W. Levy, PA-C, a physician assistant and hospitalist at Munson Medical Center in Traverse City, Mich. “We have the luxury of working as a team, so it’s especially helpful when we go to CME events and bring back very current material. We can share that with the rest of the team, and that can extend the ‘bang for the buck,’ ” Levy says.

Levy acknowledges CMS isn’t the only way to keep current, but it’s an “important way,” he says. “With the hospitalist movement having caught on the way it has, we have a much bigger opportunity to standardize care and our approach from one provider to another. I think CME can play a vital role in that.”

Although CME opportunities vary, Levy prefers settings like SHM functions when interaction with colleagues complements—and often enhances—the lessons learned.

Dr. Li agrees, noting meetings such as HM09 provide an opportunity to get away from the daily grind and “get the juices flowing” in terms of thinking, learning, and sharing ideas with colleagues. He’s particularly excited about the diversity of this year’s course lineup, as well as the behind-the-scenes efforts intended to ensure participants get the most out of the experience.

The annual meeting committee provided considerable guidance to each presenter, outlining objectives for each talk and reviewing presentations to make sure those objectives were met. “More than ever, the quality of the talks are going to be very good and very consistent,” Dr. Li says.

For a complete course schedule and faculty lineup, or to register for HM09, visit www.hospitalmedicine.org/source/AM09/event.cfm?Event=AM09. TH

Mark Leiser is a freelance writer based in New Jersey.

Mark Chassin, MD, MPP, MPH, president of the Joint Commission, will deliver the keynote address at HM09 in Chicago. A board-certified internist who practiced emergency medicine for 12 years, Dr. Chassin is recognized as an expert in quality measurement and improvement.

He recently spoke to The Hospitalist about his views on the changing world of healthcare, the commission’s evolving role, and the importance of a stronger partnership between the accrediting body and hospital-based physicians.

Question: Why are you looking forward to speaking at HM09?

Answer: Hospitalists are an especially important group of physicians for [the Joint Commission] to connect with because of the close alignment between our mission and the way they practice medicine. Accreditation alone is not enough. We need active engagement of the HM practitioners in all of the quality and safety improvement initiatives the Joint Commission has set in motion. It’s also important for us to hear from the physicians on the front lines—and from those who have taken responsibility for oversight of quality programs in hospitals—about how our efforts are working and where we need to fill in gaps.

Q: Can you provide an overview of the topics you plan to talk about?

A: At the pace everything is changing, it’s hard to know exactly what I’ll want to talk about. I’ll probably say something about the major challenges we face across healthcare that are particularly magnified in hospitals. That’s where the most vulnerable patients are. That’s where the most dangerous procedures are done. That’s where the most dangerous drugs are used, and that’s where the most complicated devices are used. All these things have the potential for improving outcomes, but also increasing the potential for harm if they’re not used well.

The environment we’re in is going in one direction, and that is to demand more of all of us in healthcare with respect to the level of excellence at which care is provided and overseen. There’s a strong push on the part of public stakeholders for accountability in healthcare. I may talk about how we might respond to that demand and close the gap between what we know we could be providing in terms of safe, high-quality care, and what we are providing.

Q: You said accreditation by itself is not sufficient. What else is needed?

A: When I was exploring this job, I wanted to determine whether the Joint Commission and its board of commissioners were ready to undertake initiatives, in addition to accreditation, in order to move the delivery system more rapidly toward higher levels of safety and quality. … It became clear to me they weren’t just willing to do it, but very enthusiastic about doing it.

Q: Can you give an example of one of those new initiatives?

A: I have watched and participated in the development of applications coming out of industry in the last 10 years or so, like Six Sigma and the Toyota Production System, that are highly promising in their ability to deliver much higher levels of excellence and sustain them. We’re in the middle of a very aggressive adoption of these tools, which we’re calling our Robust Process Improvement Initiative.

Q: What are the benefits of that initiative?

A: We are doing this to enhance our capacity to do process improvement, to simplify our processes, to focus on customer service. It does not mean it’s to make these surveys easy. It means understanding where our processes are too complicated, where we have too many bells and whistles that are not related to safety and quality, and where we can reduce our costs. At the same time, we’re exploring how we can work with organizations, hospitals, and health systems who have committed to learning these tools and methods to bring them to bear on safety and quality problems—medication reconciliation, infection control breakdown, pre-op verification to get rid of wrong site/wrong side surgery—that organizations struggle with but haven’t wrestled to the ground yet.

Q: Why is it so difficult?

A: In the last year, I’ve been challenging healthcare organizations with respect to exactly that question. I believe everyone—and I put the Joint Commission side by side with organizations that deliver the care—can’t settle for anything less than aiming to transform healthcare into a high-reliability industry. That means rates of adverse events and breakdowns and quality problems that are as low as the best high-reliability organizations in the world, like commercial air travel, nuclear power, and other organizations, that deal with risk and hazards every bit as difficult and dangerous as healthcare but do it a heck of a lot better than we do.

Q: What are the barriers that keep that from happening?

A: First, there’s no role model. There’s no example in healthcare of an organization of any size that is at that level of high reliability. We’re not really in a position to hand out a playbook or a set of blueprints and say, “If you follow these step-by-step set of processes, you’ll get there.”

Another issue is the imperfect creation of a uniform safety culture. One of the hallmarks of a true safety culture is every individual who works in a healthcare organization should be alert to the smallest deviation from safe practice and safe circumstance, and they should be expected and encouraged to report those problems. Is somebody not observing safe sterile techniques in the operating room? Is somebody giving an order for medication that is ambiguous or inaccurate? Just like the junior navigator in an airplane cockpit, everyone must feel his or her obligation to point out what he or she thinks the captain is doing wrong and bring that discrepancy to the surface.

Q: What are your thoughts on the tremendous growth of HM, as well as what the future holds for the field?

A: The growth provides challenges and opportunities. The biggest challenge is the risk the movement toward the delivery of more hospital care by hospitalists provides a discontinuity between the care that’s provided in the community on the front end and hospital care, and then a discontinuity on the back end when the patient goes back into the community. It puts a much larger burden on hospitalists and organizations to make sure they work together to develop really effective ways on both the front and back ends to minimize the unintended consequences of those potential discontinuities.

That said, the opportunity of having a group of physicians who are focused primarily on what happens in hospitals gives those of us who are in quality-oversight positions a natural constituency to work with on perfecting our safety and quality programs in hospitals. That’s an important opportunity, given how complicated it has become to deliver high-quality hospital care.

Q: When hospitalists head home from Chicago, what would you like them to know about the Joint Commission and its mission?

A: The legacy of what the Joint Commission used to be sometimes gets caricatured as a bunch of silly rules and hoops people have to jump through that have nothing to do with patient care. That caricature really is a thing of the past. The current programs we have—both in accreditation and some of these newer initiatives—really have the promise of delivering the capability of helping hospitals and other health organizations achieve the high reliability I know they want. And we need to work shoulder to shoulder on problems. That comes back to how we really need unvarnished feedback about our current programs, whether they’re working well and where we should be deploying more resources. TH

Mark Leiser is a freelance writer based in New Jersey.

Mark Chassin, MD, MPP, MPH, president of the Joint Commission, will deliver the keynote address at HM09 in Chicago. A board-certified internist who practiced emergency medicine for 12 years, Dr. Chassin is recognized as an expert in quality measurement and improvement.

He recently spoke to The Hospitalist about his views on the changing world of healthcare, the commission’s evolving role, and the importance of a stronger partnership between the accrediting body and hospital-based physicians.

Question: Why are you looking forward to speaking at HM09?

Answer: Hospitalists are an especially important group of physicians for [the Joint Commission] to connect with because of the close alignment between our mission and the way they practice medicine. Accreditation alone is not enough. We need active engagement of the HM practitioners in all of the quality and safety improvement initiatives the Joint Commission has set in motion. It’s also important for us to hear from the physicians on the front lines—and from those who have taken responsibility for oversight of quality programs in hospitals—about how our efforts are working and where we need to fill in gaps.

Q: Can you provide an overview of the topics you plan to talk about?

A: At the pace everything is changing, it’s hard to know exactly what I’ll want to talk about. I’ll probably say something about the major challenges we face across healthcare that are particularly magnified in hospitals. That’s where the most vulnerable patients are. That’s where the most dangerous procedures are done. That’s where the most dangerous drugs are used, and that’s where the most complicated devices are used. All these things have the potential for improving outcomes, but also increasing the potential for harm if they’re not used well.

The environment we’re in is going in one direction, and that is to demand more of all of us in healthcare with respect to the level of excellence at which care is provided and overseen. There’s a strong push on the part of public stakeholders for accountability in healthcare. I may talk about how we might respond to that demand and close the gap between what we know we could be providing in terms of safe, high-quality care, and what we are providing.

Q: You said accreditation by itself is not sufficient. What else is needed?

A: When I was exploring this job, I wanted to determine whether the Joint Commission and its board of commissioners were ready to undertake initiatives, in addition to accreditation, in order to move the delivery system more rapidly toward higher levels of safety and quality. … It became clear to me they weren’t just willing to do it, but very enthusiastic about doing it.

Q: Can you give an example of one of those new initiatives?

A: I have watched and participated in the development of applications coming out of industry in the last 10 years or so, like Six Sigma and the Toyota Production System, that are highly promising in their ability to deliver much higher levels of excellence and sustain them. We’re in the middle of a very aggressive adoption of these tools, which we’re calling our Robust Process Improvement Initiative.

Q: What are the benefits of that initiative?

A: We are doing this to enhance our capacity to do process improvement, to simplify our processes, to focus on customer service. It does not mean it’s to make these surveys easy. It means understanding where our processes are too complicated, where we have too many bells and whistles that are not related to safety and quality, and where we can reduce our costs. At the same time, we’re exploring how we can work with organizations, hospitals, and health systems who have committed to learning these tools and methods to bring them to bear on safety and quality problems—medication reconciliation, infection control breakdown, pre-op verification to get rid of wrong site/wrong side surgery—that organizations struggle with but haven’t wrestled to the ground yet.

Q: Why is it so difficult?

A: In the last year, I’ve been challenging healthcare organizations with respect to exactly that question. I believe everyone—and I put the Joint Commission side by side with organizations that deliver the care—can’t settle for anything less than aiming to transform healthcare into a high-reliability industry. That means rates of adverse events and breakdowns and quality problems that are as low as the best high-reliability organizations in the world, like commercial air travel, nuclear power, and other organizations, that deal with risk and hazards every bit as difficult and dangerous as healthcare but do it a heck of a lot better than we do.

Q: What are the barriers that keep that from happening?

A: First, there’s no role model. There’s no example in healthcare of an organization of any size that is at that level of high reliability. We’re not really in a position to hand out a playbook or a set of blueprints and say, “If you follow these step-by-step set of processes, you’ll get there.”

Another issue is the imperfect creation of a uniform safety culture. One of the hallmarks of a true safety culture is every individual who works in a healthcare organization should be alert to the smallest deviation from safe practice and safe circumstance, and they should be expected and encouraged to report those problems. Is somebody not observing safe sterile techniques in the operating room? Is somebody giving an order for medication that is ambiguous or inaccurate? Just like the junior navigator in an airplane cockpit, everyone must feel his or her obligation to point out what he or she thinks the captain is doing wrong and bring that discrepancy to the surface.

Q: What are your thoughts on the tremendous growth of HM, as well as what the future holds for the field?

A: The growth provides challenges and opportunities. The biggest challenge is the risk the movement toward the delivery of more hospital care by hospitalists provides a discontinuity between the care that’s provided in the community on the front end and hospital care, and then a discontinuity on the back end when the patient goes back into the community. It puts a much larger burden on hospitalists and organizations to make sure they work together to develop really effective ways on both the front and back ends to minimize the unintended consequences of those potential discontinuities.

That said, the opportunity of having a group of physicians who are focused primarily on what happens in hospitals gives those of us who are in quality-oversight positions a natural constituency to work with on perfecting our safety and quality programs in hospitals. That’s an important opportunity, given how complicated it has become to deliver high-quality hospital care.

Q: When hospitalists head home from Chicago, what would you like them to know about the Joint Commission and its mission?

A: The legacy of what the Joint Commission used to be sometimes gets caricatured as a bunch of silly rules and hoops people have to jump through that have nothing to do with patient care. That caricature really is a thing of the past. The current programs we have—both in accreditation and some of these newer initiatives—really have the promise of delivering the capability of helping hospitals and other health organizations achieve the high reliability I know they want. And we need to work shoulder to shoulder on problems. That comes back to how we really need unvarnished feedback about our current programs, whether they’re working well and where we should be deploying more resources. TH

Mark Leiser is a freelance writer based in New Jersey.

Mark Chassin, MD, MPP, MPH, president of the Joint Commission, will deliver the keynote address at HM09 in Chicago. A board-certified internist who practiced emergency medicine for 12 years, Dr. Chassin is recognized as an expert in quality measurement and improvement.

He recently spoke to The Hospitalist about his views on the changing world of healthcare, the commission’s evolving role, and the importance of a stronger partnership between the accrediting body and hospital-based physicians.

Question: Why are you looking forward to speaking at HM09?

Answer: Hospitalists are an especially important group of physicians for [the Joint Commission] to connect with because of the close alignment between our mission and the way they practice medicine. Accreditation alone is not enough. We need active engagement of the HM practitioners in all of the quality and safety improvement initiatives the Joint Commission has set in motion. It’s also important for us to hear from the physicians on the front lines—and from those who have taken responsibility for oversight of quality programs in hospitals—about how our efforts are working and where we need to fill in gaps.

Q: Can you provide an overview of the topics you plan to talk about?

A: At the pace everything is changing, it’s hard to know exactly what I’ll want to talk about. I’ll probably say something about the major challenges we face across healthcare that are particularly magnified in hospitals. That’s where the most vulnerable patients are. That’s where the most dangerous procedures are done. That’s where the most dangerous drugs are used, and that’s where the most complicated devices are used. All these things have the potential for improving outcomes, but also increasing the potential for harm if they’re not used well.

The environment we’re in is going in one direction, and that is to demand more of all of us in healthcare with respect to the level of excellence at which care is provided and overseen. There’s a strong push on the part of public stakeholders for accountability in healthcare. I may talk about how we might respond to that demand and close the gap between what we know we could be providing in terms of safe, high-quality care, and what we are providing.

Q: You said accreditation by itself is not sufficient. What else is needed?

A: When I was exploring this job, I wanted to determine whether the Joint Commission and its board of commissioners were ready to undertake initiatives, in addition to accreditation, in order to move the delivery system more rapidly toward higher levels of safety and quality. … It became clear to me they weren’t just willing to do it, but very enthusiastic about doing it.

Q: Can you give an example of one of those new initiatives?

A: I have watched and participated in the development of applications coming out of industry in the last 10 years or so, like Six Sigma and the Toyota Production System, that are highly promising in their ability to deliver much higher levels of excellence and sustain them. We’re in the middle of a very aggressive adoption of these tools, which we’re calling our Robust Process Improvement Initiative.

Q: What are the benefits of that initiative?

A: We are doing this to enhance our capacity to do process improvement, to simplify our processes, to focus on customer service. It does not mean it’s to make these surveys easy. It means understanding where our processes are too complicated, where we have too many bells and whistles that are not related to safety and quality, and where we can reduce our costs. At the same time, we’re exploring how we can work with organizations, hospitals, and health systems who have committed to learning these tools and methods to bring them to bear on safety and quality problems—medication reconciliation, infection control breakdown, pre-op verification to get rid of wrong site/wrong side surgery—that organizations struggle with but haven’t wrestled to the ground yet.

Q: Why is it so difficult?

A: In the last year, I’ve been challenging healthcare organizations with respect to exactly that question. I believe everyone—and I put the Joint Commission side by side with organizations that deliver the care—can’t settle for anything less than aiming to transform healthcare into a high-reliability industry. That means rates of adverse events and breakdowns and quality problems that are as low as the best high-reliability organizations in the world, like commercial air travel, nuclear power, and other organizations, that deal with risk and hazards every bit as difficult and dangerous as healthcare but do it a heck of a lot better than we do.

Q: What are the barriers that keep that from happening?

A: First, there’s no role model. There’s no example in healthcare of an organization of any size that is at that level of high reliability. We’re not really in a position to hand out a playbook or a set of blueprints and say, “If you follow these step-by-step set of processes, you’ll get there.”

Another issue is the imperfect creation of a uniform safety culture. One of the hallmarks of a true safety culture is every individual who works in a healthcare organization should be alert to the smallest deviation from safe practice and safe circumstance, and they should be expected and encouraged to report those problems. Is somebody not observing safe sterile techniques in the operating room? Is somebody giving an order for medication that is ambiguous or inaccurate? Just like the junior navigator in an airplane cockpit, everyone must feel his or her obligation to point out what he or she thinks the captain is doing wrong and bring that discrepancy to the surface.

Q: What are your thoughts on the tremendous growth of HM, as well as what the future holds for the field?

A: The growth provides challenges and opportunities. The biggest challenge is the risk the movement toward the delivery of more hospital care by hospitalists provides a discontinuity between the care that’s provided in the community on the front end and hospital care, and then a discontinuity on the back end when the patient goes back into the community. It puts a much larger burden on hospitalists and organizations to make sure they work together to develop really effective ways on both the front and back ends to minimize the unintended consequences of those potential discontinuities.

That said, the opportunity of having a group of physicians who are focused primarily on what happens in hospitals gives those of us who are in quality-oversight positions a natural constituency to work with on perfecting our safety and quality programs in hospitals. That’s an important opportunity, given how complicated it has become to deliver high-quality hospital care.

Q: When hospitalists head home from Chicago, what would you like them to know about the Joint Commission and its mission?

A: The legacy of what the Joint Commission used to be sometimes gets caricatured as a bunch of silly rules and hoops people have to jump through that have nothing to do with patient care. That caricature really is a thing of the past. The current programs we have—both in accreditation and some of these newer initiatives—really have the promise of delivering the capability of helping hospitals and other health organizations achieve the high reliability I know they want. And we need to work shoulder to shoulder on problems. That comes back to how we really need unvarnished feedback about our current programs, whether they’re working well and where we should be deploying more resources. TH

Mark Leiser is a freelance writer based in New Jersey.