Douglas Carlson, MD

Knowledge

Skills

Attitudes

Systems Organization and Improvement

Knowledge

Skills

Attitudes

Systems Organization and Improvement

Knowledge

Skills

Attitudes

Systems Organization and Improvement

Pediatric hospital medicine (PHM) is a relatively new field that has been growing rapidly over the past 20 years.[1] The field has been increasingly recognized for its contributions to high‐quality patient care, patient safety, systems improvement, medical education, and research.[2, 3, 4, 5, 6, 7, 8, 9] However, there appears to be significant variation among programs, even in basic factors such as how clinical effort is defined, the extent of in‐house coverage provided, and the scope of clinical services provided, and there exists a paucity of data describing these variations.[8]

Most previously published work did not specifically focus on academic programs,[2, 3, 8, 9] and specifically targeted hospital leadership,[2] practicing hospitalists,[3] residents,[7] and pediatric residency or clerkship directors,[4, 7] rather than hospitalist directors.[9] Furthermore, previous work focused on specific aspects of PHM programs such as education,[4, 7] value,[2] work environment,[9] and clinical practice,[3] rather than a more comprehensive approach.

We conducted a survey of academic PHM programs to learn about the current state and variation among programs across multiple domains (organizational, administrative, and financial). We speculated that:

• Many institutions currently lacking an academic PHM program were planning on starting a program in the next 3 years.
• Variability exists in hospitalist workload among programs.
• In programs providing clinical coverage at more than 1 site, variability exists in the relationship between the main site and satellite site(s) in terms of decision making, scheduling, and reporting of performance.

METHODS

RESULTS

Response Rates

A total of 133 responses were received. Duplicate responses from the same program (13/133) were eliminated from the analysis. This yielded an overall response rate of 48.8% (120/246). A total of 81.7% (98/120) of institutions reported having an academic PHM program. Of the 18.3% (22/120) of institutions reporting not having a program, 9.1% (2/22) reported planning on starting a program in the next 3 years. Of the 98 respondents with an academic PHM program, 17 answered only the first survey question, Does your program have an academic hospitalist program? The remaining 81 completed surveys were left for further analysis. All of these respondents identified their program, and therefore we are certain that there were no duplicate responses in the analytic dataset. Of these, 23 (28%) indicated that their programs provided clinical care at multiple sites, and 58 (72%) indicated that their program provided care at a single site (Figure 1).

Figure 1

DISCUSSION

Our study demonstrates that academic PHM programs are common, which is consistent with previous data.[4, 7, 9, 14] The data support our belief that more institutions are planning on starting PHM programs. However, there exist much variability in a variety of program factors.[2, 3, 8, 9, 14] The fact that up to 35% of categorical pediatric residents are considering a career as a hospitalist further highlights the need for better data on PHM programs.[7]

We demonstrated that variability existed in hospitalist workload at academic PHM programs. We found considerable variation in the workload per hospitalist (large ranges and standard deviations), as well as variability in how an FTE is defined (hours/year, weeks/year, shifts/year) (Table 1). In addition, survey respondents might have interpreted certain questions differently, and this might have led to increased variability in the data. For example, the question concerning the definition of an FTE was worded as A clinical FTE is defined as. Some of the reported variation in workload might be partially explained by hospitalists having additional nonclinical responsibilities within hospital medicine or another field, including protected time for quality improvement, medical education, research, or administrative activities. Furthermore, some hospitalists might have clinical responsibilities outside of hospital medicine. Given that most PHM programs lack a formal internal definition of what it means to be a hospitalist,[7] it is not surprising to find such variation between programs. The variability in the extent of in‐house coverage provided by academic PHM programs, as well as institutional plans for increased coverage with the 2011 residency work‐hours restrictions is also described, and is consistent with other recently published data.[14] This is likely to continue, as 70% of academic PHM programs reported an anticipated increase in coverage in the near future,[14] suggesting that academic hospitalists are being used to help fill gaps in coverage left by changes in resident staffing.

Our data describe the percentage of academic programs that have a distinct division of hospital medicine. The fact that multisite programs were more likely to report being a distinct division might reflect the increased complexities of providing care at more than 1 site, requiring a greater infrastructure. This might be important in institutional planning as well as academic and financial expectations of academic pediatric hospitalists.

We also demonstrated that programs with multiple sites differ as far as the degree of integration of the various sites, with variation reported in decision making, scheduling, and how quality, safety, and patient satisfaction are reported (Table 4). Whether or not increased integration between the various clinical sites of a multiple‐site program is associated with better performance and/or physician satisfaction are questions that need to be answered. However, academic PHM directors would likely agree that there are great challenges inherent in managing these programs. These challenges include professional integration (do hospitalists based at satellite sites feel that they are academically supported?), clinical work/expectations (fewer resources and fewer learners at satellite sites likely affects workload), and administrative issues (physician scheduling likely becomes more complex as the number of sites increases). As programs continue to grow and provide clinical services in multiple geographic sites, it will become more important to understand how the different sites are coordinated to identify and develop best practices.

Older studies have described that the majority of PHM programs (70%78%) reported that professional revenues do not cover expenses, unfortunately these results were not stratified for program type (academic vs community).[2, 9]

Our study describes that few academic PHM programs (26% of single site, 4% of multiple‐site programs) report revenues (defined in our survey as only the collections from professional billing) in excess of expenses. This is consistent with prior studies that have included both academic and community PHM programs.[2] Therefore, it appears to be common for PHM programs to require institutional funding to cover all program expenses, as collections from professional billing are not generally adequate for this purpose. We believe that this is a critical point for both hospitalists and administrators to understand. However, it is equally important that they be transparent about the importance and value of the nonrevenue‐generating work performed by PHM programs. It has been reported that the vast majority of pediatric hospitalists are highly involved in education, quality improvement work, practice guideline development, and other work that is vitally important to institutions.[3] Furthermore, although one might expect PHM leaders to believe that their programs add value beyond the professional revenue collected,[9] even hospital leadership has been reported to perceive that PHM programs add value in several ways, including increased patient satisfaction (94%), increased referring MD satisfaction (90%), decreased length of stay (81%), and decreased costs (62%).[2] Pediatric residency and clerkship directors report that pediatric hospitalists are more accessible than other faculty (84% vs 64%) and are associated with an increase in the practice of evidence‐based medicine (76% vs 61%).[4] Therefore, there is strong evidence supporting that pediatric hospitalist programs provide important value that is not evident on a balance sheet.

In addition, our data also indicate that programs currently use a variety of metrics in combination to report productivity, and there is no accepted gold standard for measuring the performance of a hospitalist or hospitalist program (Table 2). Given that hospitalists generally cannot control how many patients they see, and given the fact that hospitalists are strongly perceived to provide value to their institutions beyond generating clinical revenue, metrics such as RVUs and charges likely do not accurately represent actual productivity.[2] Furthermore, it is likely that the metrics currently used underestimate actual productivity as they are not designed to take into account confounding factors that might affect hospitalist productivity. For example, consider an academic hospitalist who has clinical responsibilities divided between direct patient care and supervisory patient care (such as a team with some combination of residents, medical students, and physician extenders). When providing direct patient care, the hospitalist is likely responsible or all of the tasks usually performed by residents, including writing all patient notes and prescriptions, all communication with families, nurses, specialists, and primary care providers; and discharge planning. Conversely, when providing supervisory care, it is likely that the tasks are divided among the team members, and the hospitalist has the additional responsibility for providing teaching. However, the hospitalist might be responsible for more complex and acute patients. These factors are not adequately measured by RVUs or professional billing. Furthermore, these metrics do not capture the differences in providing in‐house daytime versus evening/night coverage, and do not measure the work performed while being on call when outside of the hospital. It is important for PHM programs and leaders to develop a better representation of the value provided by hospitalists, and for institutional leaders to understand this value, because previous work has suggested that the majority of hospital leaders do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate the program(s) will be able to covercosts.[2] Given the realities of decreasing reimbursement and healthcare reform, it is unlikely to become more common for PHM programs to generate enough professional revenue to cover expenses.

The main strength of this descriptive study is the comprehensive nature of the survey, including many previously unreported data. In addition, the data are consistent with previously published work, which validates the quality of the data.

This study has several limitations including a low response rate and the exclusion of some hospitals or programs because they provided insufficient data for analysis. However, a post hoc analysis demonstrated that the majority of the institutions reporting that they did not have an academic PHM program (18/22), and those that were excluded due to insufficient data (12/17) were either smaller residency programs (<60 residents) or hospitals that were not the main site of a residency program. Therefore, our data likely are a good representation of academic PHM programs at larger academic institutions. Another potential weakness is that, although PHM program directors and pediatric residency directors were targeted, the respondent might not have been the person with the best knowledge of the program, which could have produced inaccurate data, particularly in terms of finances. However, the general consistency of our findings with previous work, particularly the high percentage of institutions with academic PHM programs,[4, 7, 9, 14] the low percentage of programs with revenues greater than expenses,[2, 9] and the trend toward increased in‐house coverage associated with the 2011 ACGME work‐hour restrictions,[14] supports the validity of our other results. In addition, survey respondents might have interpreted certain questions differently, specifically the questions concerning the definition of an FTE, and this might have led to increased variability in the data.

CONCLUSIONS

Academic PHM programs exist in the vast majority of academic centers, and more institutions are planning on starting programs in the next few years. There appears to be variability in a number of program factors, including hospitalist workload, in‐house coverage, and whether the program is a separate division or a section within another academic division. Many programs are currently providing care at more than 1 site. Programs uncommonly reported that their revenues exceeded their expenses. These data are the most comprehensive data existing for academic PHM programs.

Pediatric hospital medicine (PHM) is a relatively new field that has been growing rapidly over the past 20 years.[1] The field has been increasingly recognized for its contributions to high‐quality patient care, patient safety, systems improvement, medical education, and research.[2, 3, 4, 5, 6, 7, 8, 9] However, there appears to be significant variation among programs, even in basic factors such as how clinical effort is defined, the extent of in‐house coverage provided, and the scope of clinical services provided, and there exists a paucity of data describing these variations.[8]

Most previously published work did not specifically focus on academic programs,[2, 3, 8, 9] and specifically targeted hospital leadership,[2] practicing hospitalists,[3] residents,[7] and pediatric residency or clerkship directors,[4, 7] rather than hospitalist directors.[9] Furthermore, previous work focused on specific aspects of PHM programs such as education,[4, 7] value,[2] work environment,[9] and clinical practice,[3] rather than a more comprehensive approach.

We conducted a survey of academic PHM programs to learn about the current state and variation among programs across multiple domains (organizational, administrative, and financial). We speculated that:

• Many institutions currently lacking an academic PHM program were planning on starting a program in the next 3 years.
• Variability exists in hospitalist workload among programs.
• In programs providing clinical coverage at more than 1 site, variability exists in the relationship between the main site and satellite site(s) in terms of decision making, scheduling, and reporting of performance.

METHODS

RESULTS

Response Rates

A total of 133 responses were received. Duplicate responses from the same program (13/133) were eliminated from the analysis. This yielded an overall response rate of 48.8% (120/246). A total of 81.7% (98/120) of institutions reported having an academic PHM program. Of the 18.3% (22/120) of institutions reporting not having a program, 9.1% (2/22) reported planning on starting a program in the next 3 years. Of the 98 respondents with an academic PHM program, 17 answered only the first survey question, Does your program have an academic hospitalist program? The remaining 81 completed surveys were left for further analysis. All of these respondents identified their program, and therefore we are certain that there were no duplicate responses in the analytic dataset. Of these, 23 (28%) indicated that their programs provided clinical care at multiple sites, and 58 (72%) indicated that their program provided care at a single site (Figure 1).

Figure 1

DISCUSSION

Our study demonstrates that academic PHM programs are common, which is consistent with previous data.[4, 7, 9, 14] The data support our belief that more institutions are planning on starting PHM programs. However, there exist much variability in a variety of program factors.[2, 3, 8, 9, 14] The fact that up to 35% of categorical pediatric residents are considering a career as a hospitalist further highlights the need for better data on PHM programs.[7]

We demonstrated that variability existed in hospitalist workload at academic PHM programs. We found considerable variation in the workload per hospitalist (large ranges and standard deviations), as well as variability in how an FTE is defined (hours/year, weeks/year, shifts/year) (Table 1). In addition, survey respondents might have interpreted certain questions differently, and this might have led to increased variability in the data. For example, the question concerning the definition of an FTE was worded as A clinical FTE is defined as. Some of the reported variation in workload might be partially explained by hospitalists having additional nonclinical responsibilities within hospital medicine or another field, including protected time for quality improvement, medical education, research, or administrative activities. Furthermore, some hospitalists might have clinical responsibilities outside of hospital medicine. Given that most PHM programs lack a formal internal definition of what it means to be a hospitalist,[7] it is not surprising to find such variation between programs. The variability in the extent of in‐house coverage provided by academic PHM programs, as well as institutional plans for increased coverage with the 2011 residency work‐hours restrictions is also described, and is consistent with other recently published data.[14] This is likely to continue, as 70% of academic PHM programs reported an anticipated increase in coverage in the near future,[14] suggesting that academic hospitalists are being used to help fill gaps in coverage left by changes in resident staffing.

Our data describe the percentage of academic programs that have a distinct division of hospital medicine. The fact that multisite programs were more likely to report being a distinct division might reflect the increased complexities of providing care at more than 1 site, requiring a greater infrastructure. This might be important in institutional planning as well as academic and financial expectations of academic pediatric hospitalists.

We also demonstrated that programs with multiple sites differ as far as the degree of integration of the various sites, with variation reported in decision making, scheduling, and how quality, safety, and patient satisfaction are reported (Table 4). Whether or not increased integration between the various clinical sites of a multiple‐site program is associated with better performance and/or physician satisfaction are questions that need to be answered. However, academic PHM directors would likely agree that there are great challenges inherent in managing these programs. These challenges include professional integration (do hospitalists based at satellite sites feel that they are academically supported?), clinical work/expectations (fewer resources and fewer learners at satellite sites likely affects workload), and administrative issues (physician scheduling likely becomes more complex as the number of sites increases). As programs continue to grow and provide clinical services in multiple geographic sites, it will become more important to understand how the different sites are coordinated to identify and develop best practices.

Older studies have described that the majority of PHM programs (70%78%) reported that professional revenues do not cover expenses, unfortunately these results were not stratified for program type (academic vs community).[2, 9]

Our study describes that few academic PHM programs (26% of single site, 4% of multiple‐site programs) report revenues (defined in our survey as only the collections from professional billing) in excess of expenses. This is consistent with prior studies that have included both academic and community PHM programs.[2] Therefore, it appears to be common for PHM programs to require institutional funding to cover all program expenses, as collections from professional billing are not generally adequate for this purpose. We believe that this is a critical point for both hospitalists and administrators to understand. However, it is equally important that they be transparent about the importance and value of the nonrevenue‐generating work performed by PHM programs. It has been reported that the vast majority of pediatric hospitalists are highly involved in education, quality improvement work, practice guideline development, and other work that is vitally important to institutions.[3] Furthermore, although one might expect PHM leaders to believe that their programs add value beyond the professional revenue collected,[9] even hospital leadership has been reported to perceive that PHM programs add value in several ways, including increased patient satisfaction (94%), increased referring MD satisfaction (90%), decreased length of stay (81%), and decreased costs (62%).[2] Pediatric residency and clerkship directors report that pediatric hospitalists are more accessible than other faculty (84% vs 64%) and are associated with an increase in the practice of evidence‐based medicine (76% vs 61%).[4] Therefore, there is strong evidence supporting that pediatric hospitalist programs provide important value that is not evident on a balance sheet.

In addition, our data also indicate that programs currently use a variety of metrics in combination to report productivity, and there is no accepted gold standard for measuring the performance of a hospitalist or hospitalist program (Table 2). Given that hospitalists generally cannot control how many patients they see, and given the fact that hospitalists are strongly perceived to provide value to their institutions beyond generating clinical revenue, metrics such as RVUs and charges likely do not accurately represent actual productivity.[2] Furthermore, it is likely that the metrics currently used underestimate actual productivity as they are not designed to take into account confounding factors that might affect hospitalist productivity. For example, consider an academic hospitalist who has clinical responsibilities divided between direct patient care and supervisory patient care (such as a team with some combination of residents, medical students, and physician extenders). When providing direct patient care, the hospitalist is likely responsible or all of the tasks usually performed by residents, including writing all patient notes and prescriptions, all communication with families, nurses, specialists, and primary care providers; and discharge planning. Conversely, when providing supervisory care, it is likely that the tasks are divided among the team members, and the hospitalist has the additional responsibility for providing teaching. However, the hospitalist might be responsible for more complex and acute patients. These factors are not adequately measured by RVUs or professional billing. Furthermore, these metrics do not capture the differences in providing in‐house daytime versus evening/night coverage, and do not measure the work performed while being on call when outside of the hospital. It is important for PHM programs and leaders to develop a better representation of the value provided by hospitalists, and for institutional leaders to understand this value, because previous work has suggested that the majority of hospital leaders do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate the program(s) will be able to covercosts.[2] Given the realities of decreasing reimbursement and healthcare reform, it is unlikely to become more common for PHM programs to generate enough professional revenue to cover expenses.

The main strength of this descriptive study is the comprehensive nature of the survey, including many previously unreported data. In addition, the data are consistent with previously published work, which validates the quality of the data.

This study has several limitations including a low response rate and the exclusion of some hospitals or programs because they provided insufficient data for analysis. However, a post hoc analysis demonstrated that the majority of the institutions reporting that they did not have an academic PHM program (18/22), and those that were excluded due to insufficient data (12/17) were either smaller residency programs (<60 residents) or hospitals that were not the main site of a residency program. Therefore, our data likely are a good representation of academic PHM programs at larger academic institutions. Another potential weakness is that, although PHM program directors and pediatric residency directors were targeted, the respondent might not have been the person with the best knowledge of the program, which could have produced inaccurate data, particularly in terms of finances. However, the general consistency of our findings with previous work, particularly the high percentage of institutions with academic PHM programs,[4, 7, 9, 14] the low percentage of programs with revenues greater than expenses,[2, 9] and the trend toward increased in‐house coverage associated with the 2011 ACGME work‐hour restrictions,[14] supports the validity of our other results. In addition, survey respondents might have interpreted certain questions differently, specifically the questions concerning the definition of an FTE, and this might have led to increased variability in the data.

CONCLUSIONS

Academic PHM programs exist in the vast majority of academic centers, and more institutions are planning on starting programs in the next few years. There appears to be variability in a number of program factors, including hospitalist workload, in‐house coverage, and whether the program is a separate division or a section within another academic division. Many programs are currently providing care at more than 1 site. Programs uncommonly reported that their revenues exceeded their expenses. These data are the most comprehensive data existing for academic PHM programs.

Pediatric hospital medicine (PHM) is a relatively new field that has been growing rapidly over the past 20 years.[1] The field has been increasingly recognized for its contributions to high‐quality patient care, patient safety, systems improvement, medical education, and research.[2, 3, 4, 5, 6, 7, 8, 9] However, there appears to be significant variation among programs, even in basic factors such as how clinical effort is defined, the extent of in‐house coverage provided, and the scope of clinical services provided, and there exists a paucity of data describing these variations.[8]

Most previously published work did not specifically focus on academic programs,[2, 3, 8, 9] and specifically targeted hospital leadership,[2] practicing hospitalists,[3] residents,[7] and pediatric residency or clerkship directors,[4, 7] rather than hospitalist directors.[9] Furthermore, previous work focused on specific aspects of PHM programs such as education,[4, 7] value,[2] work environment,[9] and clinical practice,[3] rather than a more comprehensive approach.

We conducted a survey of academic PHM programs to learn about the current state and variation among programs across multiple domains (organizational, administrative, and financial). We speculated that:

• Many institutions currently lacking an academic PHM program were planning on starting a program in the next 3 years.
• Variability exists in hospitalist workload among programs.
• In programs providing clinical coverage at more than 1 site, variability exists in the relationship between the main site and satellite site(s) in terms of decision making, scheduling, and reporting of performance.

METHODS

RESULTS

Response Rates

A total of 133 responses were received. Duplicate responses from the same program (13/133) were eliminated from the analysis. This yielded an overall response rate of 48.8% (120/246). A total of 81.7% (98/120) of institutions reported having an academic PHM program. Of the 18.3% (22/120) of institutions reporting not having a program, 9.1% (2/22) reported planning on starting a program in the next 3 years. Of the 98 respondents with an academic PHM program, 17 answered only the first survey question, Does your program have an academic hospitalist program? The remaining 81 completed surveys were left for further analysis. All of these respondents identified their program, and therefore we are certain that there were no duplicate responses in the analytic dataset. Of these, 23 (28%) indicated that their programs provided clinical care at multiple sites, and 58 (72%) indicated that their program provided care at a single site (Figure 1).

Figure 1

DISCUSSION

Our study demonstrates that academic PHM programs are common, which is consistent with previous data.[4, 7, 9, 14] The data support our belief that more institutions are planning on starting PHM programs. However, there exist much variability in a variety of program factors.[2, 3, 8, 9, 14] The fact that up to 35% of categorical pediatric residents are considering a career as a hospitalist further highlights the need for better data on PHM programs.[7]

We demonstrated that variability existed in hospitalist workload at academic PHM programs. We found considerable variation in the workload per hospitalist (large ranges and standard deviations), as well as variability in how an FTE is defined (hours/year, weeks/year, shifts/year) (Table 1). In addition, survey respondents might have interpreted certain questions differently, and this might have led to increased variability in the data. For example, the question concerning the definition of an FTE was worded as A clinical FTE is defined as. Some of the reported variation in workload might be partially explained by hospitalists having additional nonclinical responsibilities within hospital medicine or another field, including protected time for quality improvement, medical education, research, or administrative activities. Furthermore, some hospitalists might have clinical responsibilities outside of hospital medicine. Given that most PHM programs lack a formal internal definition of what it means to be a hospitalist,[7] it is not surprising to find such variation between programs. The variability in the extent of in‐house coverage provided by academic PHM programs, as well as institutional plans for increased coverage with the 2011 residency work‐hours restrictions is also described, and is consistent with other recently published data.[14] This is likely to continue, as 70% of academic PHM programs reported an anticipated increase in coverage in the near future,[14] suggesting that academic hospitalists are being used to help fill gaps in coverage left by changes in resident staffing.

Our data describe the percentage of academic programs that have a distinct division of hospital medicine. The fact that multisite programs were more likely to report being a distinct division might reflect the increased complexities of providing care at more than 1 site, requiring a greater infrastructure. This might be important in institutional planning as well as academic and financial expectations of academic pediatric hospitalists.

We also demonstrated that programs with multiple sites differ as far as the degree of integration of the various sites, with variation reported in decision making, scheduling, and how quality, safety, and patient satisfaction are reported (Table 4). Whether or not increased integration between the various clinical sites of a multiple‐site program is associated with better performance and/or physician satisfaction are questions that need to be answered. However, academic PHM directors would likely agree that there are great challenges inherent in managing these programs. These challenges include professional integration (do hospitalists based at satellite sites feel that they are academically supported?), clinical work/expectations (fewer resources and fewer learners at satellite sites likely affects workload), and administrative issues (physician scheduling likely becomes more complex as the number of sites increases). As programs continue to grow and provide clinical services in multiple geographic sites, it will become more important to understand how the different sites are coordinated to identify and develop best practices.

Older studies have described that the majority of PHM programs (70%78%) reported that professional revenues do not cover expenses, unfortunately these results were not stratified for program type (academic vs community).[2, 9]

Our study describes that few academic PHM programs (26% of single site, 4% of multiple‐site programs) report revenues (defined in our survey as only the collections from professional billing) in excess of expenses. This is consistent with prior studies that have included both academic and community PHM programs.[2] Therefore, it appears to be common for PHM programs to require institutional funding to cover all program expenses, as collections from professional billing are not generally adequate for this purpose. We believe that this is a critical point for both hospitalists and administrators to understand. However, it is equally important that they be transparent about the importance and value of the nonrevenue‐generating work performed by PHM programs. It has been reported that the vast majority of pediatric hospitalists are highly involved in education, quality improvement work, practice guideline development, and other work that is vitally important to institutions.[3] Furthermore, although one might expect PHM leaders to believe that their programs add value beyond the professional revenue collected,[9] even hospital leadership has been reported to perceive that PHM programs add value in several ways, including increased patient satisfaction (94%), increased referring MD satisfaction (90%), decreased length of stay (81%), and decreased costs (62%).[2] Pediatric residency and clerkship directors report that pediatric hospitalists are more accessible than other faculty (84% vs 64%) and are associated with an increase in the practice of evidence‐based medicine (76% vs 61%).[4] Therefore, there is strong evidence supporting that pediatric hospitalist programs provide important value that is not evident on a balance sheet.

In addition, our data also indicate that programs currently use a variety of metrics in combination to report productivity, and there is no accepted gold standard for measuring the performance of a hospitalist or hospitalist program (Table 2). Given that hospitalists generally cannot control how many patients they see, and given the fact that hospitalists are strongly perceived to provide value to their institutions beyond generating clinical revenue, metrics such as RVUs and charges likely do not accurately represent actual productivity.[2] Furthermore, it is likely that the metrics currently used underestimate actual productivity as they are not designed to take into account confounding factors that might affect hospitalist productivity. For example, consider an academic hospitalist who has clinical responsibilities divided between direct patient care and supervisory patient care (such as a team with some combination of residents, medical students, and physician extenders). When providing direct patient care, the hospitalist is likely responsible or all of the tasks usually performed by residents, including writing all patient notes and prescriptions, all communication with families, nurses, specialists, and primary care providers; and discharge planning. Conversely, when providing supervisory care, it is likely that the tasks are divided among the team members, and the hospitalist has the additional responsibility for providing teaching. However, the hospitalist might be responsible for more complex and acute patients. These factors are not adequately measured by RVUs or professional billing. Furthermore, these metrics do not capture the differences in providing in‐house daytime versus evening/night coverage, and do not measure the work performed while being on call when outside of the hospital. It is important for PHM programs and leaders to develop a better representation of the value provided by hospitalists, and for institutional leaders to understand this value, because previous work has suggested that the majority of hospital leaders do not plan to phase out the subsidy of hospitalists over time, as they do not anticipate the program(s) will be able to covercosts.[2] Given the realities of decreasing reimbursement and healthcare reform, it is unlikely to become more common for PHM programs to generate enough professional revenue to cover expenses.

The main strength of this descriptive study is the comprehensive nature of the survey, including many previously unreported data. In addition, the data are consistent with previously published work, which validates the quality of the data.

This study has several limitations including a low response rate and the exclusion of some hospitals or programs because they provided insufficient data for analysis. However, a post hoc analysis demonstrated that the majority of the institutions reporting that they did not have an academic PHM program (18/22), and those that were excluded due to insufficient data (12/17) were either smaller residency programs (<60 residents) or hospitals that were not the main site of a residency program. Therefore, our data likely are a good representation of academic PHM programs at larger academic institutions. Another potential weakness is that, although PHM program directors and pediatric residency directors were targeted, the respondent might not have been the person with the best knowledge of the program, which could have produced inaccurate data, particularly in terms of finances. However, the general consistency of our findings with previous work, particularly the high percentage of institutions with academic PHM programs,[4, 7, 9, 14] the low percentage of programs with revenues greater than expenses,[2, 9] and the trend toward increased in‐house coverage associated with the 2011 ACGME work‐hour restrictions,[14] supports the validity of our other results. In addition, survey respondents might have interpreted certain questions differently, specifically the questions concerning the definition of an FTE, and this might have led to increased variability in the data.

CONCLUSIONS

Academic PHM programs exist in the vast majority of academic centers, and more institutions are planning on starting programs in the next few years. There appears to be variability in a number of program factors, including hospitalist workload, in‐house coverage, and whether the program is a separate division or a section within another academic division. Many programs are currently providing care at more than 1 site. Programs uncommonly reported that their revenues exceeded their expenses. These data are the most comprehensive data existing for academic PHM programs.

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted:

Hospitalists are the fastest growing segment of physicians in the United States.1 Given the growing field of Pediatric Hospital Medicine (PHM) and the need to define strategic direction, the Society of Hospital Medicine (SHM), the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA) sponsored a strategic planning meeting in February 2009 that brought together 22 PHM leaders to discuss the future of the field.

PHM is at a critical juncture in terms of clinical practice, research, workforce issues, and quality improvement. The field has developed sufficiently to produce leaders capable of setting an agenda and moving forward. A discussion with the American Board of Pediatrics (ABP) by PHM leaders from the AAP, APA, and SHM at the Pediatric Hospital Medicine 2007 Conference regarding subspecialty designation stimulated convening the PHM Strategic Planning Roundtable to address the task of coordinating further development of PHM (Table 1).

The objective of this article is to describe: (1) the Strategic Planning Roundtable's vision for the field of pediatric hospital medicine; (2) the generation and progress on specific initiatives in clinical practice, quality, research, and workforce identified by the Strategic Planning Roundtable; and (3) issues in the designation of PHM as a subspecialty.

METHODS

The PHM Strategic Planning Roundtable was conducted by a facilitator (S.M.) during a 2‐day retreat using established healthcare strategic planning methods.2

Participants were the existing PHM leaders from the AAP, APA, and SHM, as well as other national leaders in clinical practice, quality, research, and workforce. Development of the vision statement was a key step in which the participants developed a consensus‐based aspirational view of the future. The draft version of the vision statement was initially developed after extensive interviews with key stakeholders and experts in PHM, and was revised by the participants in the course of a facilitated group discussion during the retreat. Following creation of the vision statement, the group then defined the elements of transformation pertaining to PHM and detailed the components of the vision.

Analysis of internal and external environmental factors was critical in the strategic planning process. This type of analysis, detailing the current state of PHM practice, permitted the strategic planners to understand the gaps that existed between the aspirational vision statement and today's reality, and set the stage to identify and implement initiatives to achieve the vision. Several months before the meeting, 4 expert panels comprised of PHM specialists representing a variety of academic and clinical practice settings were brought together via e‐mail and conference calls to focus on 4 domains of PHM: clinical practice, quality of care, research, and workforce. These groups were asked to describe the current status, challenges, and opportunities in these areas. Combining literature review and key stakeholder interviews, their findings and recommendations were distilled into brief summaries that were presented at the Roundtable meeting. Following the presentations, the participants, working in small groups representing all areas of focus,provided additional feedback.

Following the creation of a consensus vision statement and review of internal and external factors, the participants worked to identify specific initiatives in the 4 domains that would advance the field towards the goals contained in the vision statement. These initiatives were grouped into categories. Initiatives by category were scored and prioritized according to predetermined criteria including potential impact, cost, operational complexity, and achievability.

For each initiative selected, the group developed targets and metrics that would be used to track progress. Assigning leadership, accountability, and a timeline to each of the selected projects completed the implementation plan. In addition, the group developed an organizational structure to provide oversight for the overall process, and designated individuals representing the sponsoring organizations into those roles. In conclusion, the group discussed potential structures to guide the future of PHM.

CLINICAL PRACTICE

The Roundtable defined clinical practice for PHM as the general medical care of the hospitalized child, including direct patient care and leadership of the inpatient service. Clinical practice is affected by a number of current national trends including: fewer primary care providers interested in, or with the time to provide, inpatient care; resident work hour restrictions; increasing complexity of clinical issues; and increasing availability of pediatric hospitalists. At the hospital level, clinical practice is affected by increasing need for quality and safety measures, electronic health records and computerized physician order entry, and mounting financial pressures on the hospital system. Hospitalists are assuming more roles in leading quality and safety initiatives, creating computerized systems that address children's needs, and creating financially viable systems of quality pediatric care.3 Hospitalists' clinical care and leadership roles are emerging, and therefore the field faces training and mentorship issues.

Progress to date in this area includes 2 textbooks that define a scope of knowledge and practice, and a newly developed journal in PHM. Core competencies in PHM have been published and provide further refinement of scope and a template for future training.4

Multiple opportunities exist for hospitalists to establish themselves as clinical leaders. Hospitalists can become the preferred providers for hospitalized chronically ill children, with specific initiatives to improve care coordination and multidisciplinary communication. In addition to care coordination and decreasing length of stay, hospitalists, with their intimate knowledge of hospital operations, can be leaders in hospital capacity management and patient flow to increase operational efficiency. Hospitalists can expand evidence‐based guidelines for, and data about, inpatient conditions, and explore the effect of workload and hours on patient care. In addition, there is an expanding role into administrative areas, as well as alternate care arenas, such as: intensive care support (pediatric and neonatal), transport, sedation, palliative care, and pain management. Activities in administrative and alternate care areas have profound direct affects on patient care, as well as providing value added services and additional revenue streams which can further support clinical needs. Finally, achieving quality targets will likely be increasingly linked to payment, so hospitalists may play a key role in the incentives paid to their hospitals. Meeting these challenges will further solidify the standing of hospitalists in the clinical realm.

QUALITY

National and governmental agencies have influenced quality and performance improvement measurements in adult healthcare, resulting in improvements in adult healthcare quality measurement.5 There is limited similar influence or measure development in pediatric medicine, so the quality chasm between adult and child healthcare has widened. Few resources are invested in improving quality and safety of pediatric inpatient care. Of the 18 private health insurance plans' quality and pay for performance programs identified by Leapfrog, only 17% developed pediatric‐specific inpatient measures.6 Only 5 of 40 controlled trials of quality improvement efforts for children published between 1980 and 1998 addressed inpatient problems.7

There have been recent efforts at the national level addressing these issues, highlighted by the introduction of The Children's Health Care Quality Act, in 2007. Early studies in PHM systems focused on overall operational efficiency, documenting 9% to 16% decreases in length of stay and cost compared to traditional models of care.8 Conway et al. identified higher reported adherence to evidence‐based care for hospitalists compared to community pediatricians.9 However, Landrigan et al. demonstrated that there is still large variation in care that exists in the management of common inpatient diagnoses, lacking strong evidence‐based guidelines even among pediatric hospitalists.10 Moreover, there have been no significant studies reviewing the impact of pediatric hospitalists on safety of inpatient care. Magnifying these challenges is the reality that our healthcare system is fragmented with various entities scrambling to define, measure, and compare the effectiveness and safety of pediatric healthcare.

These challenges create an opportunity for PHM to develop a model of how to deliver the highest quality and safest care to our patients. The solution is complex and will take cooperation at many levels of our healthcare system. Improving the safety and quality of care for children in all settings of inpatient care in the United States may best be accomplished via an effective collaborative. This collaborative should be comprehensive and inclusive, and focused on demonstrating and disseminating how standardized, evidence‐based care in both clinical and safety domains can lead to high‐value and high‐quality outcomes. The success of PHM will be measured by its ability to deliver a clear value proposition to all consumers and payers of healthcare. The creation of a robust national collaborative network is a first step towards meeting this goal and will take an extraordinary effort. A PHM Quality Improvement (QI) Collaborative workgroup was created in August 2009. Three collaboratives have been commissioned: (1) Reduction of patient identification errors; (2) Improving discharge communication to referring primary care providers for pediatric hospitalist programs, and (3) Reducing the misuse and overuse of bronchodilators for bronchiolitis. All the collaborative groups have effectively engaged key groups of stakeholders and utilized standard QI tools, demonstrating improvement by the fall of 2010 (unpublished data, S.N.).

RESEARCH

Despite being a relatively young field, there is a critical mass of pediatric hospitalist‐investigators who are establishing research career paths for themselves by securing external grant funding for their work, publishing, and receiving mentorship from largely non‐hospitalist mentors. Some hospitalists are now in a position to mentor junior investigators. These hospitalist‐investigators identified a collective goal of working together across multiple sites in a clinical research network. The goal is to conduct high‐quality studies and provide the necessary clinical information to allow practicing hospitalists to make better decisions regarding patient care. This new inpatient evidence‐base will have the added advantage of helping further define the field of PHM.

The Pediatric Research in Inpatient Settings Network (PRIS) was identified as the vehicle to accomplish these goals. A series of objectives were identified to redesign PRIS in order to accommodate and organize this new influx of hospitalist‐investigators. These objectives included having hospitalist‐investigators commit their time to the prioritization, design, and execution of multicenter studies, drafting new governance documents for PRIS, securing external funding, redefining the relationships of the 3 existing organizations that formed PRIS (AAP, APA, SHM), defining how new clinical sites could be added to PRIS, creating a pipeline for junior hospitalist‐investigators to transition to leadership roles, securing a data coordinating center with established expertise in conducting multicenter studies, and establishing an external research advisory committee of leaders in pediatric clinical research and QI.

Several critical issues were identified, but funding remained a priority for the sustainability of PRIS. Comparative effectiveness (CE) was recognized as a potential important source of future funding. Pediatric studies on CE (eg, surgery vs medical management) conducted by PRIS would provide important new data to allow hospitalists to practice evidence‐based medicine and to improve quality.

A Research Leadership Task Force was created with 4 members of the PHM Strategic Planning Roundtable to work on the identified issues. The APA leadership worked with PRIS to establish a new Executive Council (comprised of additional qualified hospitalist‐investigators). The Executive Council was charged with accomplishing the tasks outlined from the Strategic Planning Roundtable. They have created the governance documents and standard operating procedures necessary for PRIS to conduct multicenter studies, defined a strategic framework for PRIS including the mission, vision and values, and funding strategy. In February 2010, PRIS received a 3‐year award for over $1 million from the Child Health Corporation of America to both fund the infrastructure of PRIS and to conduct a Prioritization Project. The Prioritization Project seeks to identify the conditions that are costly, prevalent, and demonstrate high inter‐hospital variation in resource utilization, which signals either lack of high‐quality data upon which to base medical decisions, and/or an opportunity to standardize care across hospitals. Some of these conditions will warrant further investigation to define the evidence base, whereas other conditions may require implementation studies to reliably introduce evidence into practice. Members of the Executive Council received additional funding to investigate community settings, as most children are hospitalized outside of large children's hospitals. PRIS also reengaged all 3 societies (APA, AAP, and SHM) for support for the first face‐to‐face meeting of the Executive Council. PRIS applied for 2 Recovery Act stimulus grants, and received funding for both of approximately $12 million. The processes used to design, provide feedback, and shepherd these initial studies formed the basis for the standard operating procedures for the Network. PRIS is now reengaging its membership to establish how sites may be able to conduct research, and receive new ideas to be considered for study in PRIS.

Although much work remains to be done, the Executive Council is continuing the charge with quarterly face‐to‐face meetings, hiring of a full‐time PRIS Coordinator, and carrying out these initial projects, while maintaining the goal of meeting the needs of the membership and PHM. If PRIS is to accomplish its mission of improving the health of, and healthcare delivery to, hospitalized children and their families, then the types of studies undertaken will include not only original research questions, but also comparative implementation methods to better understand how hospitalists in a variety of settings can best translate research findings into clinical practice and ultimately improve patient outcomes.

WORKFORCE

The current number of pediatric hospitalists is difficult to gauge11; estimates range from 1500 to 3000 physicians. There are groups of pediatric hospitalists within several national organizations including the AAP, APA, and SHM, in addition to a very active listserve community. It is likely that only a portion of pediatric hospitalists are represented by membership in these organizations.

Most physicians entering the field of PHM come directly out of residency. A recent survey by Freed et al.12 reported that 3% of current pediatric residents are interested in PHM as a career. In another survey by Freed et al., about 6% of recent pediatric residency graduates reported currently practicing as pediatric hospitalists.13 This difference may indicate a number of pediatricians practicing transiently as pediatric hospitalists.

There are numerous issues that will affect the growth and sustainability of PHM. A large number of pediatric residents entering the field will be needed to maintain current numbers. With 45% of hospitalists in practice less than 3 years,11 the growth of PHM in both numbers and influence will require an increasing number of hospitalists with sustained careers in the field. Recognition as experts in inpatient care, as well as expansion of the role of hospitalists beyond the clinical realm to education, research, and hospital leadership, will foster long‐term career satisfaction. The increasingly common stature of hospital medicine as an independent division, equivalent to general pediatrics and subspecialty divisions within a department, may further bolster the perception of hospital medicine as a career.

The majority of pediatric hospitalists believe that current pediatric residency training does not provide all of the skills necessary to practice as a pediatric hospitalist,14 though there is disagreement regarding how additional training in pediatric hospital medicine should be achieved: a dedicated fellowship versus continuing medical education (CME). There are several initiatives with the potential to transform the way pediatric hospitalists are trained and certified. The Residency Review and Redesign Project indicates that pediatric residency is likely to be reformed to better meet the training demands of the individual resident's chosen career path. Changing residency to better prepare pediatric residents to take positions in pediatric hospital medicine will certainly affect the workforce emerging from residency programs and their subsequent training needs.15 The American Board of Internal Medicine and the American Board of Family Medicine have approved a Recognition of Focused Practice in Hospital Medicine. This recognition is gained through the Maintenance of Certification (MOC) Program of the respective boards after a minimum of 3 years of practice. SHM is offering fellow recognition in tiered designations of Fellow of Hospital Medicine (FHM), Senior Fellow of Hospital Medicine, and Master of Hospital Medicine. Five hundred hospitalists, including many pediatric hospitalists, received the inaugural FHM designation in 2009. Organizational recognition is a common process in many other medical fields, although previously limited in pediatrics to Fellow of the AAP. FHM is an important step, but cannot substitute for specific training and certification.

Academic fellowships in PHM will aid in the training of hospitalists with scholarly skills and will help produce more pediatric hospitalists with clinical, quality, administrative, and leadership skills. A model of subspecialty fellowship training and certification of all PHM physicians would require a several‐fold increase in available fellowships, currently approximately 15.

Ongoing CME offerings are also critical to sustaining and developing the workforce. The annual national meetings of the APA, AAP, and SHM all offer PHM‐dedicated content, and there is an annual PHM conference sponsored by these 3 organizations. There are now multiple additional national and regional meetings focused on PHM, reflecting the growing audience for PHM CME content. The AAP offers a PHM study guide and an Education in quality improvement for pediatric practice (eQIPP) module on inpatient asthma, specifically designed to facilitate the MOC process for pediatric hospitalists.

Some form of ABP recognition may be necessary to provide the status for PHM to be widely recognized as a viable academic career in the larger pediatric community. This would entail standardized fellowships that will ensure graduates have demonstrated proficiency in the core competencies. PHM leaders have engaged the ABP to better understand the subspecialty approval process and thoughtfully examine the ramifications of subspecialty status, specifically what subspecialty certification would mean for PHM providers and hospitals. Achieving ABP certification may create a new standard of care meaning that noncertified PHM providers will be at a disadvantage. It is unknown what the impact on pediatric inpatient care would be if a PHM standard was set without the supply of practitioners to provide that care.

STRUCTURE

The efforts of the Roundtable demonstrate the potential effectiveness of the current structure that guides the field: that of the cooperative interchange between the PHM leaders within the APA, AAP, and SHM. It may be that, similar to Pediatric Emergency Medicine (PEM), no formal, unifying structure is necessary. Alternatively, both Adolescent Medicine and Behavioral and Developmental Pediatrics (BDP) have their own organizations that guide their respective fields. A hybrid model is that of Pediatric Cardiology which has the Joint Council on Congenital Heart Disease. This structure assures that the leaders of the various organizations concerned with congenital heart disease meet at least annually to report on their activities and coordinate future efforts. Its makeup is similar to how the planning committee of the annual national PHM conference is constructed. Although PHM has largely succeeded with the current organizational structure, it is possible that a more formal structure is needed to continue forward.

CONCLUSION

The Roundtable members developed the following vision for PHM: Pediatric hospitalists will transform the delivery of hospital care for children. This will be done by achieving 7 goals (Table 2).

Attaining this vision will take tremendous dedication, effort, and collaboration. As a starting point, the following initiatives were proposed and implemented as noted: