Quality

No one becomes a doctor to make a fashion statement, but a new study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.864/abstract) in the Journal of Hospital Medicine reports that the choice between long-sleeved white coats and freshly laundered scrubs might be a question of taste, not safety.

The report, “Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial,” found no statistically significant differences in bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination of physicians’ white coats compared with scrubs or in contamination of the skin at the wrists of physicians wearing either garment.

In an email interview, Marisha Burden, MD, interim chief of hospital medicine at the Denver Health and Hospital Authority, says that the topic area came up during a review of research regarding MRSA and infection-control policies. Dr. Burden found references to the so-called “bare below the elbows” policy in the United Kingdom, a reference to 2007 rules from the British Department of Health banning long-sleeved coats in an attempt to stop nosocomial bacterial transmission.

“This policy was interesting to us secondary to the fact that there was no literature to support the measures being implemented,” Dr. Burden says. “ … Our data show that bacterial contamination of work clothes occurs within hours of putting them on, as well that at the end of an eight-hour workday, there is no difference in bacterial or MRSA contamination of either dress.”

Dr. Burden says the data do not support discarding white coats for uniforms that are changed on a daily basis, or for “requiring healthcare workers to avoid long-sleeved garments.” She also says that white coats have traditional lures as well as practical ones: Most of the physicians who declined to participate in the study did so because they refused to work without the pockets that came with their lab coats.

“I think we also have to consider the professional image that our physicians portray,” she adds. “Our patients expect their physicians to appear professional with clean, white coats.”—RQ

Technology

App Allows CT, MRI, PET Diagnoses Via iPhone, iPad

What can a hospitalist do the next time someone in the group has no immediate access to a work station but needs to make a medical diagnoses based on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)?

Grab the nearest iPhone.

The FDA recently approved an application from MIM Software Inc. of Cleveland to let doctors review medical images on the iPhone and iPad via a secure network transfer. The application, Mobile MIM, is the first with the FDA’s imprimatur. It allows hospitalists and other physicians to measure distance on the image and image intensity values and display measurement lines, annotations, and regions of interest, according to the FDA.

“Think of how cell phones were perceived a few decades ago; many dismissed ‘anytime access’ as not necessary,” MIM chief technology officer Mark Cain says in an email. “Yet now we know myriad of cases where the cell phone has proven immensely valuable. The same can be said of diagnostic medical image access. How many ways can this improve healthcare? More ways than I can predict.”—RQ

Quality Research

Research Confirms Benefits of ICU Safety Checklists

The value of checklists containing evidence-supported QI interventions to improve ICU outcomes, pioneered at Johns Hopkins in Baltimore, has been confirmed by several recent studies. The Keystone ICU Project, which sought to replicate the Hopkins experience in hospitals across Michigan, succeeded in nearly eliminating bloodstream infections and reducing mortality.¹

Based on Medicare claims from 95 study hospitals and comparison data from 11 surrounding states, patients in hospitals using the checklist were significantly more likely to survive a hospital stay. The project was not, however, sufficiently powered to show a significant difference in length of stay.

A second Keystone Project study showed that five simple therapies aimed at lessening the time spent on ventilators, including elevating the head of the bed 30 degrees, giving anticoagulants, and lessening sedation, combined with education and a hospital culture supporting patient safety, reduced cases of ventilator-associated pneumonia by more than 70%.²

A comprehensive, video-conference-based intervention to support implementing six evidence-based quality practices in 15 community hospital ICUs in Canada improved the adoption of these practices. Expert-led forums and educational sessions promoted the sequential dissemination of treatment algorhythms, with a new practice targeted every four months.³—LB

References

1. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
2. Berenholtz SM, Pham JC, Thompson DA, Needhamm et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;(4):305-314.
3. Scales DC, Dainty K, Hales B. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA. 2011;305:363-372.

HM-Based Quality Research

Homeless Respite Helps Avoid Rehospitalizations

Some readmissions come about because things fall apart when patients are discharged with a follow-up plan that is not realistic to their circumstances. This is especially true for homeless patients, says Audrey Kuang, MD, a hospitalist at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif., and medical director of the Santa Clara County Medical Respite Program, a shelter for homeless patients following discharge from seven San Jose area hospitals.

Dr. Kuang described the collaborative program in a plenary presentation for the Research, Innovations, and Clinical Vignettes competition at HM10.

SCVMC is a county safety net hospital, and Dr. Kuang says the hospitalists “see a fair amount of homeless patients with recurrent exacerbations.” Patients given prescriptions for medications they can’t afford, special diets, or instructions for bed rest are then discharged to the street; inevitably, they are readmitted.

Dr. Kuang began tracking patients who had prolonged hospital stays because of homelessness or unsafe social situations. Her presentation to administrators led to participating hospitals contributing $25,000 each to launch the program with a multidisciplinary team, which included Dr. Kuang.

In its first year, 200 referrals were made to the respite program; 60% were accepted. The most common diagnoses were foot fractures, foot infections, and cancer. Quantified clinical outcomes are still being compiled, Dr. Kuang said, although the participating hospitals have reported decreased rehospitalizations and bed days—results documented in other studies of respite programs.¹

“The main idea is post-acute medical care and support for homeless patients in need,” she explained. “Hospitalists may feel this is beyond our scope of practice, but it is our responsibility to know what’s going on out there.”—LB

Reference

1. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.

By The Numbers

$44,000, $46,659, $120,000: EHR Implementation Costs Higher than Medicare Reimbursement

A new study in Health Affairs on the first-year costs of implementing electronic health records (EHR) in a 450-physician North Texas primary-care network doesn’t translate directly to HM, but figures showing that the installation cost is more for an average five-physician practice than Medicare is offering in incentive pay might serve as a warning sign for HM groups looking to build EHR into their practice:

• EHR incentive payments from Medicare over five years: $44,000;
• EHR implementation cost per doctor after first year: $46,659;
• EHR adoption costs per physician, estimated: $120,000.—RQ TH

No one becomes a doctor to make a fashion statement, but a new study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.864/abstract) in the Journal of Hospital Medicine reports that the choice between long-sleeved white coats and freshly laundered scrubs might be a question of taste, not safety.

The report, “Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial,” found no statistically significant differences in bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination of physicians’ white coats compared with scrubs or in contamination of the skin at the wrists of physicians wearing either garment.

In an email interview, Marisha Burden, MD, interim chief of hospital medicine at the Denver Health and Hospital Authority, says that the topic area came up during a review of research regarding MRSA and infection-control policies. Dr. Burden found references to the so-called “bare below the elbows” policy in the United Kingdom, a reference to 2007 rules from the British Department of Health banning long-sleeved coats in an attempt to stop nosocomial bacterial transmission.

“This policy was interesting to us secondary to the fact that there was no literature to support the measures being implemented,” Dr. Burden says. “ … Our data show that bacterial contamination of work clothes occurs within hours of putting them on, as well that at the end of an eight-hour workday, there is no difference in bacterial or MRSA contamination of either dress.”

Dr. Burden says the data do not support discarding white coats for uniforms that are changed on a daily basis, or for “requiring healthcare workers to avoid long-sleeved garments.” She also says that white coats have traditional lures as well as practical ones: Most of the physicians who declined to participate in the study did so because they refused to work without the pockets that came with their lab coats.

“I think we also have to consider the professional image that our physicians portray,” she adds. “Our patients expect their physicians to appear professional with clean, white coats.”—RQ

Technology

App Allows CT, MRI, PET Diagnoses Via iPhone, iPad

What can a hospitalist do the next time someone in the group has no immediate access to a work station but needs to make a medical diagnoses based on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)?

Grab the nearest iPhone.

The FDA recently approved an application from MIM Software Inc. of Cleveland to let doctors review medical images on the iPhone and iPad via a secure network transfer. The application, Mobile MIM, is the first with the FDA’s imprimatur. It allows hospitalists and other physicians to measure distance on the image and image intensity values and display measurement lines, annotations, and regions of interest, according to the FDA.

“Think of how cell phones were perceived a few decades ago; many dismissed ‘anytime access’ as not necessary,” MIM chief technology officer Mark Cain says in an email. “Yet now we know myriad of cases where the cell phone has proven immensely valuable. The same can be said of diagnostic medical image access. How many ways can this improve healthcare? More ways than I can predict.”—RQ

Quality Research

Research Confirms Benefits of ICU Safety Checklists

The value of checklists containing evidence-supported QI interventions to improve ICU outcomes, pioneered at Johns Hopkins in Baltimore, has been confirmed by several recent studies. The Keystone ICU Project, which sought to replicate the Hopkins experience in hospitals across Michigan, succeeded in nearly eliminating bloodstream infections and reducing mortality.¹

Based on Medicare claims from 95 study hospitals and comparison data from 11 surrounding states, patients in hospitals using the checklist were significantly more likely to survive a hospital stay. The project was not, however, sufficiently powered to show a significant difference in length of stay.

A second Keystone Project study showed that five simple therapies aimed at lessening the time spent on ventilators, including elevating the head of the bed 30 degrees, giving anticoagulants, and lessening sedation, combined with education and a hospital culture supporting patient safety, reduced cases of ventilator-associated pneumonia by more than 70%.²

A comprehensive, video-conference-based intervention to support implementing six evidence-based quality practices in 15 community hospital ICUs in Canada improved the adoption of these practices. Expert-led forums and educational sessions promoted the sequential dissemination of treatment algorhythms, with a new practice targeted every four months.³—LB

References

1. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
2. Berenholtz SM, Pham JC, Thompson DA, Needhamm et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;(4):305-314.
3. Scales DC, Dainty K, Hales B. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA. 2011;305:363-372.

HM-Based Quality Research

Homeless Respite Helps Avoid Rehospitalizations

Some readmissions come about because things fall apart when patients are discharged with a follow-up plan that is not realistic to their circumstances. This is especially true for homeless patients, says Audrey Kuang, MD, a hospitalist at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif., and medical director of the Santa Clara County Medical Respite Program, a shelter for homeless patients following discharge from seven San Jose area hospitals.

Dr. Kuang described the collaborative program in a plenary presentation for the Research, Innovations, and Clinical Vignettes competition at HM10.

SCVMC is a county safety net hospital, and Dr. Kuang says the hospitalists “see a fair amount of homeless patients with recurrent exacerbations.” Patients given prescriptions for medications they can’t afford, special diets, or instructions for bed rest are then discharged to the street; inevitably, they are readmitted.

Dr. Kuang began tracking patients who had prolonged hospital stays because of homelessness or unsafe social situations. Her presentation to administrators led to participating hospitals contributing $25,000 each to launch the program with a multidisciplinary team, which included Dr. Kuang.

In its first year, 200 referrals were made to the respite program; 60% were accepted. The most common diagnoses were foot fractures, foot infections, and cancer. Quantified clinical outcomes are still being compiled, Dr. Kuang said, although the participating hospitals have reported decreased rehospitalizations and bed days—results documented in other studies of respite programs.¹

“The main idea is post-acute medical care and support for homeless patients in need,” she explained. “Hospitalists may feel this is beyond our scope of practice, but it is our responsibility to know what’s going on out there.”—LB

Reference

1. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.

By The Numbers

$44,000, $46,659, $120,000: EHR Implementation Costs Higher than Medicare Reimbursement

A new study in Health Affairs on the first-year costs of implementing electronic health records (EHR) in a 450-physician North Texas primary-care network doesn’t translate directly to HM, but figures showing that the installation cost is more for an average five-physician practice than Medicare is offering in incentive pay might serve as a warning sign for HM groups looking to build EHR into their practice:

• EHR incentive payments from Medicare over five years: $44,000;
• EHR implementation cost per doctor after first year: $46,659;
• EHR adoption costs per physician, estimated: $120,000.—RQ TH

No one becomes a doctor to make a fashion statement, but a new study (http://onlinelibrary.wiley.com/doi/10.1002/jhm.864/abstract) in the Journal of Hospital Medicine reports that the choice between long-sleeved white coats and freshly laundered scrubs might be a question of taste, not safety.

The report, “Newly Cleaned Physician Uniforms and Infrequently Washed White Coats Have Similar Rates of Bacterial Contamination After an 8-Hour Workday: A Randomized Controlled Trial,” found no statistically significant differences in bacterial or methicillin-resistant Staphylococcus aureus (MRSA) contamination of physicians’ white coats compared with scrubs or in contamination of the skin at the wrists of physicians wearing either garment.

In an email interview, Marisha Burden, MD, interim chief of hospital medicine at the Denver Health and Hospital Authority, says that the topic area came up during a review of research regarding MRSA and infection-control policies. Dr. Burden found references to the so-called “bare below the elbows” policy in the United Kingdom, a reference to 2007 rules from the British Department of Health banning long-sleeved coats in an attempt to stop nosocomial bacterial transmission.

“This policy was interesting to us secondary to the fact that there was no literature to support the measures being implemented,” Dr. Burden says. “ … Our data show that bacterial contamination of work clothes occurs within hours of putting them on, as well that at the end of an eight-hour workday, there is no difference in bacterial or MRSA contamination of either dress.”

Dr. Burden says the data do not support discarding white coats for uniforms that are changed on a daily basis, or for “requiring healthcare workers to avoid long-sleeved garments.” She also says that white coats have traditional lures as well as practical ones: Most of the physicians who declined to participate in the study did so because they refused to work without the pockets that came with their lab coats.

“I think we also have to consider the professional image that our physicians portray,” she adds. “Our patients expect their physicians to appear professional with clean, white coats.”—RQ

Technology

App Allows CT, MRI, PET Diagnoses Via iPhone, iPad

What can a hospitalist do the next time someone in the group has no immediate access to a work station but needs to make a medical diagnoses based on computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)?

Grab the nearest iPhone.

The FDA recently approved an application from MIM Software Inc. of Cleveland to let doctors review medical images on the iPhone and iPad via a secure network transfer. The application, Mobile MIM, is the first with the FDA’s imprimatur. It allows hospitalists and other physicians to measure distance on the image and image intensity values and display measurement lines, annotations, and regions of interest, according to the FDA.

“Think of how cell phones were perceived a few decades ago; many dismissed ‘anytime access’ as not necessary,” MIM chief technology officer Mark Cain says in an email. “Yet now we know myriad of cases where the cell phone has proven immensely valuable. The same can be said of diagnostic medical image access. How many ways can this improve healthcare? More ways than I can predict.”—RQ

Quality Research

Research Confirms Benefits of ICU Safety Checklists

The value of checklists containing evidence-supported QI interventions to improve ICU outcomes, pioneered at Johns Hopkins in Baltimore, has been confirmed by several recent studies. The Keystone ICU Project, which sought to replicate the Hopkins experience in hospitals across Michigan, succeeded in nearly eliminating bloodstream infections and reducing mortality.¹

Based on Medicare claims from 95 study hospitals and comparison data from 11 surrounding states, patients in hospitals using the checklist were significantly more likely to survive a hospital stay. The project was not, however, sufficiently powered to show a significant difference in length of stay.

A second Keystone Project study showed that five simple therapies aimed at lessening the time spent on ventilators, including elevating the head of the bed 30 degrees, giving anticoagulants, and lessening sedation, combined with education and a hospital culture supporting patient safety, reduced cases of ventilator-associated pneumonia by more than 70%.²

A comprehensive, video-conference-based intervention to support implementing six evidence-based quality practices in 15 community hospital ICUs in Canada improved the adoption of these practices. Expert-led forums and educational sessions promoted the sequential dissemination of treatment algorhythms, with a new practice targeted every four months.³—LB

References

1. Lipitz-Snyderman A, Steinwachs D, Needham DM, Colantuoni E, Morlock LL, Pronovost PJ. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.
2. Berenholtz SM, Pham JC, Thompson DA, Needhamm et al. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol. 2011;(4):305-314.
3. Scales DC, Dainty K, Hales B. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA. 2011;305:363-372.

HM-Based Quality Research

Homeless Respite Helps Avoid Rehospitalizations

Some readmissions come about because things fall apart when patients are discharged with a follow-up plan that is not realistic to their circumstances. This is especially true for homeless patients, says Audrey Kuang, MD, a hospitalist at Santa Clara Valley Medical Center (SCVMC) in San Jose, Calif., and medical director of the Santa Clara County Medical Respite Program, a shelter for homeless patients following discharge from seven San Jose area hospitals.

Dr. Kuang described the collaborative program in a plenary presentation for the Research, Innovations, and Clinical Vignettes competition at HM10.

SCVMC is a county safety net hospital, and Dr. Kuang says the hospitalists “see a fair amount of homeless patients with recurrent exacerbations.” Patients given prescriptions for medications they can’t afford, special diets, or instructions for bed rest are then discharged to the street; inevitably, they are readmitted.

Dr. Kuang began tracking patients who had prolonged hospital stays because of homelessness or unsafe social situations. Her presentation to administrators led to participating hospitals contributing $25,000 each to launch the program with a multidisciplinary team, which included Dr. Kuang.

In its first year, 200 referrals were made to the respite program; 60% were accepted. The most common diagnoses were foot fractures, foot infections, and cancer. Quantified clinical outcomes are still being compiled, Dr. Kuang said, although the participating hospitals have reported decreased rehospitalizations and bed days—results documented in other studies of respite programs.¹

“The main idea is post-acute medical care and support for homeless patients in need,” she explained. “Hospitalists may feel this is beyond our scope of practice, but it is our responsibility to know what’s going on out there.”—LB

Reference

1. Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006;96:1278-1281.

By The Numbers

$44,000, $46,659, $120,000: EHR Implementation Costs Higher than Medicare Reimbursement

A new study in Health Affairs on the first-year costs of implementing electronic health records (EHR) in a 450-physician North Texas primary-care network doesn’t translate directly to HM, but figures showing that the installation cost is more for an average five-physician practice than Medicare is offering in incentive pay might serve as a warning sign for HM groups looking to build EHR into their practice:

• EHR incentive payments from Medicare over five years: $44,000;
• EHR implementation cost per doctor after first year: $46,659;
• EHR adoption costs per physician, estimated: $120,000.—RQ TH

If the road to hell is paved with good intentions, then hell is full of unintended consequences.

The debate about whether hospitals’ reimbursements should be based on quality performance is not a unique concept. Similar systems have been implemented in other fields (e.g. education), and we in the medical field can learn from their experiences. In education, testing students is the driving force in measuring a “quality outcome.”

A growing number of educators now believe that the focus on testing to measure quality has actually reduced the quality of education; they cite the bureaucratic, inflexible, and cumbersome requirements placed on the educators, and the diversion of precious resources to focus on standardized test scores. The actual education of the students becomes secondary, and there are allegations of school systems manipulating their data to ensure maximum funding.

With the drive to pay-for-performance in the medical field, will the actual medical care of the patient become secondary to hitting the “quality” metrics set by the government? Add in a volatile mix of money, and this becomes a recipe for disaster.

Questions are many:

• What standards of quality are we going to use?
• Do these metrics truly translate into “quality”?
• Will the goal of reaching these metrics become the main focus of the hospitals instead of actual patient care?
• Is the goal to really improve the quality of healthcare, or is it just another vehicle for government and private third parties to come up with another excuse to reduce reimbursement in the name of quality?

Even now, ED physicians are giving antibiotics liberally for fear that they will be admonished for “missing” the pneumonia core measures. Whether this is appropriate care for the patient is irrelevant to hitting the statistical goal. Where is the incentive to deliver appropriate care? Are we even asking the right questions? Do bureaucrats know that even if appropriate, timely, quality care is given that a positive outcome is not guaranteed?

The field of medicine has made incredible advances in patient care, but the fact remains that a certain percentage of the sick and elderly become sicker and eventually die, especially in hospitals.

Potential Problems are Many

Unintended consequences pose a real danger to a system that rewards and penalizes. One potential issue is the “rich getting richer and the poor getting poorer,” as more provider focus is placed on buffering statistics by keeping healthy people healthier to achieve better outcomes, meanwhile shunning or diverting the seriously sick patients in order to keep quality metrics within goal.

How will the government and insurance providers guarantee the accuracy of each hospital’s statistics?

Think of the money and resources that will be diverted away from the clinical arena and into the bureaucratic nightmare of record-keeping needed to implement this pay-for-performance system. How many billions of dollars will be needed to fund this new bureaucracy? Do we need another bureaucratic, punitive layer in our already cumbersome medical system?

My answer is clear: No! TH

Dr. Yu is medical director of adult hospitalist services at Presbyterian Medical Group in Albuquerque, N.M., and a Team Hospitalist member.

If the road to hell is paved with good intentions, then hell is full of unintended consequences.

The debate about whether hospitals’ reimbursements should be based on quality performance is not a unique concept. Similar systems have been implemented in other fields (e.g. education), and we in the medical field can learn from their experiences. In education, testing students is the driving force in measuring a “quality outcome.”

A growing number of educators now believe that the focus on testing to measure quality has actually reduced the quality of education; they cite the bureaucratic, inflexible, and cumbersome requirements placed on the educators, and the diversion of precious resources to focus on standardized test scores. The actual education of the students becomes secondary, and there are allegations of school systems manipulating their data to ensure maximum funding.

With the drive to pay-for-performance in the medical field, will the actual medical care of the patient become secondary to hitting the “quality” metrics set by the government? Add in a volatile mix of money, and this becomes a recipe for disaster.

Questions are many:

• What standards of quality are we going to use?
• Do these metrics truly translate into “quality”?
• Will the goal of reaching these metrics become the main focus of the hospitals instead of actual patient care?
• Is the goal to really improve the quality of healthcare, or is it just another vehicle for government and private third parties to come up with another excuse to reduce reimbursement in the name of quality?

Even now, ED physicians are giving antibiotics liberally for fear that they will be admonished for “missing” the pneumonia core measures. Whether this is appropriate care for the patient is irrelevant to hitting the statistical goal. Where is the incentive to deliver appropriate care? Are we even asking the right questions? Do bureaucrats know that even if appropriate, timely, quality care is given that a positive outcome is not guaranteed?

The field of medicine has made incredible advances in patient care, but the fact remains that a certain percentage of the sick and elderly become sicker and eventually die, especially in hospitals.

Potential Problems are Many

Unintended consequences pose a real danger to a system that rewards and penalizes. One potential issue is the “rich getting richer and the poor getting poorer,” as more provider focus is placed on buffering statistics by keeping healthy people healthier to achieve better outcomes, meanwhile shunning or diverting the seriously sick patients in order to keep quality metrics within goal.

How will the government and insurance providers guarantee the accuracy of each hospital’s statistics?

Think of the money and resources that will be diverted away from the clinical arena and into the bureaucratic nightmare of record-keeping needed to implement this pay-for-performance system. How many billions of dollars will be needed to fund this new bureaucracy? Do we need another bureaucratic, punitive layer in our already cumbersome medical system?

My answer is clear: No! TH

Dr. Yu is medical director of adult hospitalist services at Presbyterian Medical Group in Albuquerque, N.M., and a Team Hospitalist member.

If the road to hell is paved with good intentions, then hell is full of unintended consequences.

The debate about whether hospitals’ reimbursements should be based on quality performance is not a unique concept. Similar systems have been implemented in other fields (e.g. education), and we in the medical field can learn from their experiences. In education, testing students is the driving force in measuring a “quality outcome.”

A growing number of educators now believe that the focus on testing to measure quality has actually reduced the quality of education; they cite the bureaucratic, inflexible, and cumbersome requirements placed on the educators, and the diversion of precious resources to focus on standardized test scores. The actual education of the students becomes secondary, and there are allegations of school systems manipulating their data to ensure maximum funding.

With the drive to pay-for-performance in the medical field, will the actual medical care of the patient become secondary to hitting the “quality” metrics set by the government? Add in a volatile mix of money, and this becomes a recipe for disaster.

Questions are many:

• What standards of quality are we going to use?
• Do these metrics truly translate into “quality”?
• Will the goal of reaching these metrics become the main focus of the hospitals instead of actual patient care?
• Is the goal to really improve the quality of healthcare, or is it just another vehicle for government and private third parties to come up with another excuse to reduce reimbursement in the name of quality?

Even now, ED physicians are giving antibiotics liberally for fear that they will be admonished for “missing” the pneumonia core measures. Whether this is appropriate care for the patient is irrelevant to hitting the statistical goal. Where is the incentive to deliver appropriate care? Are we even asking the right questions? Do bureaucrats know that even if appropriate, timely, quality care is given that a positive outcome is not guaranteed?

The field of medicine has made incredible advances in patient care, but the fact remains that a certain percentage of the sick and elderly become sicker and eventually die, especially in hospitals.

Potential Problems are Many

Unintended consequences pose a real danger to a system that rewards and penalizes. One potential issue is the “rich getting richer and the poor getting poorer,” as more provider focus is placed on buffering statistics by keeping healthy people healthier to achieve better outcomes, meanwhile shunning or diverting the seriously sick patients in order to keep quality metrics within goal.

How will the government and insurance providers guarantee the accuracy of each hospital’s statistics?

Think of the money and resources that will be diverted away from the clinical arena and into the bureaucratic nightmare of record-keeping needed to implement this pay-for-performance system. How many billions of dollars will be needed to fund this new bureaucracy? Do we need another bureaucratic, punitive layer in our already cumbersome medical system?

My answer is clear: No! TH

Dr. Yu is medical director of adult hospitalist services at Presbyterian Medical Group in Albuquerque, N.M., and a Team Hospitalist member.

Ask a hospitalist “Is quality important?” and most will answer “Yes.” Now ask the hospital’s CEO/CFO that same question, and you’ll get a resounding “Yes.”

Quality, as the primary determinant of value, has become priority No. 1 for hospitals.¹ And with the Centers for Medicare & Medicaid Services’ (CMS) proposed rules for value-based purchasing (VBP), starting with a 1% withholding of Medicare reimbursement for demonstration of quality-measure performance, big dollars are at risk for hospitals.²

As the key providers of inpatient care, hospitalists will share in this financial accountability. The next-generation HM program must show value not only through efficiency and cost reduction, but also expanded services and quality.

Quality is a means of defining good care. Historically, the medical profession has escaped external accountability for quality as part of practitioner autonomy. Today, more than ever, consumer groups, payors, and regulatory bodies are demanding demonstration of quality outcomes, which impacts reimbursement and market share.

Is this demand for quality performance negative? Misused, it can be a mechanism for cost control through seemingly arbitrary indicators. Considered more broadly, it can be positive: We will be able to evaluate our practices to improve care.

Either way, the quality ship has sailed. Accepting this change, we see that the direction and execution are largely left open-ended, which brings another positive: HM has an opportunity to charter the course.

Hospitalists are inpatient care experts; we understand and improve health systems to provide excellent care. Above all else, quality is what we stand for. As a field, we are at the leading edge of change. Getting ahead of quality at each of our institutions is a great opportunity, and helping hospitals implement and deliver on quality initiatives is job security. Being held to what we value, hospitalists should be incentivized by quality performance.

Quality and Compensation

Why tie compensation to quality outcomes? First, hospitals are financially accountable for performance, and HM is financially accountable to hospitals. Second, we incent important objectives, in addition to other mechanisms (e.g. transparent reporting), to drive performance.

The majority of HM programs have an incentive component to their compensation structure, and quality is the leading performance incentive (hospitalists in these programs also have higher incomes).³ We can expect to see HM compensation structures evolve toward pay-for-performance or gainsharing models. HM groups should turn their focus to using incentives or bonuses. Here are some tips:

1. Lead quality initiatives. Participate in hospital-based patient safety and satisfaction projects. Communicate the importance to your group to achieve buy-in.
2. Define mutual goals. Choose two or three measurable areas that are the top priority items for the hospital and your group, and put them on your scorecard. Consider measuring team performance.
3. Make it count. Make the amount of financial incentive a portion of compensation that is meaningful. Share data—and the effect on compensation—regularly to drive performance.

Quality is ours to lead. Define and deliver it, and you’ll find your group to be indispensable to the hospital, with dollars to gain—for all the right reasons. TH

Dr. Wright is senior medical officer at Hospitalists Management Company in Wisconsin and a Team Hospitalist member.

References

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
2. Centers for Medicare & Medicaid Services. Medicare program: hospital patient value-based purchasing program. Federal Register. 2011;76(9).
3. State of Hospital Medicine: 2010 Report Based on 2009 Data. SHM website. Available at: www.hospitalmedicine.org/survey. Accessed April 2, 2011.

Ask a hospitalist “Is quality important?” and most will answer “Yes.” Now ask the hospital’s CEO/CFO that same question, and you’ll get a resounding “Yes.”

Quality, as the primary determinant of value, has become priority No. 1 for hospitals.¹ And with the Centers for Medicare & Medicaid Services’ (CMS) proposed rules for value-based purchasing (VBP), starting with a 1% withholding of Medicare reimbursement for demonstration of quality-measure performance, big dollars are at risk for hospitals.²

As the key providers of inpatient care, hospitalists will share in this financial accountability. The next-generation HM program must show value not only through efficiency and cost reduction, but also expanded services and quality.

Quality is a means of defining good care. Historically, the medical profession has escaped external accountability for quality as part of practitioner autonomy. Today, more than ever, consumer groups, payors, and regulatory bodies are demanding demonstration of quality outcomes, which impacts reimbursement and market share.

Is this demand for quality performance negative? Misused, it can be a mechanism for cost control through seemingly arbitrary indicators. Considered more broadly, it can be positive: We will be able to evaluate our practices to improve care.

Either way, the quality ship has sailed. Accepting this change, we see that the direction and execution are largely left open-ended, which brings another positive: HM has an opportunity to charter the course.

Hospitalists are inpatient care experts; we understand and improve health systems to provide excellent care. Above all else, quality is what we stand for. As a field, we are at the leading edge of change. Getting ahead of quality at each of our institutions is a great opportunity, and helping hospitals implement and deliver on quality initiatives is job security. Being held to what we value, hospitalists should be incentivized by quality performance.

Quality and Compensation

Why tie compensation to quality outcomes? First, hospitals are financially accountable for performance, and HM is financially accountable to hospitals. Second, we incent important objectives, in addition to other mechanisms (e.g. transparent reporting), to drive performance.

The majority of HM programs have an incentive component to their compensation structure, and quality is the leading performance incentive (hospitalists in these programs also have higher incomes).³ We can expect to see HM compensation structures evolve toward pay-for-performance or gainsharing models. HM groups should turn their focus to using incentives or bonuses. Here are some tips:

1. Lead quality initiatives. Participate in hospital-based patient safety and satisfaction projects. Communicate the importance to your group to achieve buy-in.
2. Define mutual goals. Choose two or three measurable areas that are the top priority items for the hospital and your group, and put them on your scorecard. Consider measuring team performance.
3. Make it count. Make the amount of financial incentive a portion of compensation that is meaningful. Share data—and the effect on compensation—regularly to drive performance.

Quality is ours to lead. Define and deliver it, and you’ll find your group to be indispensable to the hospital, with dollars to gain—for all the right reasons. TH

Dr. Wright is senior medical officer at Hospitalists Management Company in Wisconsin and a Team Hospitalist member.

References

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
2. Centers for Medicare & Medicaid Services. Medicare program: hospital patient value-based purchasing program. Federal Register. 2011;76(9).
3. State of Hospital Medicine: 2010 Report Based on 2009 Data. SHM website. Available at: www.hospitalmedicine.org/survey. Accessed April 2, 2011.

Ask a hospitalist “Is quality important?” and most will answer “Yes.” Now ask the hospital’s CEO/CFO that same question, and you’ll get a resounding “Yes.”

Quality, as the primary determinant of value, has become priority No. 1 for hospitals.¹ And with the Centers for Medicare & Medicaid Services’ (CMS) proposed rules for value-based purchasing (VBP), starting with a 1% withholding of Medicare reimbursement for demonstration of quality-measure performance, big dollars are at risk for hospitals.²

As the key providers of inpatient care, hospitalists will share in this financial accountability. The next-generation HM program must show value not only through efficiency and cost reduction, but also expanded services and quality.

Quality is a means of defining good care. Historically, the medical profession has escaped external accountability for quality as part of practitioner autonomy. Today, more than ever, consumer groups, payors, and regulatory bodies are demanding demonstration of quality outcomes, which impacts reimbursement and market share.

Is this demand for quality performance negative? Misused, it can be a mechanism for cost control through seemingly arbitrary indicators. Considered more broadly, it can be positive: We will be able to evaluate our practices to improve care.

Either way, the quality ship has sailed. Accepting this change, we see that the direction and execution are largely left open-ended, which brings another positive: HM has an opportunity to charter the course.

Hospitalists are inpatient care experts; we understand and improve health systems to provide excellent care. Above all else, quality is what we stand for. As a field, we are at the leading edge of change. Getting ahead of quality at each of our institutions is a great opportunity, and helping hospitals implement and deliver on quality initiatives is job security. Being held to what we value, hospitalists should be incentivized by quality performance.

Quality and Compensation

Why tie compensation to quality outcomes? First, hospitals are financially accountable for performance, and HM is financially accountable to hospitals. Second, we incent important objectives, in addition to other mechanisms (e.g. transparent reporting), to drive performance.

The majority of HM programs have an incentive component to their compensation structure, and quality is the leading performance incentive (hospitalists in these programs also have higher incomes).³ We can expect to see HM compensation structures evolve toward pay-for-performance or gainsharing models. HM groups should turn their focus to using incentives or bonuses. Here are some tips:

1. Lead quality initiatives. Participate in hospital-based patient safety and satisfaction projects. Communicate the importance to your group to achieve buy-in.
2. Define mutual goals. Choose two or three measurable areas that are the top priority items for the hospital and your group, and put them on your scorecard. Consider measuring team performance.
3. Make it count. Make the amount of financial incentive a portion of compensation that is meaningful. Share data—and the effect on compensation—regularly to drive performance.

Quality is ours to lead. Define and deliver it, and you’ll find your group to be indispensable to the hospital, with dollars to gain—for all the right reasons. TH

Dr. Wright is senior medical officer at Hospitalists Management Company in Wisconsin and a Team Hospitalist member.

References

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA. 2002;287:487-494.
2. Centers for Medicare & Medicaid Services. Medicare program: hospital patient value-based purchasing program. Federal Register. 2011;76(9).
3. State of Hospital Medicine: 2010 Report Based on 2009 Data. SHM website. Available at: www.hospitalmedicine.org/survey. Accessed April 2, 2011.

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There may be ways to serve up the discharged medication list in a patient-friendly way using some IT or an image library of medications. ... I do not foresee a medication reconciliation IT application, unfortunately.—Jeffrey Schnipper, MD, MPH, FHM, Brigham and Women’s Hospital, Boston

Boston hospitalist Jeffrey Schnipper, MD, MPH, FHM, is no stranger to quality initiatives aimed at medication reconciliation (MR). His research at Brigham and Women’s Hospital and Massachusetts General Hospital revealed a potential reduction of serious medical errors per patient to 0.3 from 1.4 in the past four years.

“I think those are achievable results,” he says. “This is all about doing those things better than we were always doing before.”

Now Dr. Schnipper will work to bring similar results to hospitals across America as principal investigator for SHM’s three-year, multicenter, MR quality-improvement study. The study, funded by a $1.5 million grant from the Agency for Healthcare Research and Quality (AHRQ), will develop a database to research the best practices in MR and provide a mentored implementation model for other hospitals to use.

The project also will include a package of materials and tools adaptable for any hospital, as well as an implementation guide with the mentored implementation model. “It really should be everything a site needs to improve its MR process,” says Dr. Schnipper, director of clinical research at the Brigham and Women’s Hospital Hospitalist Service and assistant professor at Harvard Medical School.

According to The Institute for Safe Medication Practices, MR is the process of comparing a patient’s medication orders with their previously prescribed medication regimen and communicating any necessary changes to patients and their next providers of care. More than 1.3 million medication errors occur annually in the U.S.; MR has been shown to eliminate as many as half of those errors and 20% of adverse medical events.

JoAnne Resnic, MBA, BSN, RN, senior project manager at SHM, says SHM will use the grant to fund research investigators, SHM’s project staff, and the development of a database for each of the study’s six sites to house their data collection and provide site-specific progress reports throughout the course of the study. SHM is working with consultants and physician co-investigators, a steering committee of nationally recognized thought leaders in medication reconciliation, a research pharmacist, and others to “help us take a pretty deep dive into the process and, hopefully, explain why some interventions work in some places and why they may not in others,” Resnic says.

According to Dr. Schnipper, SHM will conduct an interrupted time series at the sites, collecting baseline data for six months at each, then for 21 months after interventions begin. The study specifically will address 13 facets of medication reconciliation, scoring the facets based on their effectiveness (see Table 1, p. 6).

Each facet will be re-evaluated when different parts of the intervention are turned on, which should reveal “the most active ingredients that correspond to improved outcomes,” he says.

Dr. Schnipper emphasizes that there are two integral facets for improving MR: patient education and access to preadmission medication sources. Technology could be an answer to advancing these components, but it is not the sole link. “There may be ways to serve up the discharged medication list in a patient-friendly way using some IT or an image library of medications to help patients,” he says. “I do not foresee a medication reconciliation IT application, unfortunately.”

AHRQ selected SHM for the grant after a “peer review process [that] evaluates the merit of the applications against very rigorous criteria,” an AHRQ representative says. SHM was chosen “based upon its leadership and previous experience in medication reconciliation.” TH

Kevin Stevens is a staff writer based in New Jersey.

click for large version

click for large version

There may be ways to serve up the discharged medication list in a patient-friendly way using some IT or an image library of medications. ... I do not foresee a medication reconciliation IT application, unfortunately.—Jeffrey Schnipper, MD, MPH, FHM, Brigham and Women’s Hospital, Boston

Boston hospitalist Jeffrey Schnipper, MD, MPH, FHM, is no stranger to quality initiatives aimed at medication reconciliation (MR). His research at Brigham and Women’s Hospital and Massachusetts General Hospital revealed a potential reduction of serious medical errors per patient to 0.3 from 1.4 in the past four years.

“I think those are achievable results,” he says. “This is all about doing those things better than we were always doing before.”

Now Dr. Schnipper will work to bring similar results to hospitals across America as principal investigator for SHM’s three-year, multicenter, MR quality-improvement study. The study, funded by a $1.5 million grant from the Agency for Healthcare Research and Quality (AHRQ), will develop a database to research the best practices in MR and provide a mentored implementation model for other hospitals to use.

The project also will include a package of materials and tools adaptable for any hospital, as well as an implementation guide with the mentored implementation model. “It really should be everything a site needs to improve its MR process,” says Dr. Schnipper, director of clinical research at the Brigham and Women’s Hospital Hospitalist Service and assistant professor at Harvard Medical School.

According to The Institute for Safe Medication Practices, MR is the process of comparing a patient’s medication orders with their previously prescribed medication regimen and communicating any necessary changes to patients and their next providers of care. More than 1.3 million medication errors occur annually in the U.S.; MR has been shown to eliminate as many as half of those errors and 20% of adverse medical events.

JoAnne Resnic, MBA, BSN, RN, senior project manager at SHM, says SHM will use the grant to fund research investigators, SHM’s project staff, and the development of a database for each of the study’s six sites to house their data collection and provide site-specific progress reports throughout the course of the study. SHM is working with consultants and physician co-investigators, a steering committee of nationally recognized thought leaders in medication reconciliation, a research pharmacist, and others to “help us take a pretty deep dive into the process and, hopefully, explain why some interventions work in some places and why they may not in others,” Resnic says.

According to Dr. Schnipper, SHM will conduct an interrupted time series at the sites, collecting baseline data for six months at each, then for 21 months after interventions begin. The study specifically will address 13 facets of medication reconciliation, scoring the facets based on their effectiveness (see Table 1, p. 6).

Each facet will be re-evaluated when different parts of the intervention are turned on, which should reveal “the most active ingredients that correspond to improved outcomes,” he says.

Dr. Schnipper emphasizes that there are two integral facets for improving MR: patient education and access to preadmission medication sources. Technology could be an answer to advancing these components, but it is not the sole link. “There may be ways to serve up the discharged medication list in a patient-friendly way using some IT or an image library of medications to help patients,” he says. “I do not foresee a medication reconciliation IT application, unfortunately.”

AHRQ selected SHM for the grant after a “peer review process [that] evaluates the merit of the applications against very rigorous criteria,” an AHRQ representative says. SHM was chosen “based upon its leadership and previous experience in medication reconciliation.” TH

Kevin Stevens is a staff writer based in New Jersey.

click for large version

click for large version

There may be ways to serve up the discharged medication list in a patient-friendly way using some IT or an image library of medications. ... I do not foresee a medication reconciliation IT application, unfortunately.—Jeffrey Schnipper, MD, MPH, FHM, Brigham and Women’s Hospital, Boston

Boston hospitalist Jeffrey Schnipper, MD, MPH, FHM, is no stranger to quality initiatives aimed at medication reconciliation (MR). His research at Brigham and Women’s Hospital and Massachusetts General Hospital revealed a potential reduction of serious medical errors per patient to 0.3 from 1.4 in the past four years.

“I think those are achievable results,” he says. “This is all about doing those things better than we were always doing before.”

Now Dr. Schnipper will work to bring similar results to hospitals across America as principal investigator for SHM’s three-year, multicenter, MR quality-improvement study. The study, funded by a $1.5 million grant from the Agency for Healthcare Research and Quality (AHRQ), will develop a database to research the best practices in MR and provide a mentored implementation model for other hospitals to use.

The project also will include a package of materials and tools adaptable for any hospital, as well as an implementation guide with the mentored implementation model. “It really should be everything a site needs to improve its MR process,” says Dr. Schnipper, director of clinical research at the Brigham and Women’s Hospital Hospitalist Service and assistant professor at Harvard Medical School.

According to The Institute for Safe Medication Practices, MR is the process of comparing a patient’s medication orders with their previously prescribed medication regimen and communicating any necessary changes to patients and their next providers of care. More than 1.3 million medication errors occur annually in the U.S.; MR has been shown to eliminate as many as half of those errors and 20% of adverse medical events.

JoAnne Resnic, MBA, BSN, RN, senior project manager at SHM, says SHM will use the grant to fund research investigators, SHM’s project staff, and the development of a database for each of the study’s six sites to house their data collection and provide site-specific progress reports throughout the course of the study. SHM is working with consultants and physician co-investigators, a steering committee of nationally recognized thought leaders in medication reconciliation, a research pharmacist, and others to “help us take a pretty deep dive into the process and, hopefully, explain why some interventions work in some places and why they may not in others,” Resnic says.

According to Dr. Schnipper, SHM will conduct an interrupted time series at the sites, collecting baseline data for six months at each, then for 21 months after interventions begin. The study specifically will address 13 facets of medication reconciliation, scoring the facets based on their effectiveness (see Table 1, p. 6).

Each facet will be re-evaluated when different parts of the intervention are turned on, which should reveal “the most active ingredients that correspond to improved outcomes,” he says.

Dr. Schnipper emphasizes that there are two integral facets for improving MR: patient education and access to preadmission medication sources. Technology could be an answer to advancing these components, but it is not the sole link. “There may be ways to serve up the discharged medication list in a patient-friendly way using some IT or an image library of medications to help patients,” he says. “I do not foresee a medication reconciliation IT application, unfortunately.”

AHRQ selected SHM for the grant after a “peer review process [that] evaluates the merit of the applications against very rigorous criteria,” an AHRQ representative says. SHM was chosen “based upon its leadership and previous experience in medication reconciliation.” TH

Kevin Stevens is a staff writer based in New Jersey.

Dr. Cox

The position of visiting professor is a bit amorphous at the SHM annual meeting. The honoree presides over the best of the Research, Innovations, and Clinical Vignettes (RIV) presentations and leads rounds of the RIV poster sessions. They can serve as an informal mentor to early-career physicians and be a sounding board for seasoned practitioners.

This year, the visiting professor will be as much a student as a teacher.

“I always think when I go to educate others … the best way of doing that is to have a bidirectional kind of interchange,” says Malcolm Cox, MD, chief academic affiliations officer for the U.S. Department of Veterans Affairs in Washington, D.C., and an adjunct professor of medicine at the University of Pennsylvania in Philadelphia. “I inevitably learn more from my ‘students’ than I think I ever provide to my students, in any teaching opportunity. That’s just a philosophy I’ve had for 40 years.”

Dr. Cox, a kidney specialist and career academician, was invited to be the visiting professor by SHM President Jeff Wiese, MD, FACP, SFHM. Dr. Cox views his role as that of an “interrogative fly on the wall,” and he hopes to stimulate discussions about HM’s role in the broader medical landscape.

“How hospitalists can work with their other colleagues to enhance continuity,” he says, “and, in particular, within that more narrow frame, an even more narrow frame is how they would relate to and work with primary-care folks in the aftercare environment to enhance continuity of care.” HM11

Richard Quinn is a freelance writer based in New Jersey.

Dr. Cox

The position of visiting professor is a bit amorphous at the SHM annual meeting. The honoree presides over the best of the Research, Innovations, and Clinical Vignettes (RIV) presentations and leads rounds of the RIV poster sessions. They can serve as an informal mentor to early-career physicians and be a sounding board for seasoned practitioners.

This year, the visiting professor will be as much a student as a teacher.

“I always think when I go to educate others … the best way of doing that is to have a bidirectional kind of interchange,” says Malcolm Cox, MD, chief academic affiliations officer for the U.S. Department of Veterans Affairs in Washington, D.C., and an adjunct professor of medicine at the University of Pennsylvania in Philadelphia. “I inevitably learn more from my ‘students’ than I think I ever provide to my students, in any teaching opportunity. That’s just a philosophy I’ve had for 40 years.”

Dr. Cox, a kidney specialist and career academician, was invited to be the visiting professor by SHM President Jeff Wiese, MD, FACP, SFHM. Dr. Cox views his role as that of an “interrogative fly on the wall,” and he hopes to stimulate discussions about HM’s role in the broader medical landscape.

“How hospitalists can work with their other colleagues to enhance continuity,” he says, “and, in particular, within that more narrow frame, an even more narrow frame is how they would relate to and work with primary-care folks in the aftercare environment to enhance continuity of care.” HM11

Richard Quinn is a freelance writer based in New Jersey.

Dr. Cox

The position of visiting professor is a bit amorphous at the SHM annual meeting. The honoree presides over the best of the Research, Innovations, and Clinical Vignettes (RIV) presentations and leads rounds of the RIV poster sessions. They can serve as an informal mentor to early-career physicians and be a sounding board for seasoned practitioners.

This year, the visiting professor will be as much a student as a teacher.

“I always think when I go to educate others … the best way of doing that is to have a bidirectional kind of interchange,” says Malcolm Cox, MD, chief academic affiliations officer for the U.S. Department of Veterans Affairs in Washington, D.C., and an adjunct professor of medicine at the University of Pennsylvania in Philadelphia. “I inevitably learn more from my ‘students’ than I think I ever provide to my students, in any teaching opportunity. That’s just a philosophy I’ve had for 40 years.”

Dr. Cox, a kidney specialist and career academician, was invited to be the visiting professor by SHM President Jeff Wiese, MD, FACP, SFHM. Dr. Cox views his role as that of an “interrogative fly on the wall,” and he hopes to stimulate discussions about HM’s role in the broader medical landscape.

“How hospitalists can work with their other colleagues to enhance continuity,” he says, “and, in particular, within that more narrow frame, an even more narrow frame is how they would relate to and work with primary-care folks in the aftercare environment to enhance continuity of care.” HM11

Richard Quinn is a freelance writer based in New Jersey.

Dr. Watcher

When Robert Wachter, MD, MHM, delivers his keynote address to unofficially close HM11, he’ll toast the field he helped define. His remarks will coincide with the 15th anniversary of the article he and Lee Goldman, MD, coauthored in The New England Journal of Medicine that coined the term “hospitalist” and fostered an understanding that the HM movement was a true phenomenon.

The milestone presents the perfect opportunity to examine the specialty’s meteoric growth and celebrate the successes of its pioneers, says Dr. Wachter, a professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center. He also considers it an ideal time to examine the unforeseen developments of the past decade and a half, believing a critical analysis of a few key case studies can help lay the groundwork for an even brighter future.

“At 15, you’re in mid- to late adolescence,” Dr. Wachter says. “We can no longer say we’re this new kid on the block and, ‘Gee, whiz, isn’t this neat?’

“This is a good chance to reflect on things that went as we expected,” he adds. “It’s an even better chance to take a second look at things that were surprising but provide valuable lessons as we think about what the next 15 years are going to be like.”

Question: Fifteen years ago, did you envision HM would grow so quickly?

Answer: I had a sense this was a trend that was starting to emerge and could fill an important niche. At the same time, when Sergey (Brin) and Larry (Page) founded Google, I doubt they believed it would become a $200 billion company. In the beginning, I couldn’t have predicted what this would become.

Q: What surprised you most in the past 15 years?

A: I didn’t fully appreciate how quickly the push toward value would become a dominant theme. Once we discovered quality was important and there was a set of skills we needed to learn to improve it, we tackled it aggressively. It has been harder to tackle the cost part of the equation.

This goes beyond making sure patients don’t stay in the hospital longer than they need to. It means looking hard at the cost of care and the way we spend money, such as our patterns of ordering X-rays, consultants, and lab tests. I’m going to focus a fair amount on that.

Q: Why do you want to emphasize that point?

A: The cost of healthcare is going to bankrupt the country unless we get a handle on it. Our field needs to lead the way to show how a good, ethical physician not only focuses on improving quality of care, but also focuses on ridding the system of waste and of care that adds no real value to our patients. We’ve been a little sluggish in that area.

Q: What other surprises do you intend to discuss?

A: I didn’t anticipate the emergence of two different versions of the hospitalist field. One is the role of comanagement. The other is what I call the hyphenated hospitalist—these OB hospitalists and surgery hospitalists. This concept we came up with for general patients has been embraced by a variety of specialties. How do those people fit into our society and our field? Are they really part of us or are they fundamentally different? I think we need to think carefully about it.

Q: Why are the unexpected developments so important to consider?

A: Leaders in the field need to get really good at reading tea leaves. One of the ways you do that is to figure out, when you didn’t read them correctly the first time, why didn’t you? Could you have read them better if you were more clever or more thoughtful?

Q: What is the biggest challenge facing HM?

A: When we have been given new tasks and new opportunities, our members have stepped up to the plate and done what they’ve been asked to do as well, if not better, than expected. I’m a little fearful of the flip side. How we will meet the demand for our services? How do we ensure the job stays attractive and we don’t burn out? We have to demonstrate our value, but we have to make sure the jobs are truly sustainable and that we don’t shoot ourselves in the foot.

Q:What do you see as the solution?

A: I don’t think we’ll be able to meet all of the demand. There will be hospitals that can only partly staff the needs they have with hospitalists. I don’t want them to go too far down the quality curve. We need to be sure people entering the field are good and have the skills they need.

I think we’ll begin to ask important questions like, “Do I really need a hospitalist for this, or can I leverage fewer hospitalists with other nonphysician providers?” Or, “Can some of the work our hospitalists are doing be done as well and more cheaply by computers?” It opens a pathway to think more creatively about people and tasks and technologies.

Q: Despite the challenges associated with growth pressure, is HM better positioned for the future because of it?

A: Definitely. We will see a further extension of our reach into other areas of the hospital and healthcare system. We will continue to see our people begin as leaders in our world of hospital medicine but rapidly graduate to become hospital CEOs, chairs of departments of medicine, and major leaders in healthcare. There is a recognition that there’s no better training ground to be a leader in healthcare than to be a leader in our field. So I can’t help but be optimistic that our place in the world of healthcare is extraordinarily secure. HM11

Mark Leiser is a freelance writer based in New Jersey.

Dr. Watcher

When Robert Wachter, MD, MHM, delivers his keynote address to unofficially close HM11, he’ll toast the field he helped define. His remarks will coincide with the 15th anniversary of the article he and Lee Goldman, MD, coauthored in The New England Journal of Medicine that coined the term “hospitalist” and fostered an understanding that the HM movement was a true phenomenon.

The milestone presents the perfect opportunity to examine the specialty’s meteoric growth and celebrate the successes of its pioneers, says Dr. Wachter, a professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center. He also considers it an ideal time to examine the unforeseen developments of the past decade and a half, believing a critical analysis of a few key case studies can help lay the groundwork for an even brighter future.

“At 15, you’re in mid- to late adolescence,” Dr. Wachter says. “We can no longer say we’re this new kid on the block and, ‘Gee, whiz, isn’t this neat?’

“This is a good chance to reflect on things that went as we expected,” he adds. “It’s an even better chance to take a second look at things that were surprising but provide valuable lessons as we think about what the next 15 years are going to be like.”

Question: Fifteen years ago, did you envision HM would grow so quickly?

Answer: I had a sense this was a trend that was starting to emerge and could fill an important niche. At the same time, when Sergey (Brin) and Larry (Page) founded Google, I doubt they believed it would become a $200 billion company. In the beginning, I couldn’t have predicted what this would become.

Q: What surprised you most in the past 15 years?

A: I didn’t fully appreciate how quickly the push toward value would become a dominant theme. Once we discovered quality was important and there was a set of skills we needed to learn to improve it, we tackled it aggressively. It has been harder to tackle the cost part of the equation.

This goes beyond making sure patients don’t stay in the hospital longer than they need to. It means looking hard at the cost of care and the way we spend money, such as our patterns of ordering X-rays, consultants, and lab tests. I’m going to focus a fair amount on that.

Q: Why do you want to emphasize that point?

A: The cost of healthcare is going to bankrupt the country unless we get a handle on it. Our field needs to lead the way to show how a good, ethical physician not only focuses on improving quality of care, but also focuses on ridding the system of waste and of care that adds no real value to our patients. We’ve been a little sluggish in that area.

Q: What other surprises do you intend to discuss?

A: I didn’t anticipate the emergence of two different versions of the hospitalist field. One is the role of comanagement. The other is what I call the hyphenated hospitalist—these OB hospitalists and surgery hospitalists. This concept we came up with for general patients has been embraced by a variety of specialties. How do those people fit into our society and our field? Are they really part of us or are they fundamentally different? I think we need to think carefully about it.

Q: Why are the unexpected developments so important to consider?

A: Leaders in the field need to get really good at reading tea leaves. One of the ways you do that is to figure out, when you didn’t read them correctly the first time, why didn’t you? Could you have read them better if you were more clever or more thoughtful?

Q: What is the biggest challenge facing HM?

A: When we have been given new tasks and new opportunities, our members have stepped up to the plate and done what they’ve been asked to do as well, if not better, than expected. I’m a little fearful of the flip side. How we will meet the demand for our services? How do we ensure the job stays attractive and we don’t burn out? We have to demonstrate our value, but we have to make sure the jobs are truly sustainable and that we don’t shoot ourselves in the foot.

Q:What do you see as the solution?

A: I don’t think we’ll be able to meet all of the demand. There will be hospitals that can only partly staff the needs they have with hospitalists. I don’t want them to go too far down the quality curve. We need to be sure people entering the field are good and have the skills they need.

I think we’ll begin to ask important questions like, “Do I really need a hospitalist for this, or can I leverage fewer hospitalists with other nonphysician providers?” Or, “Can some of the work our hospitalists are doing be done as well and more cheaply by computers?” It opens a pathway to think more creatively about people and tasks and technologies.

Q: Despite the challenges associated with growth pressure, is HM better positioned for the future because of it?

A: Definitely. We will see a further extension of our reach into other areas of the hospital and healthcare system. We will continue to see our people begin as leaders in our world of hospital medicine but rapidly graduate to become hospital CEOs, chairs of departments of medicine, and major leaders in healthcare. There is a recognition that there’s no better training ground to be a leader in healthcare than to be a leader in our field. So I can’t help but be optimistic that our place in the world of healthcare is extraordinarily secure. HM11

Mark Leiser is a freelance writer based in New Jersey.

Dr. Watcher

When Robert Wachter, MD, MHM, delivers his keynote address to unofficially close HM11, he’ll toast the field he helped define. His remarks will coincide with the 15th anniversary of the article he and Lee Goldman, MD, coauthored in The New England Journal of Medicine that coined the term “hospitalist” and fostered an understanding that the HM movement was a true phenomenon.

The milestone presents the perfect opportunity to examine the specialty’s meteoric growth and celebrate the successes of its pioneers, says Dr. Wachter, a professor, chief of the Division of Hospital Medicine, and chief of the medical service at the University of California at San Francisco Medical Center. He also considers it an ideal time to examine the unforeseen developments of the past decade and a half, believing a critical analysis of a few key case studies can help lay the groundwork for an even brighter future.

“At 15, you’re in mid- to late adolescence,” Dr. Wachter says. “We can no longer say we’re this new kid on the block and, ‘Gee, whiz, isn’t this neat?’

“This is a good chance to reflect on things that went as we expected,” he adds. “It’s an even better chance to take a second look at things that were surprising but provide valuable lessons as we think about what the next 15 years are going to be like.”

Question: Fifteen years ago, did you envision HM would grow so quickly?

Answer: I had a sense this was a trend that was starting to emerge and could fill an important niche. At the same time, when Sergey (Brin) and Larry (Page) founded Google, I doubt they believed it would become a $200 billion company. In the beginning, I couldn’t have predicted what this would become.

Q: What surprised you most in the past 15 years?

A: I didn’t fully appreciate how quickly the push toward value would become a dominant theme. Once we discovered quality was important and there was a set of skills we needed to learn to improve it, we tackled it aggressively. It has been harder to tackle the cost part of the equation.

This goes beyond making sure patients don’t stay in the hospital longer than they need to. It means looking hard at the cost of care and the way we spend money, such as our patterns of ordering X-rays, consultants, and lab tests. I’m going to focus a fair amount on that.

Q: Why do you want to emphasize that point?

A: The cost of healthcare is going to bankrupt the country unless we get a handle on it. Our field needs to lead the way to show how a good, ethical physician not only focuses on improving quality of care, but also focuses on ridding the system of waste and of care that adds no real value to our patients. We’ve been a little sluggish in that area.

Q: What other surprises do you intend to discuss?

A: I didn’t anticipate the emergence of two different versions of the hospitalist field. One is the role of comanagement. The other is what I call the hyphenated hospitalist—these OB hospitalists and surgery hospitalists. This concept we came up with for general patients has been embraced by a variety of specialties. How do those people fit into our society and our field? Are they really part of us or are they fundamentally different? I think we need to think carefully about it.

Q: Why are the unexpected developments so important to consider?

A: Leaders in the field need to get really good at reading tea leaves. One of the ways you do that is to figure out, when you didn’t read them correctly the first time, why didn’t you? Could you have read them better if you were more clever or more thoughtful?

Q: What is the biggest challenge facing HM?

A: When we have been given new tasks and new opportunities, our members have stepped up to the plate and done what they’ve been asked to do as well, if not better, than expected. I’m a little fearful of the flip side. How we will meet the demand for our services? How do we ensure the job stays attractive and we don’t burn out? We have to demonstrate our value, but we have to make sure the jobs are truly sustainable and that we don’t shoot ourselves in the foot.

Q:What do you see as the solution?

A: I don’t think we’ll be able to meet all of the demand. There will be hospitals that can only partly staff the needs they have with hospitalists. I don’t want them to go too far down the quality curve. We need to be sure people entering the field are good and have the skills they need.

I think we’ll begin to ask important questions like, “Do I really need a hospitalist for this, or can I leverage fewer hospitalists with other nonphysician providers?” Or, “Can some of the work our hospitalists are doing be done as well and more cheaply by computers?” It opens a pathway to think more creatively about people and tasks and technologies.

Q: Despite the challenges associated with growth pressure, is HM better positioned for the future because of it?

A: Definitely. We will see a further extension of our reach into other areas of the hospital and healthcare system. We will continue to see our people begin as leaders in our world of hospital medicine but rapidly graduate to become hospital CEOs, chairs of departments of medicine, and major leaders in healthcare. There is a recognition that there’s no better training ground to be a leader in healthcare than to be a leader in our field. So I can’t help but be optimistic that our place in the world of healthcare is extraordinarily secure. HM11

Mark Leiser is a freelance writer based in New Jersey.

The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.

Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.

A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.

It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?

Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.

Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.

In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.

Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.

The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH

The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.

Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.

A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.

It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?

Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.

Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.

In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.

Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.

The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH

The Agency for Healthcare Research and Quality (AHRQ) recently released the annual National Healthcare Quality & Disparities Reports. The reports provide in-depth quality information on the overall population and divide this information along such subgroups as race, ethnicity, and education level. The report is more than 200 pages long, but it can be summarized in one sentence: If you are poor, the quality of your healthcare is likely to be poor.

Despite significant quality improvement (QI) in a number of areas, disparities among poor Americans persist. For example, the percentage of heart-attack patients who underwent procedures to unblock heart arteries within 90 minutes improved to 81% in 2008 from 42% in 2005. This is very positive news, but unfortunately, these and many other gains in quality only apply to higher-income populations.

A new section of the report focused on care coordination and transitions of care contains some statistics of particular interest to hospitalists. One statistic shows that the percentage of hospitalized adult patients with heart failure who were given complete written discharge instructions improved to 82.0% in 2008, up from 57.5% in 2005.

It is important to note that this number remains more or less constant across all racial/ethnic divisions. Could part of this improvement be attributed to the growth and success of the hospitalist movement?

Hospitalists know that despite the numbers, a successful transition does not simply include discharge instructions; it is the combination of those instructions, along with coordination with primary care, that prevents avoidable readmissions.

Unfortunately, 15% to 20% of low-income patients have no regular primary-care physician (PCP). If a condition begins to deteriorate, this group often has little choice but to return to the hospital.

In the absence of a PCP, it is the hospitalist who can provide patients with the tools they need to stay healthy after leaving the hospital.

Such assistance can range from ensuring that patients truly understand their discharge instructions to being a resource for future questions. Hospitalists are ahead of the game when it comes to quality and reducing disparities; it is just a matter of the other facets of healthcare catching up.

The National Healthcare Quality & Disparities reports are available at www.ahrq.gov/qual/qrdr10.htm. TH

On Feb. 16, the Agency for Healthcare Research and Quality (AHRQ) listed SHM as a patient safety organization (PSO). A PSO serves as an independent, external, expert organization that can collect, analyze, and aggregate information in order to develop insights into the underlying causes of patient-safety events. PSOs are designed to help clinicians, hospitals, and healthcare organizations improve patient safety and the quality of healthcare delivery.

PSO status allows SHM’s current quality-improvement (QI) activities to be conducted in a secure environment that is protected from legal discovery. AHRQ currently lists 78 PSOs, including the Society for Vascular Surgery PSO, the Emergency Medicine Patient Safety Foundation, and the Biomedical Research and Education Foundation. A full list is available at www.pso.ahrq.gov/listing/psolist.htm.

To achieve PSO status, SHM worked closely with AHRQ to meet specific guidelines and requirements. One of the requirements is that the mission and primary activity of a PSO must be to conduct activities that are designed to improve patient safety and the quality of healthcare delivery.

To comply, SHM formed a separate component within the Quality Initiatives Department strictly to pursue patient safety and quality activities.

The SHM PSO will be unique. While PSOs are required to collect patient-safety data and provide some form of feedback to contracted sites, few have their own QI initiatives, and even fewer are established by a national physician’s professional society.

These differences will help the SHM PSO stand out from the crowd and will present opportunities within the healthcare reform framework. The Affordable Care Act (ACA) requires significant QI among the nation’s hospitals.

Specifically pertaining to PSOs, Section 399KK, a rarely mentioned section of the ACA, requires the Health and Human Services to establish a program for hospitals with high readmission rates to improve their rates through the use of PSOs. The details of this program remain unclear, but based upon the little bit of information currently available, there could be positive overlap between SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) and the provision.

AHRQ’s recognition of the SHM PSO exemplifies SHM’s commitment to improving the quality of healthcare delivery. It also provides additional value to sites that implement SHM’s QI initiatives and will hopefully open new doors to SHM’s members. TH

On Feb. 16, the Agency for Healthcare Research and Quality (AHRQ) listed SHM as a patient safety organization (PSO). A PSO serves as an independent, external, expert organization that can collect, analyze, and aggregate information in order to develop insights into the underlying causes of patient-safety events. PSOs are designed to help clinicians, hospitals, and healthcare organizations improve patient safety and the quality of healthcare delivery.

PSO status allows SHM’s current quality-improvement (QI) activities to be conducted in a secure environment that is protected from legal discovery. AHRQ currently lists 78 PSOs, including the Society for Vascular Surgery PSO, the Emergency Medicine Patient Safety Foundation, and the Biomedical Research and Education Foundation. A full list is available at www.pso.ahrq.gov/listing/psolist.htm.

To achieve PSO status, SHM worked closely with AHRQ to meet specific guidelines and requirements. One of the requirements is that the mission and primary activity of a PSO must be to conduct activities that are designed to improve patient safety and the quality of healthcare delivery.

To comply, SHM formed a separate component within the Quality Initiatives Department strictly to pursue patient safety and quality activities.

The SHM PSO will be unique. While PSOs are required to collect patient-safety data and provide some form of feedback to contracted sites, few have their own QI initiatives, and even fewer are established by a national physician’s professional society.

These differences will help the SHM PSO stand out from the crowd and will present opportunities within the healthcare reform framework. The Affordable Care Act (ACA) requires significant QI among the nation’s hospitals.

Specifically pertaining to PSOs, Section 399KK, a rarely mentioned section of the ACA, requires the Health and Human Services to establish a program for hospitals with high readmission rates to improve their rates through the use of PSOs. The details of this program remain unclear, but based upon the little bit of information currently available, there could be positive overlap between SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) and the provision.

AHRQ’s recognition of the SHM PSO exemplifies SHM’s commitment to improving the quality of healthcare delivery. It also provides additional value to sites that implement SHM’s QI initiatives and will hopefully open new doors to SHM’s members. TH

On Feb. 16, the Agency for Healthcare Research and Quality (AHRQ) listed SHM as a patient safety organization (PSO). A PSO serves as an independent, external, expert organization that can collect, analyze, and aggregate information in order to develop insights into the underlying causes of patient-safety events. PSOs are designed to help clinicians, hospitals, and healthcare organizations improve patient safety and the quality of healthcare delivery.

PSO status allows SHM’s current quality-improvement (QI) activities to be conducted in a secure environment that is protected from legal discovery. AHRQ currently lists 78 PSOs, including the Society for Vascular Surgery PSO, the Emergency Medicine Patient Safety Foundation, and the Biomedical Research and Education Foundation. A full list is available at www.pso.ahrq.gov/listing/psolist.htm.

To achieve PSO status, SHM worked closely with AHRQ to meet specific guidelines and requirements. One of the requirements is that the mission and primary activity of a PSO must be to conduct activities that are designed to improve patient safety and the quality of healthcare delivery.

To comply, SHM formed a separate component within the Quality Initiatives Department strictly to pursue patient safety and quality activities.

The SHM PSO will be unique. While PSOs are required to collect patient-safety data and provide some form of feedback to contracted sites, few have their own QI initiatives, and even fewer are established by a national physician’s professional society.

These differences will help the SHM PSO stand out from the crowd and will present opportunities within the healthcare reform framework. The Affordable Care Act (ACA) requires significant QI among the nation’s hospitals.

Specifically pertaining to PSOs, Section 399KK, a rarely mentioned section of the ACA, requires the Health and Human Services to establish a program for hospitals with high readmission rates to improve their rates through the use of PSOs. The details of this program remain unclear, but based upon the little bit of information currently available, there could be positive overlap between SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions) and the provision.

AHRQ’s recognition of the SHM PSO exemplifies SHM’s commitment to improving the quality of healthcare delivery. It also provides additional value to sites that implement SHM’s QI initiatives and will hopefully open new doors to SHM’s members. TH

What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.

SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.

In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.

This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.

The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.

VBP Metrics

So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.

The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.

HM to the Rescue

No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.

SHM’s board of directors recently passed the following position statement on value-based purchasing:

“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”

As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.

In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.

Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.

Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH

Dr. Wellikson is CEO of SHM.

What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.

SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.

In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.

This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.

The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.

VBP Metrics

So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.

The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.

HM to the Rescue

No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.

SHM’s board of directors recently passed the following position statement on value-based purchasing:

“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”

As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.

In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.

Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.

Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH

Dr. Wellikson is CEO of SHM.

What is value-based purchasing (VBP) and why should I care? Well, for starters, your hospital’s CFO might not know that starting in 2013 (just two years from now), the Centers for Medicare & Medicaid Services (CMS) will be withholding at least 1% of all Medicare payments, but CMS is giving your hospital a chance to get some or all of that money back. For a busy hospital, the withholding will easily be $1 million; for many hospitals, that figure is more like $2 million to $3 million.

SHM thinks hospitalists are uniquely positioned to be champions for the C-suite, helping the hospital’s balance sheet, aiding in staff retention, and providing better care for our patients. And that’s where VBP comes in.

In March 2010, Congress passed the Patient Protection and Affordable Care Act (see “Health Reform Turns 1,” p. 16). This law includes a provision that establishes a VBP program for hospital payments beginning with discharges on Oct. 1, 2012. Payment will be based on hospital performance on quality measures determined by Health and Human Services (HHS). The VBP program will pay hospitals for their actual performance on quality measures, rather than for just reporting those measures, starting in 2013.

This is a null-set game, in which the funding for the best performers is clearly coming out of the hide of low-performing hospitals. Funding will be phased in from 2013 through 2017. Hospitals will have their payments for all Medicare DRGs reduced by 1% in 2013, 1.25% in 2014, 1.5% in 2015, 1.75% in 2016, and 2% in 2017 and beyond. Just ask your CFO what this means at your hospital and see his or her brow furrow.

The good news (i.e. carrot) is that a hospital that meets or exceeds the performance standards will be eligible to earn back all the Medicare money that was withheld and even earn a bonus of as much as 2%.

VBP Metrics

So just what performance will be measured in the new VBP program? While physicians might see quality in clinical terms, the VBP program defines performance more broadly; that means it includes the patient experience. In fact, about 70% of the quality measures will be based on clinical performance, and a full 30% will come from scores on post-discharge patient satisfaction questionnaires (e.g. HCAHPS). To understand the importance of the patient satisfaction part of the VBP equation, just note that Press Ganey, the largest private company helping hospitals understand what their customers are thinking, is jumping into the VBP arena with both feet. Your hospital’s CFO (and lead hospitalist) should contact Press Ganey and run your current performance numbers through their VBP calculator to see if you are on the hilltop or in a deep hole.

The clinical measures will be selected from those used in the current Medicare pay-for-reporting program and likely will include measures for myocardial infarction, heart failure, pneumonia, and surgical care. In addition, HHS is mandated to include measures of efficiency, looking at ways to assess the spending per Medicare beneficiary. This is the real value equation: value = outcomes ÷ cost.

HM to the Rescue

No one in the hospital community sits more at the nexus of clinical care on these measures, efficiency, and the patient experience than hospitalists. This is an opportunity and a risk for hospitalists; that is why SHM is actively planning strategies to help hospitalists assist their hospitals in assessing how their current performance would play out in the payment world post-2013. In addition, SHM will have tools to assist hospitalists in creating change to help their institutions be in the top half of the nation’s hospitals—those who will get their millions of withheld dollars back.

SHM’s board of directors recently passed the following position statement on value-based purchasing:

“SHM supports the Affordable Care Act (ACA) Section 3001 directing the Secretary of HHS to establish a value-based purchasing program under the hospital inpatient prospective payment system. We believe that the Medicare reimbursement system must be changed to promote value, and we strongly support policies that link quality measurement to performance-based payment. We are pleased that under ACA the Secretary will establish performance standards that reward hospitals based on either attaining a certain performance standard or making improvements relative to a previous performance period. Hospitalists, who care for more hospitalized patients than any other physician group and lead system change and quality improvement efforts, will be critical to improving the performance of hospitals under this program.”

As mentioned above, the VBP program poses some risks to hospitalists. We cannot improve our hospital’s performance by ourselves, no matter how well motivated and trained we are. Hospitalists tend to attract a group of patients who traditionally have less satisfaction with their hospital experience (e.g. acutely ill patients admitted through the ED). But for more than a decade, hospitalists have been touting our goal to change the system for the better and to strive to be rewarded for value and performance, not simply for the doing.

In some ways, hospitals’ financial support of hospitalist groups has been predicated on the value we currently provide in efficiency (e.g. decreased length of stay, better use of resources) and effectiveness (e.g. improved measurable quality). The VBP program in ACA is just a first big step for the largest payor of hospital care—CMS—to change the ground rules.

Well-prepared hospitalists can provide leadership and help deliver their institutions to the top half of hospitals (those that will receive bonus payment) and, at the same time, begin to change the culture of their hospital to provide their patients with a better clinical outcome and a better patient experience.

Congress and President Obama are our allies here. A million dollars should get your hospital executives’ attention. Now is the time for hospitalists—with SHM’s help—to step up and show what we can do. TH

Dr. Wellikson is CEO of SHM.

I recently visited my parents in my ancestral home of Wisconsin. As parents of a certain age, they inexplicably are genetically predisposed to owning a minivan. Another quirk of their DNA is that they must own a new minivan. No sooner has the last wisp of new-car smell osmosed from the burled walnut interior than they are trading up to the newest, tricked-out minivan. Perhaps more puzzling is the manner of pride they display in their minivan.

Now, my dad, as if not readily apparent, is not cool. And to see him folded into the driver’s seat, his furry-ear-to-furry-ear grin signaling a self-satisfaction customarily reserved for his grandchildren, painstakingly recounting glory-day stories and 4:30 p.m. dinner buffets, further solidifies his place in the Annals of Uncool.

When I’m home, they tend to employ my chauffeur services (most likely in retribution for my peri-pubescent years), and on the first day back home, I stopped their newest ride near the back door of the house, foot idling on the brake while this exchange occurred: “That’s a fascinating story about how much more challenging the world was when you were my age, Dad. You are a true American hero. Would you like to get out here or in the garage?”

“Here,” he replied.

“OK, then get out,” I countered.

“I can’t,” he responded knowingly.

“Why not?” I queried, the patience seeping from my voice.

“Because the door’s not open,” he answered, seemingly mocking me.

“Then open it,” I replied, silently recounting the evidence for his institutionalization.

“I can’t,” he responded.

“Why not?” I replied again, this time calculating the likelihood that I was adopted.

“Because it’s locked,” came his retort.

“Then unlock it,” I answered, reconfirming my decision to move away for college.

“I can’t,” he replied, ostensibly encouraging parenticide.

“Why not?” I queried, strongly contemplating parenticide.

“Because you haven’t put the car in park,” he responded triumphantly.

A System So Safe

As a safety feature, the minivan needed to be in park before you could open the door to exit. I’ve never heard of anyone actually falling out of a moving car, but recollecting high school, I can fathom the right mix, type, and number of teenagers where possibility would meet inevitability. But, apparently, enough people are falling out of moving vehicles that car engineers have built a system that is so safe, this can’t happen. So no matter how hard someone tries, it just isn’t possible to fall out of a moving car (believe me, toward the end of a week of my father’s car stories, my mind had worked every possible angle).

Likewise, newer vehicles employ occupant-sensitive sensors that detect the weight, size, and position of the passenger to determine if the airbag should deploy. Rather than depending on the driver to turn the passenger-side airbag on or off, the car does it for you: heavy enough to trigger the sensor, and the airbag will deploy; too light, and the car assumes you are a child and doesn’t deploy. It’s a system that is so safe because it doesn’t depend on the operator to get it right.

Ditto motion sensors that detect objects behind the car while reversing (avoiding accidental back-overs), antilock brakes (to maintain control during panicked braking), traction control (improves stability during acceleration), electronic stability control (foils spinouts), tire-pressure-monitoring systems (avoids blowouts), daytime running lights (ensures others see you), rollover airbags (they stay inflated to keep you in the car), lane-departure warning (alerts you if you stray from your lane), and doors that automatically lock after the car starts (again, falling out of cars).

For all the negative press of late, car manufacturers understand safety.

A System Not So Safe

Contrast this to healthcare, in which 10% of patients will suffer a serious, preventable, adverse event during their hospital stay.¹ Read that sentence again. That’s 10%; that’s preventable; that’s a number that has largely remained unchanged in the past decade. If 1 in 10 drivers suffered a serious adverse preventable auto accident, Congress would do nothing but hold automotive safety hearings.

In medicine, we still largely employ unsafe systems in which even the best doctors can, and do, hurt patients. Sure, we have made strides in this arena (oxygen tubing that only works if hooked up properly, smart pumps that avert IV dosing errors, CO₂ monitors to detect proper endotracheal tube placement), but remarkably, in this era of patient safety, we still utilize systems that largely depend on the heroism of the individual.

As physicians, we are famously autonomous and value our professional independence, even to the degree that it might harm patients. We generally eschew standardization, believing that each patient is inherently different. In fact, the thrill of the improvisational theater that follows every patient’s chief compliant is one of the great satisfiers in medicine. We love that feeling that comes from sleuthing each case, deftly enacting a plan of action to shepherd the patient to health.

To suggest following protocols, guidelines, and checklists is derisively dismissed as “cookbook medicine.” To work in teams in which certain tasks are delegated to others is seen as weakness—we don’t need a system that utilizes a pharmacist; rather, we should know the doses of all medicines, their interactions, and the effect of renal and liver impairment on their clearance. To suggest otherwise is an insult to our Oslerian roots. To examine our errors, our system breakdowns, our patient harms is anathema to our practice, an admission of failure.

The result is that most of us continue to toil in systems that have become exponentially unsafe as healthcare has become more complex. Today, we still have a system that will more or less allow us to kill a patient by doing nothing more than forgetting the letter “g.” I can go to my hospital today and intend to write “4 grams of magnesium sulfate (MgSO4)” and inadvertently forget the “g” in “Mg.” This could result in an order for a lethal dose of morphine sulfate (MSO4). It’s that easy to hurt a patient. Now, you might say that would never happen, because the pharmacy would catch it. And this is likely. But is it guaranteed? Can you 100% ensure it wouldn’t happen? Consider that nearly 20% of medication doses administered in a hospital are done so incorrectly.² Nearly 1 in 5. This is the type of system we are employing to stop this lethal overdose. Is this system, which depends on another human to prevent an error, foolproof, or just a snare waiting to prove you the fool?

This represents our opportunity. As hospitalists, the hospital is our tapestry, our system of care, our responsibility. Few others are as well-positioned to ensure that the systems that envelop our patients are highly functional, reliable, and safe. This will take work—work that will feel burdensome, underappreciated, undercompensated. And, fully recognizing that none of us went into medicine to become systems engineers, this will be hard.

However, if not us, who? Who will ensure that our fathers, our mothers, our children will be as safe in the hospital as they are on the drive to the hospital? TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Global health leaders join the World Health Organization to announce accelerated efforts to improve patient safety. World Health Organization website. Available at: www.who.int/mediacentre/news/releases/2004/pr74/en/. Accessed Feb. 14, 2011.
2. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897-1903.

I recently visited my parents in my ancestral home of Wisconsin. As parents of a certain age, they inexplicably are genetically predisposed to owning a minivan. Another quirk of their DNA is that they must own a new minivan. No sooner has the last wisp of new-car smell osmosed from the burled walnut interior than they are trading up to the newest, tricked-out minivan. Perhaps more puzzling is the manner of pride they display in their minivan.

Now, my dad, as if not readily apparent, is not cool. And to see him folded into the driver’s seat, his furry-ear-to-furry-ear grin signaling a self-satisfaction customarily reserved for his grandchildren, painstakingly recounting glory-day stories and 4:30 p.m. dinner buffets, further solidifies his place in the Annals of Uncool.

When I’m home, they tend to employ my chauffeur services (most likely in retribution for my peri-pubescent years), and on the first day back home, I stopped their newest ride near the back door of the house, foot idling on the brake while this exchange occurred: “That’s a fascinating story about how much more challenging the world was when you were my age, Dad. You are a true American hero. Would you like to get out here or in the garage?”

“Here,” he replied.

“OK, then get out,” I countered.

“I can’t,” he responded knowingly.

“Why not?” I queried, the patience seeping from my voice.

“Because the door’s not open,” he answered, seemingly mocking me.

“Then open it,” I replied, silently recounting the evidence for his institutionalization.

“I can’t,” he responded.

“Why not?” I replied again, this time calculating the likelihood that I was adopted.

“Because it’s locked,” came his retort.

“Then unlock it,” I answered, reconfirming my decision to move away for college.

“I can’t,” he replied, ostensibly encouraging parenticide.

“Why not?” I queried, strongly contemplating parenticide.

“Because you haven’t put the car in park,” he responded triumphantly.

A System So Safe

As a safety feature, the minivan needed to be in park before you could open the door to exit. I’ve never heard of anyone actually falling out of a moving car, but recollecting high school, I can fathom the right mix, type, and number of teenagers where possibility would meet inevitability. But, apparently, enough people are falling out of moving vehicles that car engineers have built a system that is so safe, this can’t happen. So no matter how hard someone tries, it just isn’t possible to fall out of a moving car (believe me, toward the end of a week of my father’s car stories, my mind had worked every possible angle).

Likewise, newer vehicles employ occupant-sensitive sensors that detect the weight, size, and position of the passenger to determine if the airbag should deploy. Rather than depending on the driver to turn the passenger-side airbag on or off, the car does it for you: heavy enough to trigger the sensor, and the airbag will deploy; too light, and the car assumes you are a child and doesn’t deploy. It’s a system that is so safe because it doesn’t depend on the operator to get it right.

Ditto motion sensors that detect objects behind the car while reversing (avoiding accidental back-overs), antilock brakes (to maintain control during panicked braking), traction control (improves stability during acceleration), electronic stability control (foils spinouts), tire-pressure-monitoring systems (avoids blowouts), daytime running lights (ensures others see you), rollover airbags (they stay inflated to keep you in the car), lane-departure warning (alerts you if you stray from your lane), and doors that automatically lock after the car starts (again, falling out of cars).

For all the negative press of late, car manufacturers understand safety.

A System Not So Safe

Contrast this to healthcare, in which 10% of patients will suffer a serious, preventable, adverse event during their hospital stay.¹ Read that sentence again. That’s 10%; that’s preventable; that’s a number that has largely remained unchanged in the past decade. If 1 in 10 drivers suffered a serious adverse preventable auto accident, Congress would do nothing but hold automotive safety hearings.

In medicine, we still largely employ unsafe systems in which even the best doctors can, and do, hurt patients. Sure, we have made strides in this arena (oxygen tubing that only works if hooked up properly, smart pumps that avert IV dosing errors, CO₂ monitors to detect proper endotracheal tube placement), but remarkably, in this era of patient safety, we still utilize systems that largely depend on the heroism of the individual.

As physicians, we are famously autonomous and value our professional independence, even to the degree that it might harm patients. We generally eschew standardization, believing that each patient is inherently different. In fact, the thrill of the improvisational theater that follows every patient’s chief compliant is one of the great satisfiers in medicine. We love that feeling that comes from sleuthing each case, deftly enacting a plan of action to shepherd the patient to health.

To suggest following protocols, guidelines, and checklists is derisively dismissed as “cookbook medicine.” To work in teams in which certain tasks are delegated to others is seen as weakness—we don’t need a system that utilizes a pharmacist; rather, we should know the doses of all medicines, their interactions, and the effect of renal and liver impairment on their clearance. To suggest otherwise is an insult to our Oslerian roots. To examine our errors, our system breakdowns, our patient harms is anathema to our practice, an admission of failure.

The result is that most of us continue to toil in systems that have become exponentially unsafe as healthcare has become more complex. Today, we still have a system that will more or less allow us to kill a patient by doing nothing more than forgetting the letter “g.” I can go to my hospital today and intend to write “4 grams of magnesium sulfate (MgSO4)” and inadvertently forget the “g” in “Mg.” This could result in an order for a lethal dose of morphine sulfate (MSO4). It’s that easy to hurt a patient. Now, you might say that would never happen, because the pharmacy would catch it. And this is likely. But is it guaranteed? Can you 100% ensure it wouldn’t happen? Consider that nearly 20% of medication doses administered in a hospital are done so incorrectly.² Nearly 1 in 5. This is the type of system we are employing to stop this lethal overdose. Is this system, which depends on another human to prevent an error, foolproof, or just a snare waiting to prove you the fool?

This represents our opportunity. As hospitalists, the hospital is our tapestry, our system of care, our responsibility. Few others are as well-positioned to ensure that the systems that envelop our patients are highly functional, reliable, and safe. This will take work—work that will feel burdensome, underappreciated, undercompensated. And, fully recognizing that none of us went into medicine to become systems engineers, this will be hard.

However, if not us, who? Who will ensure that our fathers, our mothers, our children will be as safe in the hospital as they are on the drive to the hospital? TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Global health leaders join the World Health Organization to announce accelerated efforts to improve patient safety. World Health Organization website. Available at: www.who.int/mediacentre/news/releases/2004/pr74/en/. Accessed Feb. 14, 2011.
2. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897-1903.

I recently visited my parents in my ancestral home of Wisconsin. As parents of a certain age, they inexplicably are genetically predisposed to owning a minivan. Another quirk of their DNA is that they must own a new minivan. No sooner has the last wisp of new-car smell osmosed from the burled walnut interior than they are trading up to the newest, tricked-out minivan. Perhaps more puzzling is the manner of pride they display in their minivan.

Now, my dad, as if not readily apparent, is not cool. And to see him folded into the driver’s seat, his furry-ear-to-furry-ear grin signaling a self-satisfaction customarily reserved for his grandchildren, painstakingly recounting glory-day stories and 4:30 p.m. dinner buffets, further solidifies his place in the Annals of Uncool.

When I’m home, they tend to employ my chauffeur services (most likely in retribution for my peri-pubescent years), and on the first day back home, I stopped their newest ride near the back door of the house, foot idling on the brake while this exchange occurred: “That’s a fascinating story about how much more challenging the world was when you were my age, Dad. You are a true American hero. Would you like to get out here or in the garage?”

“Here,” he replied.

“OK, then get out,” I countered.

“I can’t,” he responded knowingly.

“Why not?” I queried, the patience seeping from my voice.

“Because the door’s not open,” he answered, seemingly mocking me.

“Then open it,” I replied, silently recounting the evidence for his institutionalization.

“I can’t,” he responded.

“Why not?” I replied again, this time calculating the likelihood that I was adopted.

“Because it’s locked,” came his retort.

“Then unlock it,” I answered, reconfirming my decision to move away for college.

“I can’t,” he replied, ostensibly encouraging parenticide.

“Why not?” I queried, strongly contemplating parenticide.

“Because you haven’t put the car in park,” he responded triumphantly.

A System So Safe

As a safety feature, the minivan needed to be in park before you could open the door to exit. I’ve never heard of anyone actually falling out of a moving car, but recollecting high school, I can fathom the right mix, type, and number of teenagers where possibility would meet inevitability. But, apparently, enough people are falling out of moving vehicles that car engineers have built a system that is so safe, this can’t happen. So no matter how hard someone tries, it just isn’t possible to fall out of a moving car (believe me, toward the end of a week of my father’s car stories, my mind had worked every possible angle).

Likewise, newer vehicles employ occupant-sensitive sensors that detect the weight, size, and position of the passenger to determine if the airbag should deploy. Rather than depending on the driver to turn the passenger-side airbag on or off, the car does it for you: heavy enough to trigger the sensor, and the airbag will deploy; too light, and the car assumes you are a child and doesn’t deploy. It’s a system that is so safe because it doesn’t depend on the operator to get it right.

Ditto motion sensors that detect objects behind the car while reversing (avoiding accidental back-overs), antilock brakes (to maintain control during panicked braking), traction control (improves stability during acceleration), electronic stability control (foils spinouts), tire-pressure-monitoring systems (avoids blowouts), daytime running lights (ensures others see you), rollover airbags (they stay inflated to keep you in the car), lane-departure warning (alerts you if you stray from your lane), and doors that automatically lock after the car starts (again, falling out of cars).

For all the negative press of late, car manufacturers understand safety.

A System Not So Safe

Contrast this to healthcare, in which 10% of patients will suffer a serious, preventable, adverse event during their hospital stay.¹ Read that sentence again. That’s 10%; that’s preventable; that’s a number that has largely remained unchanged in the past decade. If 1 in 10 drivers suffered a serious adverse preventable auto accident, Congress would do nothing but hold automotive safety hearings.

In medicine, we still largely employ unsafe systems in which even the best doctors can, and do, hurt patients. Sure, we have made strides in this arena (oxygen tubing that only works if hooked up properly, smart pumps that avert IV dosing errors, CO₂ monitors to detect proper endotracheal tube placement), but remarkably, in this era of patient safety, we still utilize systems that largely depend on the heroism of the individual.

As physicians, we are famously autonomous and value our professional independence, even to the degree that it might harm patients. We generally eschew standardization, believing that each patient is inherently different. In fact, the thrill of the improvisational theater that follows every patient’s chief compliant is one of the great satisfiers in medicine. We love that feeling that comes from sleuthing each case, deftly enacting a plan of action to shepherd the patient to health.

To suggest following protocols, guidelines, and checklists is derisively dismissed as “cookbook medicine.” To work in teams in which certain tasks are delegated to others is seen as weakness—we don’t need a system that utilizes a pharmacist; rather, we should know the doses of all medicines, their interactions, and the effect of renal and liver impairment on their clearance. To suggest otherwise is an insult to our Oslerian roots. To examine our errors, our system breakdowns, our patient harms is anathema to our practice, an admission of failure.

The result is that most of us continue to toil in systems that have become exponentially unsafe as healthcare has become more complex. Today, we still have a system that will more or less allow us to kill a patient by doing nothing more than forgetting the letter “g.” I can go to my hospital today and intend to write “4 grams of magnesium sulfate (MgSO4)” and inadvertently forget the “g” in “Mg.” This could result in an order for a lethal dose of morphine sulfate (MSO4). It’s that easy to hurt a patient. Now, you might say that would never happen, because the pharmacy would catch it. And this is likely. But is it guaranteed? Can you 100% ensure it wouldn’t happen? Consider that nearly 20% of medication doses administered in a hospital are done so incorrectly.² Nearly 1 in 5. This is the type of system we are employing to stop this lethal overdose. Is this system, which depends on another human to prevent an error, foolproof, or just a snare waiting to prove you the fool?

This represents our opportunity. As hospitalists, the hospital is our tapestry, our system of care, our responsibility. Few others are as well-positioned to ensure that the systems that envelop our patients are highly functional, reliable, and safe. This will take work—work that will feel burdensome, underappreciated, undercompensated. And, fully recognizing that none of us went into medicine to become systems engineers, this will be hard.

However, if not us, who? Who will ensure that our fathers, our mothers, our children will be as safe in the hospital as they are on the drive to the hospital? TH

Dr. Glasheen is associate professor of medicine at the University of Colorado Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.

References

1. Global health leaders join the World Health Organization to announce accelerated efforts to improve patient safety. World Health Organization website. Available at: www.who.int/mediacentre/news/releases/2004/pr74/en/. Accessed Feb. 14, 2011.
2. Barker KN, Flynn EA, Pepper GA, Bates DW, Mikeal RL. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162(16):1897-1903.