Larry Beresford

An emerging category of hospital quality initiatives, comparable to preventing medical errors and improving quality and patient safety, could be labeled “waste management” or “waste reduction.” "Waste" in this sense refers not to biohazardous substances in need of disposal, but to the overuse of medical resources—such as lab tests and pharmaceuticals—when they are not helpful to a patient's medical management.

This will be a growing focus for hospitalists, says Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center, and author of the HM-focused blog, Wachter's World.

"If patients are getting CAT scans they don't really need or an extra day of telemetry because we don't have criteria for who should be on telemetry, that's wasteful, it's costly, and it could be dangerous,” Dr. Wachter explained at the UCSF Management of the Hospitalized Patient meeting last October. "The data are clear that 30% of what we do in American medicine is of no value to patients—and some substantial portion of that is harmful as well. I think we as hospitalists should be identifying what these wasteful things are—and making the hard decisions to stop them."

In an academic setting such as UCSF, many of the hospitalists lead quality, safety, and "waste reduction" projects, which often use similar tools and methods but have a different focus. Dr. Wachter's colleague Niraj Sehgal, MD, MPH, the department of medicine's associate chair for quality improvement (QI) and patient safety, says that process-improvement tools such as Six Sigma and Lean methodologies can put unnecessary variation and waste under the microscope. But at UCSF, these efforts start with just looking at the data, then sharing the data with trainees and faculty.

"Clearly, attention is growing to this issue," Dr. Sehgal says. "We often talk about generating value in healthcare where value equals quality divided by cost, but we need to include the concept of appropriateness in that equation as well."

A radiology utilization awareness project at UCSF is looking at whether cost and radiation exposure information might influence the ordering of five common radiologic tests that together generate annual charges of nearly $10 million at UCSF's Moffitt-Long Medical Service. The project uses a number of educational strategies to encourage providers to think about whether the tests will change their clinical management.

"The preliminary data suggest that simply providing the cost and utilization data decreased utilization for three of the five tests evaluated," Dr. Sehgal says.

Physicians didn't necessarily ignore inefficiency and overuse in the past, he adds, but healthcare reform offers new opportunities to leverage greater cost consciousness in medical education and practice. "We're not having to convince our trainees and faculty that cost is important," he says. "They just don't always see the costs involved."

An emerging category of hospital quality initiatives, comparable to preventing medical errors and improving quality and patient safety, could be labeled “waste management” or “waste reduction.” "Waste" in this sense refers not to biohazardous substances in need of disposal, but to the overuse of medical resources—such as lab tests and pharmaceuticals—when they are not helpful to a patient's medical management.

This will be a growing focus for hospitalists, says Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center, and author of the HM-focused blog, Wachter's World.

"If patients are getting CAT scans they don't really need or an extra day of telemetry because we don't have criteria for who should be on telemetry, that's wasteful, it's costly, and it could be dangerous,” Dr. Wachter explained at the UCSF Management of the Hospitalized Patient meeting last October. "The data are clear that 30% of what we do in American medicine is of no value to patients—and some substantial portion of that is harmful as well. I think we as hospitalists should be identifying what these wasteful things are—and making the hard decisions to stop them."

In an academic setting such as UCSF, many of the hospitalists lead quality, safety, and "waste reduction" projects, which often use similar tools and methods but have a different focus. Dr. Wachter's colleague Niraj Sehgal, MD, MPH, the department of medicine's associate chair for quality improvement (QI) and patient safety, says that process-improvement tools such as Six Sigma and Lean methodologies can put unnecessary variation and waste under the microscope. But at UCSF, these efforts start with just looking at the data, then sharing the data with trainees and faculty.

"Clearly, attention is growing to this issue," Dr. Sehgal says. "We often talk about generating value in healthcare where value equals quality divided by cost, but we need to include the concept of appropriateness in that equation as well."

A radiology utilization awareness project at UCSF is looking at whether cost and radiation exposure information might influence the ordering of five common radiologic tests that together generate annual charges of nearly $10 million at UCSF's Moffitt-Long Medical Service. The project uses a number of educational strategies to encourage providers to think about whether the tests will change their clinical management.

"The preliminary data suggest that simply providing the cost and utilization data decreased utilization for three of the five tests evaluated," Dr. Sehgal says.

Physicians didn't necessarily ignore inefficiency and overuse in the past, he adds, but healthcare reform offers new opportunities to leverage greater cost consciousness in medical education and practice. "We're not having to convince our trainees and faculty that cost is important," he says. "They just don't always see the costs involved."

An emerging category of hospital quality initiatives, comparable to preventing medical errors and improving quality and patient safety, could be labeled “waste management” or “waste reduction.” "Waste" in this sense refers not to biohazardous substances in need of disposal, but to the overuse of medical resources—such as lab tests and pharmaceuticals—when they are not helpful to a patient's medical management.

This will be a growing focus for hospitalists, says Robert Wachter, MD, MHM, chief of the division of hospital medicine at the University of California at San Francisco (UCSF) Medical Center, and author of the HM-focused blog, Wachter's World.

"If patients are getting CAT scans they don't really need or an extra day of telemetry because we don't have criteria for who should be on telemetry, that's wasteful, it's costly, and it could be dangerous,” Dr. Wachter explained at the UCSF Management of the Hospitalized Patient meeting last October. "The data are clear that 30% of what we do in American medicine is of no value to patients—and some substantial portion of that is harmful as well. I think we as hospitalists should be identifying what these wasteful things are—and making the hard decisions to stop them."

In an academic setting such as UCSF, many of the hospitalists lead quality, safety, and "waste reduction" projects, which often use similar tools and methods but have a different focus. Dr. Wachter's colleague Niraj Sehgal, MD, MPH, the department of medicine's associate chair for quality improvement (QI) and patient safety, says that process-improvement tools such as Six Sigma and Lean methodologies can put unnecessary variation and waste under the microscope. But at UCSF, these efforts start with just looking at the data, then sharing the data with trainees and faculty.

"Clearly, attention is growing to this issue," Dr. Sehgal says. "We often talk about generating value in healthcare where value equals quality divided by cost, but we need to include the concept of appropriateness in that equation as well."

A radiology utilization awareness project at UCSF is looking at whether cost and radiation exposure information might influence the ordering of five common radiologic tests that together generate annual charges of nearly $10 million at UCSF's Moffitt-Long Medical Service. The project uses a number of educational strategies to encourage providers to think about whether the tests will change their clinical management.

"The preliminary data suggest that simply providing the cost and utilization data decreased utilization for three of the five tests evaluated," Dr. Sehgal says.

Physicians didn't necessarily ignore inefficiency and overuse in the past, he adds, but healthcare reform offers new opportunities to leverage greater cost consciousness in medical education and practice. "We're not having to convince our trainees and faculty that cost is important," he says. "They just don't always see the costs involved."

A poster presented at the Center to Advance Palliative Care national seminar in San Diego in November described a growing collaboration between the HM service and the palliative-care team at a Wisconsin medical center as part of efforts to control readmissions using tools from SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions).

On admission to 227-bed Aurora West Allis (Wis.) Medical Center, all patients assigned to a hospitalist are assessed for readmission risk factors. If a risk factor is identified, the hospital has established a set of specific interventions, including a palliative-care consultation.

“Basically, we took the BOOST tools and developed a physician action plan behind those risk factors,” says Andrew McDonagh, MD, head of the center’s hospitalist service.

Dr. McDonagh started Aurora West Allis’ HM service in 2008, and Timothy Jessick, DO, initiated the palliative-care service in 2010. “As our programs grew together, it became apparent that there were significant synergies between the two specialties, so we took the opportunity to work together in several ways,” Dr. McDonagh says.

A Palliative Care Quality Indicators Checklist, which looks for four key clinical indicators, triggers hospitalists and unit nurses to order the palliative consult. If an elderly patient has multiple admissions for the same diagnosis, the second admission triggers a geriatric consultation, and the third admission gets a palliative-care consult.

Hospitalists at the medical center are given education and modeling on how to hold family conferences with patients and their families to elicit their goals of care. Collaboration between HM and palliative care is spreading to the hospital’s ICUs, to patients transitioning out of the hospital to nursing homes, and to two other Aurora hospitals in the Milwaukee area, Dr. McDonagh explains. Since the BOOST tools have been implemented, preliminary evidence points to reduced readmissions, increased patient satisfaction, and increased palliative-care consults at the hospital.

“In the future, doing our job well as hospitalists will be more than just addressing medical needs but tailoring our care plans to the individual patient. Palliative care helps us better define appropriate care for these patients, looking beyond the trees for the forest,” he says. “I believe I’m a better clinician for being part of this relationship.”

A poster presented at the Center to Advance Palliative Care national seminar in San Diego in November described a growing collaboration between the HM service and the palliative-care team at a Wisconsin medical center as part of efforts to control readmissions using tools from SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions).

On admission to 227-bed Aurora West Allis (Wis.) Medical Center, all patients assigned to a hospitalist are assessed for readmission risk factors. If a risk factor is identified, the hospital has established a set of specific interventions, including a palliative-care consultation.

“Basically, we took the BOOST tools and developed a physician action plan behind those risk factors,” says Andrew McDonagh, MD, head of the center’s hospitalist service.

Dr. McDonagh started Aurora West Allis’ HM service in 2008, and Timothy Jessick, DO, initiated the palliative-care service in 2010. “As our programs grew together, it became apparent that there were significant synergies between the two specialties, so we took the opportunity to work together in several ways,” Dr. McDonagh says.

A Palliative Care Quality Indicators Checklist, which looks for four key clinical indicators, triggers hospitalists and unit nurses to order the palliative consult. If an elderly patient has multiple admissions for the same diagnosis, the second admission triggers a geriatric consultation, and the third admission gets a palliative-care consult.

Hospitalists at the medical center are given education and modeling on how to hold family conferences with patients and their families to elicit their goals of care. Collaboration between HM and palliative care is spreading to the hospital’s ICUs, to patients transitioning out of the hospital to nursing homes, and to two other Aurora hospitals in the Milwaukee area, Dr. McDonagh explains. Since the BOOST tools have been implemented, preliminary evidence points to reduced readmissions, increased patient satisfaction, and increased palliative-care consults at the hospital.

“In the future, doing our job well as hospitalists will be more than just addressing medical needs but tailoring our care plans to the individual patient. Palliative care helps us better define appropriate care for these patients, looking beyond the trees for the forest,” he says. “I believe I’m a better clinician for being part of this relationship.”

A poster presented at the Center to Advance Palliative Care national seminar in San Diego in November described a growing collaboration between the HM service and the palliative-care team at a Wisconsin medical center as part of efforts to control readmissions using tools from SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions).

On admission to 227-bed Aurora West Allis (Wis.) Medical Center, all patients assigned to a hospitalist are assessed for readmission risk factors. If a risk factor is identified, the hospital has established a set of specific interventions, including a palliative-care consultation.

“Basically, we took the BOOST tools and developed a physician action plan behind those risk factors,” says Andrew McDonagh, MD, head of the center’s hospitalist service.

Dr. McDonagh started Aurora West Allis’ HM service in 2008, and Timothy Jessick, DO, initiated the palliative-care service in 2010. “As our programs grew together, it became apparent that there were significant synergies between the two specialties, so we took the opportunity to work together in several ways,” Dr. McDonagh says.

A Palliative Care Quality Indicators Checklist, which looks for four key clinical indicators, triggers hospitalists and unit nurses to order the palliative consult. If an elderly patient has multiple admissions for the same diagnosis, the second admission triggers a geriatric consultation, and the third admission gets a palliative-care consult.

Hospitalists at the medical center are given education and modeling on how to hold family conferences with patients and their families to elicit their goals of care. Collaboration between HM and palliative care is spreading to the hospital’s ICUs, to patients transitioning out of the hospital to nursing homes, and to two other Aurora hospitals in the Milwaukee area, Dr. McDonagh explains. Since the BOOST tools have been implemented, preliminary evidence points to reduced readmissions, increased patient satisfaction, and increased palliative-care consults at the hospital.

“In the future, doing our job well as hospitalists will be more than just addressing medical needs but tailoring our care plans to the individual patient. Palliative care helps us better define appropriate care for these patients, looking beyond the trees for the forest,” he says. “I believe I’m a better clinician for being part of this relationship.”

Aultidisciplinary patient rounding system implemented on a non-teaching hospitalist unit at the Ohio State University Medical Center (OSUMC) has been well received by unit staff, according to an HM11 abstract presentation. Key to its success, says lead author and OSUMC hospitalist Eric Schumacher, DO, MBA, was to involve nursing staff from the start and to work closely with the unit’s nurse manager and charge nurse.

“Once we got their buy-in, we proposed what we wanted to do and asked for their suggestions,” Dr. Schumacher says.

Hospitalists partner with the nurse leaders to establish a morning bedside rounding process on the unit, using a “Physician Nurse Rounding Sheet” for each hospitalist. The sheet is prepared daily by the charge nurse and unit clerks, listing the hospitalist’s patients, assigned nurses, and phone numbers. A short debriefing is performed outside the patient’s room before each encounter, and a daily feedback sheet is given to the patient and family with a picture of the hospitalist, a list of all care-team members, and such information as goals for the day, pending tests and consultations, and anticipated discharge date.

“Part of the challenge is to create a process that is efficient for both doctors and nurses, given multiple nurses caring for multiple patients,” Dr. Schumacher says.

Charge nurses or nursing managers provide backup when the bedside nurse is not available for bedside rounding. “Right now we’re rounding with hospitalists and nurses only, but a long-term goal is to expand it to include the social worker and other ancillary professionals,” he says.

Preliminary data on the project show the feasibility of multidisciplinary rounding, with elevated Press Ganey patient satisfaction scores on the unit in the first two months after rounding began. In the third month, compliance with rounding went down, and so did satisfaction scores, but with a renewed commitment the following month, scores went back up again. Subjective reports from hospitalists also suggest fewer interruptions during the day from nursing pages, Dr. Schumacher says.

Aultidisciplinary patient rounding system implemented on a non-teaching hospitalist unit at the Ohio State University Medical Center (OSUMC) has been well received by unit staff, according to an HM11 abstract presentation. Key to its success, says lead author and OSUMC hospitalist Eric Schumacher, DO, MBA, was to involve nursing staff from the start and to work closely with the unit’s nurse manager and charge nurse.

“Once we got their buy-in, we proposed what we wanted to do and asked for their suggestions,” Dr. Schumacher says.

Hospitalists partner with the nurse leaders to establish a morning bedside rounding process on the unit, using a “Physician Nurse Rounding Sheet” for each hospitalist. The sheet is prepared daily by the charge nurse and unit clerks, listing the hospitalist’s patients, assigned nurses, and phone numbers. A short debriefing is performed outside the patient’s room before each encounter, and a daily feedback sheet is given to the patient and family with a picture of the hospitalist, a list of all care-team members, and such information as goals for the day, pending tests and consultations, and anticipated discharge date.

“Part of the challenge is to create a process that is efficient for both doctors and nurses, given multiple nurses caring for multiple patients,” Dr. Schumacher says.

Charge nurses or nursing managers provide backup when the bedside nurse is not available for bedside rounding. “Right now we’re rounding with hospitalists and nurses only, but a long-term goal is to expand it to include the social worker and other ancillary professionals,” he says.

Preliminary data on the project show the feasibility of multidisciplinary rounding, with elevated Press Ganey patient satisfaction scores on the unit in the first two months after rounding began. In the third month, compliance with rounding went down, and so did satisfaction scores, but with a renewed commitment the following month, scores went back up again. Subjective reports from hospitalists also suggest fewer interruptions during the day from nursing pages, Dr. Schumacher says.

Aultidisciplinary patient rounding system implemented on a non-teaching hospitalist unit at the Ohio State University Medical Center (OSUMC) has been well received by unit staff, according to an HM11 abstract presentation. Key to its success, says lead author and OSUMC hospitalist Eric Schumacher, DO, MBA, was to involve nursing staff from the start and to work closely with the unit’s nurse manager and charge nurse.

“Once we got their buy-in, we proposed what we wanted to do and asked for their suggestions,” Dr. Schumacher says.

Hospitalists partner with the nurse leaders to establish a morning bedside rounding process on the unit, using a “Physician Nurse Rounding Sheet” for each hospitalist. The sheet is prepared daily by the charge nurse and unit clerks, listing the hospitalist’s patients, assigned nurses, and phone numbers. A short debriefing is performed outside the patient’s room before each encounter, and a daily feedback sheet is given to the patient and family with a picture of the hospitalist, a list of all care-team members, and such information as goals for the day, pending tests and consultations, and anticipated discharge date.

“Part of the challenge is to create a process that is efficient for both doctors and nurses, given multiple nurses caring for multiple patients,” Dr. Schumacher says.

Charge nurses or nursing managers provide backup when the bedside nurse is not available for bedside rounding. “Right now we’re rounding with hospitalists and nurses only, but a long-term goal is to expand it to include the social worker and other ancillary professionals,” he says.

Preliminary data on the project show the feasibility of multidisciplinary rounding, with elevated Press Ganey patient satisfaction scores on the unit in the first two months after rounding began. In the third month, compliance with rounding went down, and so did satisfaction scores, but with a renewed commitment the following month, scores went back up again. Subjective reports from hospitalists also suggest fewer interruptions during the day from nursing pages, Dr. Schumacher says.

The Center on Patient Safety at Florida State University College of Medicine in Tallahassee has been awarded a two-year, $908,000 grant from the federal Agency for Healthcare Research and Quality to study adverse events during the three weeks following hospital discharge, both for urban patients and, for the first time, those returning to rural settings.

Center director Dennis Tsilimingras, MD, MPH, says the project will enroll 600 patients, half urban and half rural, discharged by the Tallahassee Memorial Hospitalist Group, and track injuries resulting from medical errors, including medication errors, procedure-related injuries, nosocomial infections, and pressure ulcers.

Errors or injuries to patients may occur in the hospital but not be identified until after the patient goes home, he says, and such errors could contribute to rehospitalizations. “Our hypothesis is that the rate of adverse events post-discharge may be greater among rural patients because they have less access to follow-up care,” he adds.

Dr. Tsilimingras will be working closely with hospitalists, and Phase 2 of the research will use the hospital’s post-discharge transitional care clinic (see “Is a Post-Discharge Clinic in Your Hospital’s Future?,” December 2011) as an intervention strategy.

The eventual goal is to develop a screening tool to flag risk for post-discharge adverse events and develop strategies to reduce post-discharge problems, including readmissions, a quarter of which may be related to post-discharge adverse events, Dr. Tsilimingras says. He encourages hospitalists to reevaluate their patients and review their charts at the time of discharge, to see if post-discharge problems loom, and to reach out to primary care physicians by telephone, rather than just sending discharge summaries.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare [published online ahead of print Nov. 21, 2011. Clin Infect Dis. doi;10.1093/cid/cir773.
2. Fuller C, Savage J, Besser S, et al. “The dirty handin the latex glove”: a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol. 2011;32(12):1194-1199.

The Center on Patient Safety at Florida State University College of Medicine in Tallahassee has been awarded a two-year, $908,000 grant from the federal Agency for Healthcare Research and Quality to study adverse events during the three weeks following hospital discharge, both for urban patients and, for the first time, those returning to rural settings.

Center director Dennis Tsilimingras, MD, MPH, says the project will enroll 600 patients, half urban and half rural, discharged by the Tallahassee Memorial Hospitalist Group, and track injuries resulting from medical errors, including medication errors, procedure-related injuries, nosocomial infections, and pressure ulcers.

Errors or injuries to patients may occur in the hospital but not be identified until after the patient goes home, he says, and such errors could contribute to rehospitalizations. “Our hypothesis is that the rate of adverse events post-discharge may be greater among rural patients because they have less access to follow-up care,” he adds.

Dr. Tsilimingras will be working closely with hospitalists, and Phase 2 of the research will use the hospital’s post-discharge transitional care clinic (see “Is a Post-Discharge Clinic in Your Hospital’s Future?,” December 2011) as an intervention strategy.

The eventual goal is to develop a screening tool to flag risk for post-discharge adverse events and develop strategies to reduce post-discharge problems, including readmissions, a quarter of which may be related to post-discharge adverse events, Dr. Tsilimingras says. He encourages hospitalists to reevaluate their patients and review their charts at the time of discharge, to see if post-discharge problems loom, and to reach out to primary care physicians by telephone, rather than just sending discharge summaries.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare [published online ahead of print Nov. 21, 2011. Clin Infect Dis. doi;10.1093/cid/cir773.
2. Fuller C, Savage J, Besser S, et al. “The dirty handin the latex glove”: a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol. 2011;32(12):1194-1199.

The Center on Patient Safety at Florida State University College of Medicine in Tallahassee has been awarded a two-year, $908,000 grant from the federal Agency for Healthcare Research and Quality to study adverse events during the three weeks following hospital discharge, both for urban patients and, for the first time, those returning to rural settings.

Center director Dennis Tsilimingras, MD, MPH, says the project will enroll 600 patients, half urban and half rural, discharged by the Tallahassee Memorial Hospitalist Group, and track injuries resulting from medical errors, including medication errors, procedure-related injuries, nosocomial infections, and pressure ulcers.

Errors or injuries to patients may occur in the hospital but not be identified until after the patient goes home, he says, and such errors could contribute to rehospitalizations. “Our hypothesis is that the rate of adverse events post-discharge may be greater among rural patients because they have less access to follow-up care,” he adds.

Dr. Tsilimingras will be working closely with hospitalists, and Phase 2 of the research will use the hospital’s post-discharge transitional care clinic (see “Is a Post-Discharge Clinic in Your Hospital’s Future?,” December 2011) as an intervention strategy.

The eventual goal is to develop a screening tool to flag risk for post-discharge adverse events and develop strategies to reduce post-discharge problems, including readmissions, a quarter of which may be related to post-discharge adverse events, Dr. Tsilimingras says. He encourages hospitalists to reevaluate their patients and review their charts at the time of discharge, to see if post-discharge problems loom, and to reach out to primary care physicians by telephone, rather than just sending discharge summaries.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Armellino D, Hussain E, Schilling ME, et al. Using high-technology to enforce low-technology safety measures: the use of third-party remote video auditing and real-time feedback in healthcare [published online ahead of print Nov. 21, 2011. Clin Infect Dis. doi;10.1093/cid/cir773.
2. Fuller C, Savage J, Besser S, et al. “The dirty handin the latex glove”: a study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol. 2011;32(12):1194-1199.

Recent efforts to raise awareness about proper hand hygiene in health facilities in order to prevent disease transmission, range from the ScrubUp! campaign in Ohio to the World Health Organization’s global Clean Care is Safer Care campaign (www.who.int/gpsc/en/), which advocates for improving hand hygiene practices of health care workers around the world.

Twenty hospitals in Central Ohio staged ScrubUp! rallies on Dec. 5, 2011, during National Handwashing Awareness Week, not only to raise awareness of the hospitals’ commitment to hand hygiene, but also to encourage hospital visitors to wash their hands. The Ohio Hospital Association estimates that 50,000 people were exposed to these messages via a full-page ad in the Columbus Dispatch, overhead announcements and distribution tables in each hospital, handing out hand sanitizers to visitors, and engaging staff with humor, food, and prizes.

A recent study conducted at North Shore University Hospital in Manhasset, N.Y., found that hand hygiene compliance rates improve when remote video auditing platforms provide professionals with continuous feedback.¹ During 16 weeks of real-time feedback on compliance with strict hand hygiene (i.e. within 10 seconds of entering/leaving patients’ rooms) via LED screens mounted on the walls of a MICU, compliance jumped to more than 80%.

A British study of 7,000 contacts in ICUs and geriatric units found that wearing latex gloves may discourage guideline-recommended hand washing, even though such failures to wash may contribute to spreading disease.² Compliance was 47.7% without gloves, and 41% with gloves.

One of the study’s authors calls for further study of the behavioral reasons why healthcare workers are less likely to wash their hands when gloved, but urges that hand hygiene associated with gloving be part of educational campaigns.

Recent efforts to raise awareness about proper hand hygiene in health facilities in order to prevent disease transmission, range from the ScrubUp! campaign in Ohio to the World Health Organization’s global Clean Care is Safer Care campaign (www.who.int/gpsc/en/), which advocates for improving hand hygiene practices of health care workers around the world.

Twenty hospitals in Central Ohio staged ScrubUp! rallies on Dec. 5, 2011, during National Handwashing Awareness Week, not only to raise awareness of the hospitals’ commitment to hand hygiene, but also to encourage hospital visitors to wash their hands. The Ohio Hospital Association estimates that 50,000 people were exposed to these messages via a full-page ad in the Columbus Dispatch, overhead announcements and distribution tables in each hospital, handing out hand sanitizers to visitors, and engaging staff with humor, food, and prizes.

A recent study conducted at North Shore University Hospital in Manhasset, N.Y., found that hand hygiene compliance rates improve when remote video auditing platforms provide professionals with continuous feedback.¹ During 16 weeks of real-time feedback on compliance with strict hand hygiene (i.e. within 10 seconds of entering/leaving patients’ rooms) via LED screens mounted on the walls of a MICU, compliance jumped to more than 80%.

A British study of 7,000 contacts in ICUs and geriatric units found that wearing latex gloves may discourage guideline-recommended hand washing, even though such failures to wash may contribute to spreading disease.² Compliance was 47.7% without gloves, and 41% with gloves.

One of the study’s authors calls for further study of the behavioral reasons why healthcare workers are less likely to wash their hands when gloved, but urges that hand hygiene associated with gloving be part of educational campaigns.

Recent efforts to raise awareness about proper hand hygiene in health facilities in order to prevent disease transmission, range from the ScrubUp! campaign in Ohio to the World Health Organization’s global Clean Care is Safer Care campaign (www.who.int/gpsc/en/), which advocates for improving hand hygiene practices of health care workers around the world.

Twenty hospitals in Central Ohio staged ScrubUp! rallies on Dec. 5, 2011, during National Handwashing Awareness Week, not only to raise awareness of the hospitals’ commitment to hand hygiene, but also to encourage hospital visitors to wash their hands. The Ohio Hospital Association estimates that 50,000 people were exposed to these messages via a full-page ad in the Columbus Dispatch, overhead announcements and distribution tables in each hospital, handing out hand sanitizers to visitors, and engaging staff with humor, food, and prizes.

A recent study conducted at North Shore University Hospital in Manhasset, N.Y., found that hand hygiene compliance rates improve when remote video auditing platforms provide professionals with continuous feedback.¹ During 16 weeks of real-time feedback on compliance with strict hand hygiene (i.e. within 10 seconds of entering/leaving patients’ rooms) via LED screens mounted on the walls of a MICU, compliance jumped to more than 80%.

A British study of 7,000 contacts in ICUs and geriatric units found that wearing latex gloves may discourage guideline-recommended hand washing, even though such failures to wash may contribute to spreading disease.² Compliance was 47.7% without gloves, and 41% with gloves.

One of the study’s authors calls for further study of the behavioral reasons why healthcare workers are less likely to wash their hands when gloved, but urges that hand hygiene associated with gloving be part of educational campaigns.

Percentage of responding physicians who say they are using electronic health records (EHR), according to a survey of 10,000 office-based physicians by the National Center for Health Statistics, up from 51% usage in 2010. More than half say they intend to apply for meaningful use incentives offered by the government for implementing EHR, and 43% of those respondents report having computerized systems meeting Stage 1 Core Set criteria to qualify.

Percentage of responding physicians who say they are using electronic health records (EHR), according to a survey of 10,000 office-based physicians by the National Center for Health Statistics, up from 51% usage in 2010. More than half say they intend to apply for meaningful use incentives offered by the government for implementing EHR, and 43% of those respondents report having computerized systems meeting Stage 1 Core Set criteria to qualify.

Percentage of responding physicians who say they are using electronic health records (EHR), according to a survey of 10,000 office-based physicians by the National Center for Health Statistics, up from 51% usage in 2010. More than half say they intend to apply for meaningful use incentives offered by the government for implementing EHR, and 43% of those respondents report having computerized systems meeting Stage 1 Core Set criteria to qualify.

Piedmont Hospital in Atlanta is one of several hospitals participating in SHM’s care-transitions initiative Project BOOST (Better Outcomes for Older Adults through Safe Transitions) to be included in the first round of Community-Based Care Transitions Project (CCTP) awards.

Matthew Schreiber, MD, vice president and chief medical officer for Piedmont Hospital, says hospitalists should look for ways to participate in the community coalitions applying for CCTP awards, because managing their hospitals’ readmissions rates eventually will be essential to their job security.

“I said to my hospital, ‘Right now, people are giving out money for us to be in the figuring-it-out mode regarding readmissions,” Dr. Schreiber explains. “Eventually, we’ll just have to do it anyway.’”

CCTP is part of the government’s efforts (PDF) to reduce hospital readmissions by encouraging coalitions of health providers to collaborate on care transitions and ongoing care coordination after patients leave the hospital. The $500 million program initially dished out seven awards to community-based coalitions, not directly to hospitals. Most of these coalitions are housed at regional Agencies on Aging and involve multiple hospitals or health systems.

According to the Centers for Medicare & Medicaid Services (CMS), CCTP differs from a traditional grant program in that it pays community-based organizations an all-inclusive rate per eligible discharge, based on the cost of care transition services and of systemic changes at the hospital level.

The seven awardees also employ the Care Transitions Intervention program developed by Eric Coleman, MD, MPH, of the University of Colorado, co-chair of Project BOOST’s national advisory board. The intervention program is a recognized tool for improving care transitions and reducing preventable rehospitalizations through the use of social worker "transition coaches" to provide discharged patients with self-care education and encouragement.

Other BOOST site hospitals participating in CCTP-awarded coalitions include Northwestern Memorial in Chicago and Emory University Hospital Midtown in Atlanta.

Dr. Schreiber says being a Project BOOST site and using Dr. Coleman's Care Transitions Intervention should be complementary for any hospital striving to reduce readmissions. “Both together were greater than the sum of their parts,” he says, adding that Piedmont has reduced its readmission rate by 50%.

Summaries of the first seven sites and information on how to apply for ongoing CCTP grants can be found here.

Piedmont Hospital in Atlanta is one of several hospitals participating in SHM’s care-transitions initiative Project BOOST (Better Outcomes for Older Adults through Safe Transitions) to be included in the first round of Community-Based Care Transitions Project (CCTP) awards.

Matthew Schreiber, MD, vice president and chief medical officer for Piedmont Hospital, says hospitalists should look for ways to participate in the community coalitions applying for CCTP awards, because managing their hospitals’ readmissions rates eventually will be essential to their job security.

“I said to my hospital, ‘Right now, people are giving out money for us to be in the figuring-it-out mode regarding readmissions,” Dr. Schreiber explains. “Eventually, we’ll just have to do it anyway.’”

CCTP is part of the government’s efforts (PDF) to reduce hospital readmissions by encouraging coalitions of health providers to collaborate on care transitions and ongoing care coordination after patients leave the hospital. The $500 million program initially dished out seven awards to community-based coalitions, not directly to hospitals. Most of these coalitions are housed at regional Agencies on Aging and involve multiple hospitals or health systems.

According to the Centers for Medicare & Medicaid Services (CMS), CCTP differs from a traditional grant program in that it pays community-based organizations an all-inclusive rate per eligible discharge, based on the cost of care transition services and of systemic changes at the hospital level.

The seven awardees also employ the Care Transitions Intervention program developed by Eric Coleman, MD, MPH, of the University of Colorado, co-chair of Project BOOST’s national advisory board. The intervention program is a recognized tool for improving care transitions and reducing preventable rehospitalizations through the use of social worker "transition coaches" to provide discharged patients with self-care education and encouragement.

Other BOOST site hospitals participating in CCTP-awarded coalitions include Northwestern Memorial in Chicago and Emory University Hospital Midtown in Atlanta.

Dr. Schreiber says being a Project BOOST site and using Dr. Coleman's Care Transitions Intervention should be complementary for any hospital striving to reduce readmissions. “Both together were greater than the sum of their parts,” he says, adding that Piedmont has reduced its readmission rate by 50%.

Summaries of the first seven sites and information on how to apply for ongoing CCTP grants can be found here.

Piedmont Hospital in Atlanta is one of several hospitals participating in SHM’s care-transitions initiative Project BOOST (Better Outcomes for Older Adults through Safe Transitions) to be included in the first round of Community-Based Care Transitions Project (CCTP) awards.

Matthew Schreiber, MD, vice president and chief medical officer for Piedmont Hospital, says hospitalists should look for ways to participate in the community coalitions applying for CCTP awards, because managing their hospitals’ readmissions rates eventually will be essential to their job security.

“I said to my hospital, ‘Right now, people are giving out money for us to be in the figuring-it-out mode regarding readmissions,” Dr. Schreiber explains. “Eventually, we’ll just have to do it anyway.’”

CCTP is part of the government’s efforts (PDF) to reduce hospital readmissions by encouraging coalitions of health providers to collaborate on care transitions and ongoing care coordination after patients leave the hospital. The $500 million program initially dished out seven awards to community-based coalitions, not directly to hospitals. Most of these coalitions are housed at regional Agencies on Aging and involve multiple hospitals or health systems.

According to the Centers for Medicare & Medicaid Services (CMS), CCTP differs from a traditional grant program in that it pays community-based organizations an all-inclusive rate per eligible discharge, based on the cost of care transition services and of systemic changes at the hospital level.

The seven awardees also employ the Care Transitions Intervention program developed by Eric Coleman, MD, MPH, of the University of Colorado, co-chair of Project BOOST’s national advisory board. The intervention program is a recognized tool for improving care transitions and reducing preventable rehospitalizations through the use of social worker "transition coaches" to provide discharged patients with self-care education and encouragement.

Other BOOST site hospitals participating in CCTP-awarded coalitions include Northwestern Memorial in Chicago and Emory University Hospital Midtown in Atlanta.

Dr. Schreiber says being a Project BOOST site and using Dr. Coleman's Care Transitions Intervention should be complementary for any hospital striving to reduce readmissions. “Both together were greater than the sum of their parts,” he says, adding that Piedmont has reduced its readmission rate by 50%.

Summaries of the first seven sites and information on how to apply for ongoing CCTP grants can be found here.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

A recent study of care transitions for nursing home residents with advanced cognitive impairments (N Engl J Med. 2011; 365:1212-1221) finds that transitions into the hospital can be burdensome, with such negative outcomes as medical errors and hospital-acquired infections, but have limited clinical benefit for some patients, such as those with dementia and other impairments. One in 5 nursing home residents had at least one burdensome transition in the last 90 days of life, researchers found, and some experienced repeated hospitalizations.

Hospitals may not be able to prevent nursing home residents who are nearing the end of life from turning up in their EDs, says study coauthor Joan Teno, MD, from Brown University in Providence, R.I. But physicians and other members of the care team might help to stave off repeat visits by engaging in frank discussions with the patient (and/or patients’ family) about the course of a disease and goals of care. A referral to hospice or for a palliative-care consultation might be appropriate, or the patient could be sent back to long-term care with a “do not rehospitalize” order. In some cases, she adds, these conversations happen in the ED without an admission, and are facilitated by a palliative-care team.

“We have this assumption that hospitalization is a good thing. But hospitals can be dangerous places for some elderly patients,” Dr. Teno says.

A more proactive response could be to identify the nursing homes that transfer the majority of cognitively impaired patients and meet with them to talk about appropriate transfers, how to treat such conditions as pneumonia in place, and the use of advance directives and POLST (physician orders for life-sustaining treatment: www.ohsu.edu/polst/).

A recent study of care transitions for nursing home residents with advanced cognitive impairments (N Engl J Med. 2011; 365:1212-1221) finds that transitions into the hospital can be burdensome, with such negative outcomes as medical errors and hospital-acquired infections, but have limited clinical benefit for some patients, such as those with dementia and other impairments. One in 5 nursing home residents had at least one burdensome transition in the last 90 days of life, researchers found, and some experienced repeated hospitalizations.

Hospitals may not be able to prevent nursing home residents who are nearing the end of life from turning up in their EDs, says study coauthor Joan Teno, MD, from Brown University in Providence, R.I. But physicians and other members of the care team might help to stave off repeat visits by engaging in frank discussions with the patient (and/or patients’ family) about the course of a disease and goals of care. A referral to hospice or for a palliative-care consultation might be appropriate, or the patient could be sent back to long-term care with a “do not rehospitalize” order. In some cases, she adds, these conversations happen in the ED without an admission, and are facilitated by a palliative-care team.

“We have this assumption that hospitalization is a good thing. But hospitals can be dangerous places for some elderly patients,” Dr. Teno says.

A more proactive response could be to identify the nursing homes that transfer the majority of cognitively impaired patients and meet with them to talk about appropriate transfers, how to treat such conditions as pneumonia in place, and the use of advance directives and POLST (physician orders for life-sustaining treatment: www.ohsu.edu/polst/).

A recent study of care transitions for nursing home residents with advanced cognitive impairments (N Engl J Med. 2011; 365:1212-1221) finds that transitions into the hospital can be burdensome, with such negative outcomes as medical errors and hospital-acquired infections, but have limited clinical benefit for some patients, such as those with dementia and other impairments. One in 5 nursing home residents had at least one burdensome transition in the last 90 days of life, researchers found, and some experienced repeated hospitalizations.

Hospitals may not be able to prevent nursing home residents who are nearing the end of life from turning up in their EDs, says study coauthor Joan Teno, MD, from Brown University in Providence, R.I. But physicians and other members of the care team might help to stave off repeat visits by engaging in frank discussions with the patient (and/or patients’ family) about the course of a disease and goals of care. A referral to hospice or for a palliative-care consultation might be appropriate, or the patient could be sent back to long-term care with a “do not rehospitalize” order. In some cases, she adds, these conversations happen in the ED without an admission, and are facilitated by a palliative-care team.

“We have this assumption that hospitalization is a good thing. But hospitals can be dangerous places for some elderly patients,” Dr. Teno says.

A more proactive response could be to identify the nursing homes that transfer the majority of cognitively impaired patients and meet with them to talk about appropriate transfers, how to treat such conditions as pneumonia in place, and the use of advance directives and POLST (physician orders for life-sustaining treatment: www.ohsu.edu/polst/).