Larry Beresford

Peter Pronovost, MD, PhD, an intensivist and patient-safety researcher at Johns Hopkins University School of Medicine in Baltimore, has been widely profiled as the “checklist doctor” for his celebrated five-step checklist to reduce the incidence of central-line infections. But he objects to the label.

Just handing doctors and nurses a piece of paper is not likely to improve patient safety without two other essential steps: “We must also measure the results and give clinicians feedback, and we must change the culture so that they work collaboratively together,” he explains.

Dr. Pronovost shares his personal story as a safety expert who borrowed from aviation in developing his first checklist in 2001 in a Johns Hopkins surgical ICU in his new book, Safe Patients, Smart Hospitals, co-authored with Eric Vohr (New York: Hudson Street Press, 2010).

Dr. Pronovost says he still encounters resistance to the checklist in many U.S. hospitals. “Nobody debates that we should be doing the things on the checklist,” he says. “The evidence is strong. The barrier is culture or medical hierarchy. In what other industry would there be an accepted standard that failure to comply with it kills, in this case, 30,000 people per year, and yet we’re not comfortable having one worker question another about compliance with it?”

Hospitalists have a huge role in hospital quality and safety, he adds.

“I envision that they could take almost any practice guideline that’s out there and convert it into a checklist,” he says, emphasizing that hospitalists should appoint an interdisciplinary team to work on the project and make the checklists specific to one time and place. It also is important for hospitals to support hospitalists with dedicated time to work on such projects. “But in return, the hospitalists have to commit measuring safety performance and producing positive results,” he says.

Peter Pronovost, MD, PhD, an intensivist and patient-safety researcher at Johns Hopkins University School of Medicine in Baltimore, has been widely profiled as the “checklist doctor” for his celebrated five-step checklist to reduce the incidence of central-line infections. But he objects to the label.

Just handing doctors and nurses a piece of paper is not likely to improve patient safety without two other essential steps: “We must also measure the results and give clinicians feedback, and we must change the culture so that they work collaboratively together,” he explains.

Dr. Pronovost shares his personal story as a safety expert who borrowed from aviation in developing his first checklist in 2001 in a Johns Hopkins surgical ICU in his new book, Safe Patients, Smart Hospitals, co-authored with Eric Vohr (New York: Hudson Street Press, 2010).

Dr. Pronovost says he still encounters resistance to the checklist in many U.S. hospitals. “Nobody debates that we should be doing the things on the checklist,” he says. “The evidence is strong. The barrier is culture or medical hierarchy. In what other industry would there be an accepted standard that failure to comply with it kills, in this case, 30,000 people per year, and yet we’re not comfortable having one worker question another about compliance with it?”

Hospitalists have a huge role in hospital quality and safety, he adds.

“I envision that they could take almost any practice guideline that’s out there and convert it into a checklist,” he says, emphasizing that hospitalists should appoint an interdisciplinary team to work on the project and make the checklists specific to one time and place. It also is important for hospitals to support hospitalists with dedicated time to work on such projects. “But in return, the hospitalists have to commit measuring safety performance and producing positive results,” he says.

Peter Pronovost, MD, PhD, an intensivist and patient-safety researcher at Johns Hopkins University School of Medicine in Baltimore, has been widely profiled as the “checklist doctor” for his celebrated five-step checklist to reduce the incidence of central-line infections. But he objects to the label.

Just handing doctors and nurses a piece of paper is not likely to improve patient safety without two other essential steps: “We must also measure the results and give clinicians feedback, and we must change the culture so that they work collaboratively together,” he explains.

Dr. Pronovost shares his personal story as a safety expert who borrowed from aviation in developing his first checklist in 2001 in a Johns Hopkins surgical ICU in his new book, Safe Patients, Smart Hospitals, co-authored with Eric Vohr (New York: Hudson Street Press, 2010).

Dr. Pronovost says he still encounters resistance to the checklist in many U.S. hospitals. “Nobody debates that we should be doing the things on the checklist,” he says. “The evidence is strong. The barrier is culture or medical hierarchy. In what other industry would there be an accepted standard that failure to comply with it kills, in this case, 30,000 people per year, and yet we’re not comfortable having one worker question another about compliance with it?”

Hospitalists have a huge role in hospital quality and safety, he adds.

“I envision that they could take almost any practice guideline that’s out there and convert it into a checklist,” he says, emphasizing that hospitalists should appoint an interdisciplinary team to work on the project and make the checklists specific to one time and place. It also is important for hospitals to support hospitalists with dedicated time to work on such projects. “But in return, the hospitalists have to commit measuring safety performance and producing positive results,” he says.

When and how the national focus on reducing hospital readmissions will hit hospitals’ bottom lines is not clear, but it’s more a matter of when, not if, says Eric Coleman, MD, MPH, AGSF, FACP, director of the Care Transitions Program at the University of Colorado Denver.

Reducing readmissions “jumps off the page as an area where we could see enormous savings in national health expenditures,” Dr. Coleman told participants in an SHM webinar last month. The challenge, he said, is to align incentives with quality and safety for a moving target that also happens to be highly politicized. “We’re generally pretty good at identifying who’s at risk of readmission, but it’s harder to say who’s at modifiable risk,” he explained.

Evidence shows that hospitalists already reduce costs through improved length of stay. “Can hospitalists demonstrate the ability to reduce readmission rates as well?” Dr. Coleman asked.

Bundling payment for hospital stays with various post-hospital providers is a major focus of national efforts to reduce healthcare costs. Bundling gives providers on the healthcare continuum strong motivation to work together, Dr. Coleman said. The government won’t tell providers how to divide bundled payments, but Dr. Coleman predicts that consulting firms offering ideas for divvying up the money will emerge.

The Medicare Payment Advisory Commission (MEDPAC) has signaled its interest in changing payment incentives by reducing reimbursement for readmissions as well as several provisions that directly address readmissions in the healthcare reform package signed by President Obama in March. These include:

- A national pilot program on payment bundling;

- A hospital readmissions reduction program with financial penalties starting in October 2012 for select conditions; and

- A QI program to help hospitals with high severity-adjusted readmission rates.

When and how the national focus on reducing hospital readmissions will hit hospitals’ bottom lines is not clear, but it’s more a matter of when, not if, says Eric Coleman, MD, MPH, AGSF, FACP, director of the Care Transitions Program at the University of Colorado Denver.

Reducing readmissions “jumps off the page as an area where we could see enormous savings in national health expenditures,” Dr. Coleman told participants in an SHM webinar last month. The challenge, he said, is to align incentives with quality and safety for a moving target that also happens to be highly politicized. “We’re generally pretty good at identifying who’s at risk of readmission, but it’s harder to say who’s at modifiable risk,” he explained.

Evidence shows that hospitalists already reduce costs through improved length of stay. “Can hospitalists demonstrate the ability to reduce readmission rates as well?” Dr. Coleman asked.

Bundling payment for hospital stays with various post-hospital providers is a major focus of national efforts to reduce healthcare costs. Bundling gives providers on the healthcare continuum strong motivation to work together, Dr. Coleman said. The government won’t tell providers how to divide bundled payments, but Dr. Coleman predicts that consulting firms offering ideas for divvying up the money will emerge.

The Medicare Payment Advisory Commission (MEDPAC) has signaled its interest in changing payment incentives by reducing reimbursement for readmissions as well as several provisions that directly address readmissions in the healthcare reform package signed by President Obama in March. These include:

- A national pilot program on payment bundling;

- A hospital readmissions reduction program with financial penalties starting in October 2012 for select conditions; and

- A QI program to help hospitals with high severity-adjusted readmission rates.

When and how the national focus on reducing hospital readmissions will hit hospitals’ bottom lines is not clear, but it’s more a matter of when, not if, says Eric Coleman, MD, MPH, AGSF, FACP, director of the Care Transitions Program at the University of Colorado Denver.

Reducing readmissions “jumps off the page as an area where we could see enormous savings in national health expenditures,” Dr. Coleman told participants in an SHM webinar last month. The challenge, he said, is to align incentives with quality and safety for a moving target that also happens to be highly politicized. “We’re generally pretty good at identifying who’s at risk of readmission, but it’s harder to say who’s at modifiable risk,” he explained.

Evidence shows that hospitalists already reduce costs through improved length of stay. “Can hospitalists demonstrate the ability to reduce readmission rates as well?” Dr. Coleman asked.

Bundling payment for hospital stays with various post-hospital providers is a major focus of national efforts to reduce healthcare costs. Bundling gives providers on the healthcare continuum strong motivation to work together, Dr. Coleman said. The government won’t tell providers how to divide bundled payments, but Dr. Coleman predicts that consulting firms offering ideas for divvying up the money will emerge.

The Medicare Payment Advisory Commission (MEDPAC) has signaled its interest in changing payment incentives by reducing reimbursement for readmissions as well as several provisions that directly address readmissions in the healthcare reform package signed by President Obama in March. These include:

- A national pilot program on payment bundling;

- A hospital readmissions reduction program with financial penalties starting in October 2012 for select conditions; and

- A QI program to help hospitals with high severity-adjusted readmission rates.

Research reported in the Archives of Neurology (2010;67(1):39-44) found that stroke patients admitted to hospitals over the weekend are more likely than those who arrive on weekdays to receive the FDA-approved clot-busting therapy intravenous tissue plasminogen activator (tPA).

Abby S. Kazley, PhD, assistant professor of health policy administration, and colleagues at Medical University of South Carolina in Charleston studied nearly 80,000 stroke patients admitted to Virginia hospitals from 1998 to 2006. The researchers found that those arriving on weekends were 20% more likely to receive tPA treatment, which has been shown to reverse the effects of ischemic stroke if given within a time-sensitive window of therapeutic opportunity. However, there was no statistically significant difference in death rates between the two groups.

University of Colorado Denver hospitalist Ethan Cumbler, MD (see “Spotlight on Stroke,” The Hospitalist, December 2009, p. 1), says the outcome was counter-intuitive, given prior research documenting limits in weekend hospital care, although lack of competition from elective hospital procedures and reduced road traffic on weekends might have contributed to the result. Stroke treatment benefits from well-designed systems of care that are able to respond quickly to emergent strokes, "especially in Joint Commission-certified primary stroke centers, which are mandated to provide rapid evaluation and response 24 hours a day." Dr. Cumbler notes, however, that in both groups, stroke patients received the critical treatment only about 1% of the time.

"It's hard to know what to make of this study," adds University of California at San Francisco neurohospitalist J. Andrew Josephson, MD. "We know we deliver different care on nights and weekends; in this case not better or worse—just different.”

Research reported in the Archives of Neurology (2010;67(1):39-44) found that stroke patients admitted to hospitals over the weekend are more likely than those who arrive on weekdays to receive the FDA-approved clot-busting therapy intravenous tissue plasminogen activator (tPA).

Abby S. Kazley, PhD, assistant professor of health policy administration, and colleagues at Medical University of South Carolina in Charleston studied nearly 80,000 stroke patients admitted to Virginia hospitals from 1998 to 2006. The researchers found that those arriving on weekends were 20% more likely to receive tPA treatment, which has been shown to reverse the effects of ischemic stroke if given within a time-sensitive window of therapeutic opportunity. However, there was no statistically significant difference in death rates between the two groups.

University of Colorado Denver hospitalist Ethan Cumbler, MD (see “Spotlight on Stroke,” The Hospitalist, December 2009, p. 1), says the outcome was counter-intuitive, given prior research documenting limits in weekend hospital care, although lack of competition from elective hospital procedures and reduced road traffic on weekends might have contributed to the result. Stroke treatment benefits from well-designed systems of care that are able to respond quickly to emergent strokes, "especially in Joint Commission-certified primary stroke centers, which are mandated to provide rapid evaluation and response 24 hours a day." Dr. Cumbler notes, however, that in both groups, stroke patients received the critical treatment only about 1% of the time.

"It's hard to know what to make of this study," adds University of California at San Francisco neurohospitalist J. Andrew Josephson, MD. "We know we deliver different care on nights and weekends; in this case not better or worse—just different.”

Research reported in the Archives of Neurology (2010;67(1):39-44) found that stroke patients admitted to hospitals over the weekend are more likely than those who arrive on weekdays to receive the FDA-approved clot-busting therapy intravenous tissue plasminogen activator (tPA).

Abby S. Kazley, PhD, assistant professor of health policy administration, and colleagues at Medical University of South Carolina in Charleston studied nearly 80,000 stroke patients admitted to Virginia hospitals from 1998 to 2006. The researchers found that those arriving on weekends were 20% more likely to receive tPA treatment, which has been shown to reverse the effects of ischemic stroke if given within a time-sensitive window of therapeutic opportunity. However, there was no statistically significant difference in death rates between the two groups.

University of Colorado Denver hospitalist Ethan Cumbler, MD (see “Spotlight on Stroke,” The Hospitalist, December 2009, p. 1), says the outcome was counter-intuitive, given prior research documenting limits in weekend hospital care, although lack of competition from elective hospital procedures and reduced road traffic on weekends might have contributed to the result. Stroke treatment benefits from well-designed systems of care that are able to respond quickly to emergent strokes, "especially in Joint Commission-certified primary stroke centers, which are mandated to provide rapid evaluation and response 24 hours a day." Dr. Cumbler notes, however, that in both groups, stroke patients received the critical treatment only about 1% of the time.

"It's hard to know what to make of this study," adds University of California at San Francisco neurohospitalist J. Andrew Josephson, MD. "We know we deliver different care on nights and weekends; in this case not better or worse—just different.”

A recent article in the New England Journal of Medicine (2009;361:2637-2645) questions whether improved planning for hospital discharges decreases readmission rates.

Ashish Jha, MD, MPH, of the Harvard School of Public Health and colleagues examined two publicly reported discharge-planning quality measures from the Centers for Medicare and Medicaid Services’ (CMS) Hospital Quality Alliance. The measures focus on documentation that discharge instructions were provided to patients with congestive heart failure and patients’ self-reported experience with discharge planning.

The researchers found no correlation with rates of readmission for congestive heart failure and pneumonia, and only weak correlation between the two quality measures. Based on their findings, the team concluded that public reporting of quality-related discharge-planning measures is unlikely to yield significant reductions in rehospitalization rates.

A number of national initiatives, including SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), are focused on improving hospital discharge planning processes and care transitions, which are significant themes in the national health reform debate.

But the NEJM results should not be surprising, says Arpana Vidyarthi, MD, hospitalist and director of quality at the University of California at San Francisco. “Discharge planning is not a five-minute thing you do on the day of discharge. Improving the discharge process actually starts on the day of hospital admission. It is a complex problem and it needs multifaceted, evidence-based solutions,” including process evaluations by hospital teams and the application of supporting communications technology.

A recent article in the New England Journal of Medicine (2009;361:2637-2645) questions whether improved planning for hospital discharges decreases readmission rates.

Ashish Jha, MD, MPH, of the Harvard School of Public Health and colleagues examined two publicly reported discharge-planning quality measures from the Centers for Medicare and Medicaid Services’ (CMS) Hospital Quality Alliance. The measures focus on documentation that discharge instructions were provided to patients with congestive heart failure and patients’ self-reported experience with discharge planning.

The researchers found no correlation with rates of readmission for congestive heart failure and pneumonia, and only weak correlation between the two quality measures. Based on their findings, the team concluded that public reporting of quality-related discharge-planning measures is unlikely to yield significant reductions in rehospitalization rates.

A number of national initiatives, including SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), are focused on improving hospital discharge planning processes and care transitions, which are significant themes in the national health reform debate.

But the NEJM results should not be surprising, says Arpana Vidyarthi, MD, hospitalist and director of quality at the University of California at San Francisco. “Discharge planning is not a five-minute thing you do on the day of discharge. Improving the discharge process actually starts on the day of hospital admission. It is a complex problem and it needs multifaceted, evidence-based solutions,” including process evaluations by hospital teams and the application of supporting communications technology.

A recent article in the New England Journal of Medicine (2009;361:2637-2645) questions whether improved planning for hospital discharges decreases readmission rates.

Ashish Jha, MD, MPH, of the Harvard School of Public Health and colleagues examined two publicly reported discharge-planning quality measures from the Centers for Medicare and Medicaid Services’ (CMS) Hospital Quality Alliance. The measures focus on documentation that discharge instructions were provided to patients with congestive heart failure and patients’ self-reported experience with discharge planning.

The researchers found no correlation with rates of readmission for congestive heart failure and pneumonia, and only weak correlation between the two quality measures. Based on their findings, the team concluded that public reporting of quality-related discharge-planning measures is unlikely to yield significant reductions in rehospitalization rates.

A number of national initiatives, including SHM’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), are focused on improving hospital discharge planning processes and care transitions, which are significant themes in the national health reform debate.

But the NEJM results should not be surprising, says Arpana Vidyarthi, MD, hospitalist and director of quality at the University of California at San Francisco. “Discharge planning is not a five-minute thing you do on the day of discharge. Improving the discharge process actually starts on the day of hospital admission. It is a complex problem and it needs multifaceted, evidence-based solutions,” including process evaluations by hospital teams and the application of supporting communications technology.

Ethan Cumbler, MD, is board-certified in internal medicine and pediatrics, and has practiced hospital medicine for six years, first at a community hospital and now at the University of Colorado Denver (UCD), where he directs the Acute Care for the Elderly service. The prevalence of stroke in his practice and the daily challenges of managing stroke patients led Dr. Cumbler to seek additional training in stroke care. He is the hospitalist representative to the UCD stroke council, a researcher in the arena of acute stroke care, and is helping UCD become a Joint Commission-certified stroke center.

“There are a variety of roles for the hospitalist in stroke care,” Dr. Cumbler says, explaining that HM physicians can be admitting attendings for stroke patients or part of acute stroke teams, and participate in decisions to start such treatments as intravenous recombinant tissue plasminogen activator (t-PA), the Food and Drug Administration-approved clot-busting therapy. “[Hospitalists] can be medical consultants on stroke patients admitted to other hospital services, managing common comorbid conditions such as blood pressure and glucose levels, which have particular character for patients immediately post-stroke.”

Stroke is the third-leading cause of death in the U.S., as well as a leading cause of serious, long-term disability. How many stroke patients are seen by hospitalists is not known, but it is reasonable to assume that a majority of hospitalized stroke patients will encounter a hospitalist, if not for acute treatment, then for ongoing medical management.

Some hospitalists think stroke and transient ischemic attacks (TIAs)—temporary neurological deficits sometimes called “mini-strokes,” and a major risk factor for full-blown strokes—are among the most common diseases seen by hospitalists.1 Acute stroke care is a growing part of HM practice because neurologist availability in emergent situations varies widely between hospitals. The rapid evolution of stroke treatment and the time-sensitive needs of stroke patients represents a huge opportunity for hospitalists to fill that void for their hospitals—whether they want to or not.

“I think hospitalists are fully capable of learning and mastering stroke care, but it requires both interest and training,” Dr. Cumbler says.

HM Can Help Fill a Void

According to the American Heart Association (AHA), there are four neurologists per 100,000 Americans, and not all of those neurologists specialize in stroke care.2 The scarcity of neurological specialists means that in many hospitals, a neurologist won’t be available for the critical assessment and treatment decisions required in the first few hours after a stroke is diagnosed. Yet many hospitalists complain that their preparation during internal-medicine residency did not equip them to care for acute stroke patients.3

S. Andrew Josephson, MD, a neurovascular physician and director of the neurohospitalist program at the University of California at San Francisco Medical Center, says the number of hospitalists on the front lines of acute stroke care is growing every day. “A new stroke is a very treatable neurological emergency that requires ultra-fast intervention,”7 Dr. Josephson says, “and hospitalists, increasingly, are the people who matter most in that intervention.” The reason, in most cases, is hospitalists are available at all times, and neurologists aren’t.

Given variable access to neurologists at the time of urgent need in many hospitals, the actions hospitalists can take in acute stroke management include:

• Become better trained in stroke care. Sessions on stroke management are included in numerous HM educational programs, including SHM conferences and in continuing medical education (CME) offerings from such groups as the American Academy of Neurology (see “Stroke Training, Resources, and Opportunities,” p. 30).
• Partner with neurologists in your hospital. One trend is to develop a neurohospitalist practice.
• Push for increased organization and response times for stroke patients. Given HM’s focus on quality and patient safety, hospitalists are natural champions for improving systems of care for stroke. Hospitalists can work with neurologists, radiologists, pharmacists, and other providers to develop stroke treatment protocols and rapid response capabilities.
• Help develop a stroke team, and seek certification as a primary stroke center. The Joint Commission certifies stroke centers (www.jointcommission.org/CertificationPrograms/PrimaryStroke Centers) based on demonstrated compliance with disease-based standards, effective use of clinical practice guidelines, and performance-improvement activities.
• Establish a collaborative relationship with a regional stroke center or tertiary hospital. This could manifest as a telemedicine link to aid in stroke assessment and treatment decisions (see “Rural Response: The ‘Drip and Ship’ Method,” p. 28).
• Refine approaches to more rapidly identify and work up patients who experience a stroke while they are in the hospital.

Hospitalists are going to continue to be out front on stroke management.

—S. Andrew Josephson, MD, director, neurohospitalist program, University of California at San Francisco Medical Center

Streamline In-Hospital Stroke Response

From 6.5% to 15% of stroke patients experience their stroke while they are in the hospital.4 “Hospitals are not always geared up to deal with neurological emergencies, and yet these patients are firmly within our domain,” Dr. Cumbler says. “We found that it took three times longer in our hospital to complete the evaluation when the stroke happened in the hospital than for strokes presenting in the emergency department.”

Through a hospitalwide quality-improvement (QI) project, UCD’s in-hospital stroke response time was reduced to 37 minutes from 70 minutes.

A comprehensive approach to stroke QI should include training first witnesses in the hospital (e.g., nurses, physical therapists, and housekeepers) to recognize potential stroke symptoms; creating a rapid response capability from personnel who understand how to evaluate and treat suspected stroke and are able to respond quickly; and making suspected stroke a top priority in the radiology lab.

Stroke patient management processes need to be improved and provider roles better defined. Hospitalists can help on the frontlines, and should advocate for quality and patient safety measures.

“Stroke has so many facets: the need to reduce risk, to educate the public about the need for prompt response, the appropriate evaluation of risks and benefits of treatment,” Dr. Cumbler says. “How do you achieve a system in the hospital where patients are fully able to realize benefits of all these advances? I think there’s something in stroke treatment for every hospitalist and, for those with a particular interest, opportunities to play leadership roles.”

New Era in Stroke Care

Many compare the evolution of stroke care to that of more common conditions, and hospitalists have a buffet of new and improved treatments and technologies at their disposal. “This is an interesting time in the treatment of stroke,” Dr. Cumbler says. “We are at the cusp of a new era. Previously, stroke was one of the classic neurologic issues in hospital medicine, but we did not have much to offer. Now, as with heart attack, we have a growing array of urgent and effective treatment options, and new imaging techniques to determine whether to treat and with what type of treatment.”

New and emerging treatment approaches include:

• Induced hypothermia, to protect the brain;
• Enhanced thrombolytics by ultrasound;
• Perfusion-based treatment time windows;
• Recanalization;
• Extended cardiac telemetry targeting atrial fibrillation;
• Neuroprotective agents; and
• Pressor usage to raise blood pressure in the post-stroke patient.

Interventional strategies seek to combine intravenous t-PA with localized techniques to open occluded vessels. While these are cutting-edge and not yet integrated into medical routine, “they illustrate why stroke management is so exciting right now,” Dr. Cumbler says.

As stroke treatment becomes more standardized, hospitals will expect HM physicians to be thoroughly versed in optimal stroke care, says David Yu, MD, MBA, FACP, medical director of hospitalist services at Decatur Memorial Hospital in Illinois and a member of Team Hospitalist. “There will be a shift in hospital medicine, with the practice of neurology becoming more open to non-neurologists,” he says. “As opportunities for stroke treatment increase, more responsibility will fall on hospitalists. It is part of the evolution of our field.”

That evolution is reflected in Medicare’s decision in 2005 to begin paying hospitals a higher diagnostic-related grouping (DRG) rate for administering intravenous t-PA.5 DRG 559 pays a hospital about $6,000 more, regionally adjusted, for stroke treatment that includes intravenous t-PA, compared with stroke care without it. That differential creates incentives for the hospital to invest in infrastructure, staffing, and training.

The Neurohospitalist

Recent journal articles have explored the emergence of neurohospitalists—hybrid physicians who are loosely defined as neurologists whose primary focus is the care of hospitalized patients. The neurohospitalist trend is spurred by the same time and fiscal constraints that drove the HM movement, says William Freeman, MD, neurologist at the Mayo Clinic in Jacksonville, Fla., and coauthor of one of those articles.6

Office-based neurologists increasingly are unavailable to respond to neurological emergencies in the hospital. Depending on the size of the hospital and its need for specialist access, an organized neurohospitalist group covering a schedule in the hospital could make significant contributions to quality of care, length of stay, and other stroke outcomes, Dr. Freeman says. “This field is starting to gel and crystallize, as more neurologists find themselves focusing their practice on site of care,” he notes.

Although not all experts agree, Dr. Freeman says that general hospitalists could become neurohospitalists, and vice versa. Neurologists could learn more internal medicine, and the two groups could work together more closely, he says.

Dr. Josephson of the University of California at San Francisco Medical Center reserves the term “neurohospitalist” for neurologists, but adds that medical hospitalists can manage neurologic disorders. He also sees potential for joint research on the management of hospitalized neurologic patients.

Drs. Freeman and Josephson have led discussions of the neurohospitalist model, both within AAN and in a recent conference call with SHM representatives. Data are limited on the numbers of physicians practicing this specialty, but job postings are growing and a neurohospitalist listserv sponsored by AAN grew to 250 members from 50 within six months. The University of California at San Francisco Medical Center established the first neurohospitalist fellowship in 2008, and a neurohospitalist journal is in development. “Most stroke patients are not seen by neurologists. I keep saying that at stroke conventions,” Dr. Josephson explains. “Hospitalists are going to continue to be out front on stroke management. Some will have a neurologist available. More likely, the hospitalist and neurologist will be participating in acute stroke management as part of some system of care with the emergency department or critical care.” TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Glasheen J, Cumbler E, Tailoring internal medicine training to improve hospitalist outcomes. Arch Intern Med. 2009;169:204-205.
2. Telemedicine helps experts treat stroke from afar. National Stroke Association Web site. Available at: http://www.stroke.org/site/News2?page=NewsArticle&id=8208&news_iv_ctrl=1221. Accessed Nov. 4, 2009.
3. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3)247-254.
4. Blacker DJ. In-hospital stroke. Lancet Neurol. 2003;2(12):741-746.
5. Demaerschalk BM, Durocher DL. How diagnosis-related group 559 will change the US Medicare cost reimbursement ratio for stroke centers. Stroke. 2007;38:1309-1312.
6. Freeman WD, Gronseth G, Eidelman BH. Is it time for neurohospitalists? Neurology. 2009;72:476-477.
7. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329.
8. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40(8):2945-2948.
9. Lyden P. Thrombolytic therapy for acute stroke—not a moment to lose. N Engl J Med. 2008;359:1393-1397.
10. Doheny K. Few stroke patients get clot-busting drug. Business Week Web site. Available at: http://www.businessweek.com/lifestyle/content/healthday/624280.html. Accessed Sept. 23, 2009.
11. Sacco RL, Diener HC, Yusuf S, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent strokes. N Engl J Med. 2008;359:1238-1251.
12. Cumbler E, Glasheen J. Risk stratification tools for TIA: Which patients require hospital admission? J Hosp Med. 2009;4:247-251.
13. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369:283-292.
14. Cumbler E, Glasheen J. Management of blood pressure after acute ischemic stroke: An evidence-based guide for the hospitalist. J Hosp Med. 2007;2:261-267.

Image Source: FORESTPATH/ISTOCKPHOTO.COM

Ethan Cumbler, MD, is board-certified in internal medicine and pediatrics, and has practiced hospital medicine for six years, first at a community hospital and now at the University of Colorado Denver (UCD), where he directs the Acute Care for the Elderly service. The prevalence of stroke in his practice and the daily challenges of managing stroke patients led Dr. Cumbler to seek additional training in stroke care. He is the hospitalist representative to the UCD stroke council, a researcher in the arena of acute stroke care, and is helping UCD become a Joint Commission-certified stroke center.

“There are a variety of roles for the hospitalist in stroke care,” Dr. Cumbler says, explaining that HM physicians can be admitting attendings for stroke patients or part of acute stroke teams, and participate in decisions to start such treatments as intravenous recombinant tissue plasminogen activator (t-PA), the Food and Drug Administration-approved clot-busting therapy. “[Hospitalists] can be medical consultants on stroke patients admitted to other hospital services, managing common comorbid conditions such as blood pressure and glucose levels, which have particular character for patients immediately post-stroke.”

Stroke is the third-leading cause of death in the U.S., as well as a leading cause of serious, long-term disability. How many stroke patients are seen by hospitalists is not known, but it is reasonable to assume that a majority of hospitalized stroke patients will encounter a hospitalist, if not for acute treatment, then for ongoing medical management.

Some hospitalists think stroke and transient ischemic attacks (TIAs)—temporary neurological deficits sometimes called “mini-strokes,” and a major risk factor for full-blown strokes—are among the most common diseases seen by hospitalists.1 Acute stroke care is a growing part of HM practice because neurologist availability in emergent situations varies widely between hospitals. The rapid evolution of stroke treatment and the time-sensitive needs of stroke patients represents a huge opportunity for hospitalists to fill that void for their hospitals—whether they want to or not.

“I think hospitalists are fully capable of learning and mastering stroke care, but it requires both interest and training,” Dr. Cumbler says.

HM Can Help Fill a Void

According to the American Heart Association (AHA), there are four neurologists per 100,000 Americans, and not all of those neurologists specialize in stroke care.2 The scarcity of neurological specialists means that in many hospitals, a neurologist won’t be available for the critical assessment and treatment decisions required in the first few hours after a stroke is diagnosed. Yet many hospitalists complain that their preparation during internal-medicine residency did not equip them to care for acute stroke patients.3

S. Andrew Josephson, MD, a neurovascular physician and director of the neurohospitalist program at the University of California at San Francisco Medical Center, says the number of hospitalists on the front lines of acute stroke care is growing every day. “A new stroke is a very treatable neurological emergency that requires ultra-fast intervention,”7 Dr. Josephson says, “and hospitalists, increasingly, are the people who matter most in that intervention.” The reason, in most cases, is hospitalists are available at all times, and neurologists aren’t.

Given variable access to neurologists at the time of urgent need in many hospitals, the actions hospitalists can take in acute stroke management include:

• Become better trained in stroke care. Sessions on stroke management are included in numerous HM educational programs, including SHM conferences and in continuing medical education (CME) offerings from such groups as the American Academy of Neurology (see “Stroke Training, Resources, and Opportunities,” p. 30).
• Partner with neurologists in your hospital. One trend is to develop a neurohospitalist practice.
• Push for increased organization and response times for stroke patients. Given HM’s focus on quality and patient safety, hospitalists are natural champions for improving systems of care for stroke. Hospitalists can work with neurologists, radiologists, pharmacists, and other providers to develop stroke treatment protocols and rapid response capabilities.
• Help develop a stroke team, and seek certification as a primary stroke center. The Joint Commission certifies stroke centers (www.jointcommission.org/CertificationPrograms/PrimaryStroke Centers) based on demonstrated compliance with disease-based standards, effective use of clinical practice guidelines, and performance-improvement activities.
• Establish a collaborative relationship with a regional stroke center or tertiary hospital. This could manifest as a telemedicine link to aid in stroke assessment and treatment decisions (see “Rural Response: The ‘Drip and Ship’ Method,” p. 28).
• Refine approaches to more rapidly identify and work up patients who experience a stroke while they are in the hospital.

Hospitalists are going to continue to be out front on stroke management.

—S. Andrew Josephson, MD, director, neurohospitalist program, University of California at San Francisco Medical Center

Streamline In-Hospital Stroke Response

From 6.5% to 15% of stroke patients experience their stroke while they are in the hospital.4 “Hospitals are not always geared up to deal with neurological emergencies, and yet these patients are firmly within our domain,” Dr. Cumbler says. “We found that it took three times longer in our hospital to complete the evaluation when the stroke happened in the hospital than for strokes presenting in the emergency department.”

Through a hospitalwide quality-improvement (QI) project, UCD’s in-hospital stroke response time was reduced to 37 minutes from 70 minutes.

A comprehensive approach to stroke QI should include training first witnesses in the hospital (e.g., nurses, physical therapists, and housekeepers) to recognize potential stroke symptoms; creating a rapid response capability from personnel who understand how to evaluate and treat suspected stroke and are able to respond quickly; and making suspected stroke a top priority in the radiology lab.

Stroke patient management processes need to be improved and provider roles better defined. Hospitalists can help on the frontlines, and should advocate for quality and patient safety measures.

“Stroke has so many facets: the need to reduce risk, to educate the public about the need for prompt response, the appropriate evaluation of risks and benefits of treatment,” Dr. Cumbler says. “How do you achieve a system in the hospital where patients are fully able to realize benefits of all these advances? I think there’s something in stroke treatment for every hospitalist and, for those with a particular interest, opportunities to play leadership roles.”

New Era in Stroke Care

Many compare the evolution of stroke care to that of more common conditions, and hospitalists have a buffet of new and improved treatments and technologies at their disposal. “This is an interesting time in the treatment of stroke,” Dr. Cumbler says. “We are at the cusp of a new era. Previously, stroke was one of the classic neurologic issues in hospital medicine, but we did not have much to offer. Now, as with heart attack, we have a growing array of urgent and effective treatment options, and new imaging techniques to determine whether to treat and with what type of treatment.”

New and emerging treatment approaches include:

• Induced hypothermia, to protect the brain;
• Enhanced thrombolytics by ultrasound;
• Perfusion-based treatment time windows;
• Recanalization;
• Extended cardiac telemetry targeting atrial fibrillation;
• Neuroprotective agents; and
• Pressor usage to raise blood pressure in the post-stroke patient.

Interventional strategies seek to combine intravenous t-PA with localized techniques to open occluded vessels. While these are cutting-edge and not yet integrated into medical routine, “they illustrate why stroke management is so exciting right now,” Dr. Cumbler says.

As stroke treatment becomes more standardized, hospitals will expect HM physicians to be thoroughly versed in optimal stroke care, says David Yu, MD, MBA, FACP, medical director of hospitalist services at Decatur Memorial Hospital in Illinois and a member of Team Hospitalist. “There will be a shift in hospital medicine, with the practice of neurology becoming more open to non-neurologists,” he says. “As opportunities for stroke treatment increase, more responsibility will fall on hospitalists. It is part of the evolution of our field.”

That evolution is reflected in Medicare’s decision in 2005 to begin paying hospitals a higher diagnostic-related grouping (DRG) rate for administering intravenous t-PA.5 DRG 559 pays a hospital about $6,000 more, regionally adjusted, for stroke treatment that includes intravenous t-PA, compared with stroke care without it. That differential creates incentives for the hospital to invest in infrastructure, staffing, and training.

The Neurohospitalist

Recent journal articles have explored the emergence of neurohospitalists—hybrid physicians who are loosely defined as neurologists whose primary focus is the care of hospitalized patients. The neurohospitalist trend is spurred by the same time and fiscal constraints that drove the HM movement, says William Freeman, MD, neurologist at the Mayo Clinic in Jacksonville, Fla., and coauthor of one of those articles.6

Office-based neurologists increasingly are unavailable to respond to neurological emergencies in the hospital. Depending on the size of the hospital and its need for specialist access, an organized neurohospitalist group covering a schedule in the hospital could make significant contributions to quality of care, length of stay, and other stroke outcomes, Dr. Freeman says. “This field is starting to gel and crystallize, as more neurologists find themselves focusing their practice on site of care,” he notes.

Although not all experts agree, Dr. Freeman says that general hospitalists could become neurohospitalists, and vice versa. Neurologists could learn more internal medicine, and the two groups could work together more closely, he says.

Dr. Josephson of the University of California at San Francisco Medical Center reserves the term “neurohospitalist” for neurologists, but adds that medical hospitalists can manage neurologic disorders. He also sees potential for joint research on the management of hospitalized neurologic patients.

Drs. Freeman and Josephson have led discussions of the neurohospitalist model, both within AAN and in a recent conference call with SHM representatives. Data are limited on the numbers of physicians practicing this specialty, but job postings are growing and a neurohospitalist listserv sponsored by AAN grew to 250 members from 50 within six months. The University of California at San Francisco Medical Center established the first neurohospitalist fellowship in 2008, and a neurohospitalist journal is in development. “Most stroke patients are not seen by neurologists. I keep saying that at stroke conventions,” Dr. Josephson explains. “Hospitalists are going to continue to be out front on stroke management. Some will have a neurologist available. More likely, the hospitalist and neurologist will be participating in acute stroke management as part of some system of care with the emergency department or critical care.” TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Glasheen J, Cumbler E, Tailoring internal medicine training to improve hospitalist outcomes. Arch Intern Med. 2009;169:204-205.
2. Telemedicine helps experts treat stroke from afar. National Stroke Association Web site. Available at: http://www.stroke.org/site/News2?page=NewsArticle&id=8208&news_iv_ctrl=1221. Accessed Nov. 4, 2009.
3. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3)247-254.
4. Blacker DJ. In-hospital stroke. Lancet Neurol. 2003;2(12):741-746.
5. Demaerschalk BM, Durocher DL. How diagnosis-related group 559 will change the US Medicare cost reimbursement ratio for stroke centers. Stroke. 2007;38:1309-1312.
6. Freeman WD, Gronseth G, Eidelman BH. Is it time for neurohospitalists? Neurology. 2009;72:476-477.
7. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329.
8. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40(8):2945-2948.
9. Lyden P. Thrombolytic therapy for acute stroke—not a moment to lose. N Engl J Med. 2008;359:1393-1397.
10. Doheny K. Few stroke patients get clot-busting drug. Business Week Web site. Available at: http://www.businessweek.com/lifestyle/content/healthday/624280.html. Accessed Sept. 23, 2009.
11. Sacco RL, Diener HC, Yusuf S, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent strokes. N Engl J Med. 2008;359:1238-1251.
12. Cumbler E, Glasheen J. Risk stratification tools for TIA: Which patients require hospital admission? J Hosp Med. 2009;4:247-251.
13. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369:283-292.
14. Cumbler E, Glasheen J. Management of blood pressure after acute ischemic stroke: An evidence-based guide for the hospitalist. J Hosp Med. 2007;2:261-267.

Image Source: FORESTPATH/ISTOCKPHOTO.COM

Ethan Cumbler, MD, is board-certified in internal medicine and pediatrics, and has practiced hospital medicine for six years, first at a community hospital and now at the University of Colorado Denver (UCD), where he directs the Acute Care for the Elderly service. The prevalence of stroke in his practice and the daily challenges of managing stroke patients led Dr. Cumbler to seek additional training in stroke care. He is the hospitalist representative to the UCD stroke council, a researcher in the arena of acute stroke care, and is helping UCD become a Joint Commission-certified stroke center.

“There are a variety of roles for the hospitalist in stroke care,” Dr. Cumbler says, explaining that HM physicians can be admitting attendings for stroke patients or part of acute stroke teams, and participate in decisions to start such treatments as intravenous recombinant tissue plasminogen activator (t-PA), the Food and Drug Administration-approved clot-busting therapy. “[Hospitalists] can be medical consultants on stroke patients admitted to other hospital services, managing common comorbid conditions such as blood pressure and glucose levels, which have particular character for patients immediately post-stroke.”

Stroke is the third-leading cause of death in the U.S., as well as a leading cause of serious, long-term disability. How many stroke patients are seen by hospitalists is not known, but it is reasonable to assume that a majority of hospitalized stroke patients will encounter a hospitalist, if not for acute treatment, then for ongoing medical management.

Some hospitalists think stroke and transient ischemic attacks (TIAs)—temporary neurological deficits sometimes called “mini-strokes,” and a major risk factor for full-blown strokes—are among the most common diseases seen by hospitalists.1 Acute stroke care is a growing part of HM practice because neurologist availability in emergent situations varies widely between hospitals. The rapid evolution of stroke treatment and the time-sensitive needs of stroke patients represents a huge opportunity for hospitalists to fill that void for their hospitals—whether they want to or not.

“I think hospitalists are fully capable of learning and mastering stroke care, but it requires both interest and training,” Dr. Cumbler says.

HM Can Help Fill a Void

According to the American Heart Association (AHA), there are four neurologists per 100,000 Americans, and not all of those neurologists specialize in stroke care.2 The scarcity of neurological specialists means that in many hospitals, a neurologist won’t be available for the critical assessment and treatment decisions required in the first few hours after a stroke is diagnosed. Yet many hospitalists complain that their preparation during internal-medicine residency did not equip them to care for acute stroke patients.3

S. Andrew Josephson, MD, a neurovascular physician and director of the neurohospitalist program at the University of California at San Francisco Medical Center, says the number of hospitalists on the front lines of acute stroke care is growing every day. “A new stroke is a very treatable neurological emergency that requires ultra-fast intervention,”7 Dr. Josephson says, “and hospitalists, increasingly, are the people who matter most in that intervention.” The reason, in most cases, is hospitalists are available at all times, and neurologists aren’t.

Given variable access to neurologists at the time of urgent need in many hospitals, the actions hospitalists can take in acute stroke management include:

• Become better trained in stroke care. Sessions on stroke management are included in numerous HM educational programs, including SHM conferences and in continuing medical education (CME) offerings from such groups as the American Academy of Neurology (see “Stroke Training, Resources, and Opportunities,” p. 30).
• Partner with neurologists in your hospital. One trend is to develop a neurohospitalist practice.
• Push for increased organization and response times for stroke patients. Given HM’s focus on quality and patient safety, hospitalists are natural champions for improving systems of care for stroke. Hospitalists can work with neurologists, radiologists, pharmacists, and other providers to develop stroke treatment protocols and rapid response capabilities.
• Help develop a stroke team, and seek certification as a primary stroke center. The Joint Commission certifies stroke centers (www.jointcommission.org/CertificationPrograms/PrimaryStroke Centers) based on demonstrated compliance with disease-based standards, effective use of clinical practice guidelines, and performance-improvement activities.
• Establish a collaborative relationship with a regional stroke center or tertiary hospital. This could manifest as a telemedicine link to aid in stroke assessment and treatment decisions (see “Rural Response: The ‘Drip and Ship’ Method,” p. 28).
• Refine approaches to more rapidly identify and work up patients who experience a stroke while they are in the hospital.

Hospitalists are going to continue to be out front on stroke management.

—S. Andrew Josephson, MD, director, neurohospitalist program, University of California at San Francisco Medical Center

Streamline In-Hospital Stroke Response

From 6.5% to 15% of stroke patients experience their stroke while they are in the hospital.4 “Hospitals are not always geared up to deal with neurological emergencies, and yet these patients are firmly within our domain,” Dr. Cumbler says. “We found that it took three times longer in our hospital to complete the evaluation when the stroke happened in the hospital than for strokes presenting in the emergency department.”

Through a hospitalwide quality-improvement (QI) project, UCD’s in-hospital stroke response time was reduced to 37 minutes from 70 minutes.

A comprehensive approach to stroke QI should include training first witnesses in the hospital (e.g., nurses, physical therapists, and housekeepers) to recognize potential stroke symptoms; creating a rapid response capability from personnel who understand how to evaluate and treat suspected stroke and are able to respond quickly; and making suspected stroke a top priority in the radiology lab.

Stroke patient management processes need to be improved and provider roles better defined. Hospitalists can help on the frontlines, and should advocate for quality and patient safety measures.

“Stroke has so many facets: the need to reduce risk, to educate the public about the need for prompt response, the appropriate evaluation of risks and benefits of treatment,” Dr. Cumbler says. “How do you achieve a system in the hospital where patients are fully able to realize benefits of all these advances? I think there’s something in stroke treatment for every hospitalist and, for those with a particular interest, opportunities to play leadership roles.”

New Era in Stroke Care

Many compare the evolution of stroke care to that of more common conditions, and hospitalists have a buffet of new and improved treatments and technologies at their disposal. “This is an interesting time in the treatment of stroke,” Dr. Cumbler says. “We are at the cusp of a new era. Previously, stroke was one of the classic neurologic issues in hospital medicine, but we did not have much to offer. Now, as with heart attack, we have a growing array of urgent and effective treatment options, and new imaging techniques to determine whether to treat and with what type of treatment.”

New and emerging treatment approaches include:

• Induced hypothermia, to protect the brain;
• Enhanced thrombolytics by ultrasound;
• Perfusion-based treatment time windows;
• Recanalization;
• Extended cardiac telemetry targeting atrial fibrillation;
• Neuroprotective agents; and
• Pressor usage to raise blood pressure in the post-stroke patient.

Interventional strategies seek to combine intravenous t-PA with localized techniques to open occluded vessels. While these are cutting-edge and not yet integrated into medical routine, “they illustrate why stroke management is so exciting right now,” Dr. Cumbler says.

As stroke treatment becomes more standardized, hospitals will expect HM physicians to be thoroughly versed in optimal stroke care, says David Yu, MD, MBA, FACP, medical director of hospitalist services at Decatur Memorial Hospital in Illinois and a member of Team Hospitalist. “There will be a shift in hospital medicine, with the practice of neurology becoming more open to non-neurologists,” he says. “As opportunities for stroke treatment increase, more responsibility will fall on hospitalists. It is part of the evolution of our field.”

That evolution is reflected in Medicare’s decision in 2005 to begin paying hospitals a higher diagnostic-related grouping (DRG) rate for administering intravenous t-PA.5 DRG 559 pays a hospital about $6,000 more, regionally adjusted, for stroke treatment that includes intravenous t-PA, compared with stroke care without it. That differential creates incentives for the hospital to invest in infrastructure, staffing, and training.

The Neurohospitalist

Recent journal articles have explored the emergence of neurohospitalists—hybrid physicians who are loosely defined as neurologists whose primary focus is the care of hospitalized patients. The neurohospitalist trend is spurred by the same time and fiscal constraints that drove the HM movement, says William Freeman, MD, neurologist at the Mayo Clinic in Jacksonville, Fla., and coauthor of one of those articles.6

Office-based neurologists increasingly are unavailable to respond to neurological emergencies in the hospital. Depending on the size of the hospital and its need for specialist access, an organized neurohospitalist group covering a schedule in the hospital could make significant contributions to quality of care, length of stay, and other stroke outcomes, Dr. Freeman says. “This field is starting to gel and crystallize, as more neurologists find themselves focusing their practice on site of care,” he notes.

Although not all experts agree, Dr. Freeman says that general hospitalists could become neurohospitalists, and vice versa. Neurologists could learn more internal medicine, and the two groups could work together more closely, he says.

Dr. Josephson of the University of California at San Francisco Medical Center reserves the term “neurohospitalist” for neurologists, but adds that medical hospitalists can manage neurologic disorders. He also sees potential for joint research on the management of hospitalized neurologic patients.

Drs. Freeman and Josephson have led discussions of the neurohospitalist model, both within AAN and in a recent conference call with SHM representatives. Data are limited on the numbers of physicians practicing this specialty, but job postings are growing and a neurohospitalist listserv sponsored by AAN grew to 250 members from 50 within six months. The University of California at San Francisco Medical Center established the first neurohospitalist fellowship in 2008, and a neurohospitalist journal is in development. “Most stroke patients are not seen by neurologists. I keep saying that at stroke conventions,” Dr. Josephson explains. “Hospitalists are going to continue to be out front on stroke management. Some will have a neurologist available. More likely, the hospitalist and neurologist will be participating in acute stroke management as part of some system of care with the emergency department or critical care.” TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Glasheen J, Cumbler E, Tailoring internal medicine training to improve hospitalist outcomes. Arch Intern Med. 2009;169:204-205.
2. Telemedicine helps experts treat stroke from afar. National Stroke Association Web site. Available at: http://www.stroke.org/site/News2?page=NewsArticle&id=8208&news_iv_ctrl=1221. Accessed Nov. 4, 2009.
3. Plauth WH, Pantilat SZ, Wachter RM, Fenton CL. Hospitalists’ perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111(3)247-254.
4. Blacker DJ. In-hospital stroke. Lancet Neurol. 2003;2(12):741-746.
5. Demaerschalk BM, Durocher DL. How diagnosis-related group 559 will change the US Medicare cost reimbursement ratio for stroke centers. Stroke. 2007;38:1309-1312.
6. Freeman WD, Gronseth G, Eidelman BH. Is it time for neurohospitalists? Neurology. 2009;72:476-477.
7. Hacke W, Kaste M, Bluhmki E, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317-1329.
8. Del Zoppo GJ, Saver JL, Jauch EC, Adams HP Jr. American Heart Association Stroke Council. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: a science advisory from the American Heart Association/American Stroke Association. Stroke. 2009;40(8):2945-2948.
9. Lyden P. Thrombolytic therapy for acute stroke—not a moment to lose. N Engl J Med. 2008;359:1393-1397.
10. Doheny K. Few stroke patients get clot-busting drug. Business Week Web site. Available at: http://www.businessweek.com/lifestyle/content/healthday/624280.html. Accessed Sept. 23, 2009.
11. Sacco RL, Diener HC, Yusuf S, et al. Aspirin and extended-release dipyridamole versus clopidogrel for recurrent strokes. N Engl J Med. 2008;359:1238-1251.
12. Cumbler E, Glasheen J. Risk stratification tools for TIA: Which patients require hospital admission? J Hosp Med. 2009;4:247-251.
13. Johnston SC, Rothwell PM, Nguyen-Huynh MN, et al. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. Lancet. 2007; 369:283-292.
14. Cumbler E, Glasheen J. Management of blood pressure after acute ischemic stroke: An evidence-based guide for the hospitalist. J Hosp Med. 2007;2:261-267.

Image Source: FORESTPATH/ISTOCKPHOTO.COM

Given the varying access to acute-stroke expertise and the roles hospitalists play in treatment (see “Spotlight on Stroke,” p. 1), stroke protocol differs from hospital to hospital throughout the U.S. One response is known as “drip and ship.” Physicians at remote hospitals consult experts at a tertiary-care medical center by phone or video before initiating clot-busting intravenous recombinant tissue plasminogen activator (t-PA) within its three- to 4.5-hour therapeutic window. Once t-PA is administered, the patient is transferred to the medical center for ongoing care.

“But what is the best way to provide that expertise at the bedside to support the first-responding physician who is not a stroke expert?” asks Lee Schwamm, MD, director of acute-stroke services at Massachusetts General Hospital (MGH) in Boston. While the goal is to disseminate stroke treatment expertise as widely as possible, there are other benefits to the arrangement, from the quality of the infrastructure, ongoing education, and a growing relationship that is more than just “transactional” telemedicine.

MGH and Brigham and Women’s Hospital are the hubs for the relationship-building Partners TeleStroke Network. It connects 27 participating hospitals across three states with an escalating chain of access to stroke resources. Spoke hospitals transmit, through a secure link, such clinical data as noncontrast head CT scans to the hub, where a stroke expert “examines” the patient via live video feed and shares in the responsibility for deciding whether to initiate t-PA. The network’s resources include clinical and information technology advocates at the hub and spokes; managers of business processes, contracts, licensure, and credentialing; consultation recording for quality purposes; regular telemedicine grand rounds; and the network’s leadership in an alliance of hub-and-spokes stroke networks at other academic medical centers. “This is not a game to play casually. It’s about developing new healthcare delivery models, with lots of complicating factors,” Dr. Schwamm says.

Hospitalists should not only note that stroke care is coming under greater regulatory scrutiny, but also that stroke information increasingly is available on the Web, Dr. Schwamm says. He also urges hospitals to participate in one of the national quality programs for stroke care, including the American Stroke Association’s Get with the Guidelines: Stroke, the Joint Commission’s primary stroke center accreditation, or the CDC’s Paul Coverdell National Acute Stroke Registry. “Each of these provides a structure for improving the quality of stroke care,” Dr. Schwamm explains, “and is money well spent by the hospital.”

Given the varying access to acute-stroke expertise and the roles hospitalists play in treatment (see “Spotlight on Stroke,” p. 1), stroke protocol differs from hospital to hospital throughout the U.S. One response is known as “drip and ship.” Physicians at remote hospitals consult experts at a tertiary-care medical center by phone or video before initiating clot-busting intravenous recombinant tissue plasminogen activator (t-PA) within its three- to 4.5-hour therapeutic window. Once t-PA is administered, the patient is transferred to the medical center for ongoing care.

“But what is the best way to provide that expertise at the bedside to support the first-responding physician who is not a stroke expert?” asks Lee Schwamm, MD, director of acute-stroke services at Massachusetts General Hospital (MGH) in Boston. While the goal is to disseminate stroke treatment expertise as widely as possible, there are other benefits to the arrangement, from the quality of the infrastructure, ongoing education, and a growing relationship that is more than just “transactional” telemedicine.

MGH and Brigham and Women’s Hospital are the hubs for the relationship-building Partners TeleStroke Network. It connects 27 participating hospitals across three states with an escalating chain of access to stroke resources. Spoke hospitals transmit, through a secure link, such clinical data as noncontrast head CT scans to the hub, where a stroke expert “examines” the patient via live video feed and shares in the responsibility for deciding whether to initiate t-PA. The network’s resources include clinical and information technology advocates at the hub and spokes; managers of business processes, contracts, licensure, and credentialing; consultation recording for quality purposes; regular telemedicine grand rounds; and the network’s leadership in an alliance of hub-and-spokes stroke networks at other academic medical centers. “This is not a game to play casually. It’s about developing new healthcare delivery models, with lots of complicating factors,” Dr. Schwamm says.

Hospitalists should not only note that stroke care is coming under greater regulatory scrutiny, but also that stroke information increasingly is available on the Web, Dr. Schwamm says. He also urges hospitals to participate in one of the national quality programs for stroke care, including the American Stroke Association’s Get with the Guidelines: Stroke, the Joint Commission’s primary stroke center accreditation, or the CDC’s Paul Coverdell National Acute Stroke Registry. “Each of these provides a structure for improving the quality of stroke care,” Dr. Schwamm explains, “and is money well spent by the hospital.”

Given the varying access to acute-stroke expertise and the roles hospitalists play in treatment (see “Spotlight on Stroke,” p. 1), stroke protocol differs from hospital to hospital throughout the U.S. One response is known as “drip and ship.” Physicians at remote hospitals consult experts at a tertiary-care medical center by phone or video before initiating clot-busting intravenous recombinant tissue plasminogen activator (t-PA) within its three- to 4.5-hour therapeutic window. Once t-PA is administered, the patient is transferred to the medical center for ongoing care.

“But what is the best way to provide that expertise at the bedside to support the first-responding physician who is not a stroke expert?” asks Lee Schwamm, MD, director of acute-stroke services at Massachusetts General Hospital (MGH) in Boston. While the goal is to disseminate stroke treatment expertise as widely as possible, there are other benefits to the arrangement, from the quality of the infrastructure, ongoing education, and a growing relationship that is more than just “transactional” telemedicine.

MGH and Brigham and Women’s Hospital are the hubs for the relationship-building Partners TeleStroke Network. It connects 27 participating hospitals across three states with an escalating chain of access to stroke resources. Spoke hospitals transmit, through a secure link, such clinical data as noncontrast head CT scans to the hub, where a stroke expert “examines” the patient via live video feed and shares in the responsibility for deciding whether to initiate t-PA. The network’s resources include clinical and information technology advocates at the hub and spokes; managers of business processes, contracts, licensure, and credentialing; consultation recording for quality purposes; regular telemedicine grand rounds; and the network’s leadership in an alliance of hub-and-spokes stroke networks at other academic medical centers. “This is not a game to play casually. It’s about developing new healthcare delivery models, with lots of complicating factors,” Dr. Schwamm says.

Hospitalists should not only note that stroke care is coming under greater regulatory scrutiny, but also that stroke information increasingly is available on the Web, Dr. Schwamm says. He also urges hospitals to participate in one of the national quality programs for stroke care, including the American Stroke Association’s Get with the Guidelines: Stroke, the Joint Commission’s primary stroke center accreditation, or the CDC’s Paul Coverdell National Acute Stroke Registry. “Each of these provides a structure for improving the quality of stroke care,” Dr. Schwamm explains, “and is money well spent by the hospital.”

Improving patient discharges and reducing preventable "bounce-back" readmissions will have increasing implications for hospitals’ bottom lines—especially if proposed Medicare payment bundling reforms are adopted by Congress. Discharge improvement also enhances a hospital’s reputation with patients and providers, says Neil Gupta, MD, a hospitalist at the University of California at San Francisco.

"I think we all recognize in our daily practice that there are things we can do better for patients at discharge," Dr. Gupta says. "It's sometimes hard to get the resources and motivation to do this. But we know it could really impact patient care and make it better."

Dr. Gupta's hospital is one of 24 participating in SHM's Project BOOST (Better Outcomes for Older Adults through Safe Transitions). The mentorship program is developing a consensus and resources for best practices in patient discharges. National data show that about one in five hospitalized Medicare patients are readmitted within 30 days. While some of these readmissions are appropriate, the sheer quantity of readmissions shows room for improvement, says Dr. Gupta's colleague, Arpana Vidyarthi, MD, a hospitalist and director of quality at UCSF. "In reality, no one in the United States is doing it very well," she says.

Drs. Gupta and Vidyarthi suggest focusing your HM group's communication with primary-care physicians (PCPs): Study whether the hospitalist's messages are getting through to the PCPs and ask for their feedback. Other targets should include identifying high-risk patients, reconciling medications, scheduling the patient's first outpatient visit prior to discharge, and confirming the patient's understanding of the discharge plan.

The first step is to form an interdisciplinary team that approaches discharges as a QI project, Dr. Gupta explains. "Building that team is huge," he says. "It adds a whole new perspective." At UCSF, the team meets monthly and includes hospitalists, PCPs, staff nurses and nursing supervisors, pharmacists, care managers, and patients.

For more information about Project BOOST, visit SHM's resource room.

Improving patient discharges and reducing preventable "bounce-back" readmissions will have increasing implications for hospitals’ bottom lines—especially if proposed Medicare payment bundling reforms are adopted by Congress. Discharge improvement also enhances a hospital’s reputation with patients and providers, says Neil Gupta, MD, a hospitalist at the University of California at San Francisco.

"I think we all recognize in our daily practice that there are things we can do better for patients at discharge," Dr. Gupta says. "It's sometimes hard to get the resources and motivation to do this. But we know it could really impact patient care and make it better."

Dr. Gupta's hospital is one of 24 participating in SHM's Project BOOST (Better Outcomes for Older Adults through Safe Transitions). The mentorship program is developing a consensus and resources for best practices in patient discharges. National data show that about one in five hospitalized Medicare patients are readmitted within 30 days. While some of these readmissions are appropriate, the sheer quantity of readmissions shows room for improvement, says Dr. Gupta's colleague, Arpana Vidyarthi, MD, a hospitalist and director of quality at UCSF. "In reality, no one in the United States is doing it very well," she says.

Drs. Gupta and Vidyarthi suggest focusing your HM group's communication with primary-care physicians (PCPs): Study whether the hospitalist's messages are getting through to the PCPs and ask for their feedback. Other targets should include identifying high-risk patients, reconciling medications, scheduling the patient's first outpatient visit prior to discharge, and confirming the patient's understanding of the discharge plan.

The first step is to form an interdisciplinary team that approaches discharges as a QI project, Dr. Gupta explains. "Building that team is huge," he says. "It adds a whole new perspective." At UCSF, the team meets monthly and includes hospitalists, PCPs, staff nurses and nursing supervisors, pharmacists, care managers, and patients.

For more information about Project BOOST, visit SHM's resource room.

Improving patient discharges and reducing preventable "bounce-back" readmissions will have increasing implications for hospitals’ bottom lines—especially if proposed Medicare payment bundling reforms are adopted by Congress. Discharge improvement also enhances a hospital’s reputation with patients and providers, says Neil Gupta, MD, a hospitalist at the University of California at San Francisco.

"I think we all recognize in our daily practice that there are things we can do better for patients at discharge," Dr. Gupta says. "It's sometimes hard to get the resources and motivation to do this. But we know it could really impact patient care and make it better."

Dr. Gupta's hospital is one of 24 participating in SHM's Project BOOST (Better Outcomes for Older Adults through Safe Transitions). The mentorship program is developing a consensus and resources for best practices in patient discharges. National data show that about one in five hospitalized Medicare patients are readmitted within 30 days. While some of these readmissions are appropriate, the sheer quantity of readmissions shows room for improvement, says Dr. Gupta's colleague, Arpana Vidyarthi, MD, a hospitalist and director of quality at UCSF. "In reality, no one in the United States is doing it very well," she says.

Drs. Gupta and Vidyarthi suggest focusing your HM group's communication with primary-care physicians (PCPs): Study whether the hospitalist's messages are getting through to the PCPs and ask for their feedback. Other targets should include identifying high-risk patients, reconciling medications, scheduling the patient's first outpatient visit prior to discharge, and confirming the patient's understanding of the discharge plan.

The first step is to form an interdisciplinary team that approaches discharges as a QI project, Dr. Gupta explains. "Building that team is huge," he says. "It adds a whole new perspective." At UCSF, the team meets monthly and includes hospitalists, PCPs, staff nurses and nursing supervisors, pharmacists, care managers, and patients.

For more information about Project BOOST, visit SHM's resource room.

It’s November 1999, and the release of an advance copy of a breakthrough Institute of Medicine (IOM) report on patient safety provokes headlines around the world with its estimate that as many as 98,000 people per year die from medical errors in U.S. hospitals. The report and subsequent book, To Err is Human: Building a Safer Health System, already is labeled a landmark event for modern medicine.1 It launches a nationwide effort to systematically improve patient safety and reduce errors.

Believe it or not, the IOM report celebrates its 10th anniversary this month. Many healthcare leaders point out that the QI and patient-safety revolution birthed by the IOM report has paralleled the simultaneous—and seismic—growth of HM.

The IOM report drew upon data from Harvard Medical Practice Studies and other existing research for its shocking estimates of error-induced deaths. The report, to a large degree, focused on prescribing errors, with less emphasis on hospital-acquired infections and other safety and quality issues that have emerged since its publication. The report also proposed a comprehensive safety strategy for government, industry, consumers, and healthcare providers—a proposal that has been adopted only in pieces.

In commemorating the 10th anniversary of the IOM report, industry leaders agree that HM more than any other medical specialty will continue to play a leading role in pushing the quality and patient-safety agenda in hospitals throughout America.

IOM’s Committee on Quality of Healthcare in America, which was made up of physicians, researchers, and healthcare leaders, authored the breakthrough report on medical errors, and followed up two years later with Crossing the Quality Chasm: A New Health System for the 21st Century (www.iom.edu/?id=12736).2

The Hospitalist caught up with two of the original committee members, Donald Berwick, MD, MPP, FRCP, president and CEO of the Institute for Healthcare Improvement (IHI), and Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM), to discuss how far medicine has come—and how far it has to go—in the areas of hospital quality and patient safety.

When we think about how we train doctors … they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change.

—Christine Cassel, MD, president, CEO, American Board of Internal Medicine, Philadelphia

Question: What is the legacy of the IOM report?

Dr. Berwick: It didn’t launch the patient-safety movement, but it was the most important single contributor to that movement. In one step, it took the focus on safety as a goal in medicine from a relatively fringe concern to a central issue, and a central task for health providers.

Its most important element was the focus on systems improvement, rather than exhortations to individual health professionals to do a better job with patient safety. It is a cultural norm to blame someone when something goes wrong. That hasn’t changed fundamentally. But the IOM report made the point that it’s not people who are to blame for problems in patient safety, and blame won’t get us where we need to go.

HM Jumps into Quality and Patient Safety with Both Feet

An incredible, happy coincidence: That is how Robert Wachter, MD, FHM, explains the paralleled growth of HM and patient-safety awareness in U.S. hospitals. HM had “just emerged in the mid-1990s and was still figuring out what it was about when the IOM report [To Err is Human] was published,” says Dr. Wachter, chief of the hospital medicine division, professor and associate chair of the Department of Medicine, the University of California at San Francisco, former SHM president and author of the blog “Wachter’s World,” noting concerns at the time that HM would be branded as a cost-saving measure for hospitals and health plans.

“I remember vividly when the IOM report came out. A light bulb went off for me—what a spectacular opportunity for our field,” the well-known HM pioneer recalls. “Here was this huge report saying patient safety stinks and needs to be fixed. I was pretty sure other medical specialties would not welcome the findings. I and other hospitalist leaders pushed very hard to say ‘we own this’—we believe the report is true and we believe it requires a new kind of physician who believes in systems thinking, teamwork, and collaboration. I still think it was a good call for hospital medicine to jump with both feet into the quality and safety field.”

The IOM report sparked a patient-safety renaissance, Dr. Wachter says. “We recognized that there is a science here—a core knowledge, a way of thinking and an understanding that we were not going to make much progress on patient safety until we understood that knowledge, learned its science, and did the research. We have since learned that fixing patient safety is tricky, and yet as you scan the landscape, you see all of the important actors are doing something to make patient care safer.”

One of the first steps to fixing the problem is “owning up” to the fact people die because of medical mistakes. Hospitals’ willingness to adopt transparency, from the first floor to the C-suite, has changed in the past decade, Dr. Wachter says.

“We have created an environment where we’re on the path to getting safer,” he says. “We’re much more open and honest about errors. We attack them with root-cause analysis and find better ways to fix the problem. For me, that’s all healthy. It leaves me with great confidence that things are safer in American hospitals than they were 10 years ago—although certainly not as safe as they need to be.”—LB

Q: How do you rate the impact of To Err is Human on the medical industry as a whole?

Dr. Cassel: The Agency for Healthcare Research and Quality, five years after the IOM report, said we hadn’t made enough progress. We have, most importantly, been able to talk about it and understand some of the approaches to safety and quality. But that’s not nearly enough, in my opinion.

Dr. Berwick: I’d give it a C-minus. There has been a change in awareness of medical safety. Before the IOM report, you just didn’t hear about it. A scientific basis for the statement of the problem was created, and we can never go back. Prototypes of what could be achieved have started to emerge, not just in this country but worldwide. The problem is that the success is just in pockets—not fundamental change in the nature of the American healthcare industry. That level of execution just is not there yet. Now it’s game time—time to take safety and quality mainstream.

Q: In retrospect, what was missed in the report?

Dr. Berwick: If we missed any boat in our analysis, the idea of “no blame” is not meant to relieve everyone of responsibility for medical errors, but to relocate responsibility for safety in the offices and work of leaders of healthcare institutions. The finger points to the executive suite. There’s more and more evidence that safety does not improve without the clear commitment of leaders.

Dr. Cassel: When we think about how we train doctors, which I spend a lot of time doing, they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change. ABIM’s new pathway for hospitalists, which will be rolled out in another year or so (see “A-Plus Achievement,” p. 1), treats questions of how … to identify patient-safety issues as core knowledge.

Q: What is the relationship of the patient-safety movement to the hospitalist movement?

Dr. Cassel: The development and growth of patient safety has paralleled the growth of hospital medicine, and I think that’s a good thing. Most of the literature on available errors focuses on the hospital because that’s the easiest place to find numbers of patients and shine a light on safety. Specialists in hospital medicine have a unique opportunity and responsibility to be leaders in continuing to advance the cause of patient safety.

Q: What should HM’s patient-safety agenda look like going forward?

Dr. Berwick: No. 1, aim for zero. There are types of injuries and infections that can be nearly eliminated in the hospital. When you look at safety-oriented efforts in other industries, they strive to get to the point where they’re no longer talking about ratios, only numerators (how many actual incidents).

Second is to broaden the focus from safety to all the other dimensions of quality. Think about reliability, processes and performance across the board.

Third is to be authentic about teamwork across professions. In the medical culture at large, there still is too much focus on turf issues between doctors and nurses. I believe in the long run new safety initiatives will be fostered by teams working at unprecedented levels of collaboration, reaching across traditional boundaries.

Dr. Cassel: The issue of diagnostic error is also emerging as another kind of medical error.

In order for patients to get the right treatment, they need to get the right diagnosis. That’s where all of your medical training, knowledge, and judgment come into play. For ABIM, that’s how we evaluate physicians’ judgment.

The next frontier in patient safety is the handoff, from ambulatory to hospital and back, but also with long-term care, which is a black box. An enlightened and energetic hospitalist movement could decide to take that issue on.

Where it would happen is at the community level, although some of the healthcare reform legislation includes ideas about innovation zones and how to create payment mechanisms to support continuity of care. TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press, 2001.
3. Moser R. Diseases of Medical Progress: A Contemporary Analysis of Illnesses Produced by Drugs and Other Therapeutic Procedures. Springfield, Ill.: Charles C. Thomas, 1959.
4. Reason, J. Human Error. Cambridge, England: Cambridge University Press, 1990.
5. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
6. United Kingdom Department of Health. An Organisation with a Memory. 2000.
7. Jerrard J. No fee for errors. The Hospitalist. 2008;(5):18.
8. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-221.

The Evolution of Patient Safety

Key milestones in the patient-safety and medical QI movement:

200 B.C. - Hippocrates, the Greek scholar and father of modern medicine, promulgates the concept primum non nocere, which translates to “first, do no harm.”

1910 - Ernest Codman, a Boston surgeon who loses his privileges at Massachusetts General Hospital for pushing his end-results system (known today as medical outcomes), establishes the “End Result Hospital” and helps found the American College of Surgeons’ Hospital Standardization Program. This program evolves into the Joint Commission.

1959 - Diseases of Medical Progress by Robert Moser argues that iatrogenic disease is both common and preventable.2

1980s-1990s - Various medical errors result in high-profile patient deaths, including that of Libby Zion at New York Hospital in 1984 and Betsy Lehman at the Dana-Farber Cancer Institute in Boston in 1994. The deaths keep medical errors in the headlines.

1985 - The Anesthesia Patient Safety Foundation is established; anesthesiology is the first specialty to dedicate resources to preventing medical error.

1990 - James Reason’s Human Error describes his theory of error as systems failure.3 It is undiscovered by healthcare until …

1994 - … Lucien Leape’s article “Error in Medicine” is published in the Journal of the American Medical Association, drawing upon advances in error prevention from fields other than medicine.4

1999- The Institute of Medicine releases its landmark patient safety report, To Err Is Human.

2000 - The National Health Service in the United Kingdom releases another major medical safety report, An Organisation with a Memory.5

2001 - Congress establishes the Agency for Healthcare Research and Quality (AHRQ) to begin an aggressive patient-safety research and improvement program.

2001 - IOM releases a follow-up safety and quality report, Crossing the Quality Chasm.2

2002 - The Joint Commission releases its first National Patient Safety Goals.

2004 - The federal government creates the Office of the National Coordinator for Healthcare Information Technology to promote systems improvements in the medical industry.

2005 - The Institute for Healthcare Improvement’s 100,000 Lives campaign begins; it encourages hospitals to adopt basic steps to reduce harm and deaths.

2006 - The National Quality Forum issues its list of “never events,” 28 medical errors that should never occur in hospitals.6

2007 - Medical checklist research spearheaded by Peter Pronovost, MD, of Johns Hopkins University, including a patient- safety project involving all ICUs in the state of Michigan, is highlighted in a widely noted New Yorker profile and elsewhere.

2009 - The American Recovery and Reinvestment Act passes Congress and is signed by President Obama. It contains $19 billion for advancing healthcare information technology.

Source: Adapted from Wachter, R. Understanding Patient Safety (Lang Clinical Medicine), McGraw-Hill: 2007, Appendix III, Selected Milestones in the Field of Patient Safety, p. 280-281, which was adapted from sources including Vincent C. Patient Safety. London; Elsevier, 2006; and Sharpe VA, Faden AI. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic illness. New York: Cambridge University Press, 1998.

Image Sources: DNY59, ZEFFSS1, AYZEK, DON BAYLEY, BECKY REED/ISTOCKPHOTO.COM

HM Leaders Weigh In

Question 1: What was hospital medicine’s contribution and role in the patient-safety movement that ensued following the IOM report?

“I believe that hospitalists have been integral to improving patient safety and reducing medical errors in those hospitals. Patients are safer and better off if there is a physician in the house ready to respond should patients have a change in health status. Hospitalists see the hospital as their office, if you will, and they focus not only on treating the patient in the bed, but treating the hospital itself by becoming engaged with quality improvement and patient-safety initiatives that improve the system of care.”—Mark Williams, MD, FHM, chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago; SHM past president; editor of the Journal of Hospital Medicine

“The role hospital medicine has filled has been as a major supplier of physicians to quality-improvement teams and other hospital teams at the front lines, prior to which physicians were conspicuously absent. If you look, for example, at nurses and other healthcare professionals, they came to the party much earlier than we did. Physicians have only recently on a broad scale become involved on these teams, and I think the major contributors have been hospitalists.”—Winthrop Whitcomb, MD, FHM, director of performance improvement, Mercy Medical Center, Springfield, Mass.; SHM co-founder

“There was a tremendous kind of synergy where hospital medicine was defining itself by its focus on systems of care, safety culture, error reporting, collaboration, interdisciplinary teams and so forth. The IOM report did a beautiful job of taking the knowledge and literature, not just from within medicine but more importantly from outside, and showing how a lot of those concepts that had been implemented successfully elsewhere were lacking in medicine in general. That really just teed it up for hospital medicine to take the impetus and framework IOM supplied and use it as a rubric for what hospital medicine could do for its part of the health system.”—Russ Cucina, MD, assistant professor of medicine and associate medical director for information technology, University of California at San Francisco

Question 2: What is the most important unfinished business for hospitalists regarding the patient-safety movement?

“I think we have made tremendous strides but there is much more to do. Although we have pockets of success, what we need to do is make those successes more uniform, so they happen in every hospital, not just some hospitals that have the right hospitalist leader or the right skill set or the right culture. We want to create the right culture and skill set and team in every hospital, and one of our challenges at SHM is to work on a mentoring program for hospitalists. That means using those who have been successful to mentor other sites and bring them on board to reproduce and replicate the good work.”—Janet Nagamine, MD, FHM, hospitalist, Kaiser Permanente Medical Center, Santa Clara, Calif.; SHM Hospital Quality/Patient Safety Committee chairwoman

“The patients who enter hospitals today are incredibly sick, with multiple organ failures and other complications. Taking care of these patients is incredibly challenging, and there are always going to be things that do not go well. Hospitalists have begun to uncover and tackle a lot of these problems, but even as they eliminate one problem, new treatments, devices, procedures and strategies for caring for patients—all designed to improve care—may have unintended consequences. It is hospitalists’ job to try to mitigate those consequences and redesign the strategies to continue to improve outcomes. But this is a long road—a marathon, not a sprint.”—Scott Flanders, MD, FHM, director of the hospitalist division, University of Michigan Health System, Ann Arbor; president of SHM

“The greatest area of unfinished business I see is preserving continuity of care for our patients as they transition in and out of the hospital. So much is happening, and there is a great need to get information quickly and communicate between the inpatient and community-based practitioner. I should say we’ve come a long way, but there’s a lot more to do in this area, and that’s why six medical societies, including SHM, came together to produce the recent Transitions of Care Consensus Statement, acknowledging that this is a crucial part of patient safety and describing what are effective transitions of care in and out of the hospital.”—Vineet Arora, MD, MA, FHM, assistant professor, Department of Medicine, University of Chicago

—LB

It’s November 1999, and the release of an advance copy of a breakthrough Institute of Medicine (IOM) report on patient safety provokes headlines around the world with its estimate that as many as 98,000 people per year die from medical errors in U.S. hospitals. The report and subsequent book, To Err is Human: Building a Safer Health System, already is labeled a landmark event for modern medicine.1 It launches a nationwide effort to systematically improve patient safety and reduce errors.

Believe it or not, the IOM report celebrates its 10th anniversary this month. Many healthcare leaders point out that the QI and patient-safety revolution birthed by the IOM report has paralleled the simultaneous—and seismic—growth of HM.

The IOM report drew upon data from Harvard Medical Practice Studies and other existing research for its shocking estimates of error-induced deaths. The report, to a large degree, focused on prescribing errors, with less emphasis on hospital-acquired infections and other safety and quality issues that have emerged since its publication. The report also proposed a comprehensive safety strategy for government, industry, consumers, and healthcare providers—a proposal that has been adopted only in pieces.

In commemorating the 10th anniversary of the IOM report, industry leaders agree that HM more than any other medical specialty will continue to play a leading role in pushing the quality and patient-safety agenda in hospitals throughout America.

IOM’s Committee on Quality of Healthcare in America, which was made up of physicians, researchers, and healthcare leaders, authored the breakthrough report on medical errors, and followed up two years later with Crossing the Quality Chasm: A New Health System for the 21st Century (www.iom.edu/?id=12736).2

The Hospitalist caught up with two of the original committee members, Donald Berwick, MD, MPP, FRCP, president and CEO of the Institute for Healthcare Improvement (IHI), and Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM), to discuss how far medicine has come—and how far it has to go—in the areas of hospital quality and patient safety.

When we think about how we train doctors … they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change.

—Christine Cassel, MD, president, CEO, American Board of Internal Medicine, Philadelphia

Question: What is the legacy of the IOM report?

Dr. Berwick: It didn’t launch the patient-safety movement, but it was the most important single contributor to that movement. In one step, it took the focus on safety as a goal in medicine from a relatively fringe concern to a central issue, and a central task for health providers.

Its most important element was the focus on systems improvement, rather than exhortations to individual health professionals to do a better job with patient safety. It is a cultural norm to blame someone when something goes wrong. That hasn’t changed fundamentally. But the IOM report made the point that it’s not people who are to blame for problems in patient safety, and blame won’t get us where we need to go.

HM Jumps into Quality and Patient Safety with Both Feet

An incredible, happy coincidence: That is how Robert Wachter, MD, FHM, explains the paralleled growth of HM and patient-safety awareness in U.S. hospitals. HM had “just emerged in the mid-1990s and was still figuring out what it was about when the IOM report [To Err is Human] was published,” says Dr. Wachter, chief of the hospital medicine division, professor and associate chair of the Department of Medicine, the University of California at San Francisco, former SHM president and author of the blog “Wachter’s World,” noting concerns at the time that HM would be branded as a cost-saving measure for hospitals and health plans.

“I remember vividly when the IOM report came out. A light bulb went off for me—what a spectacular opportunity for our field,” the well-known HM pioneer recalls. “Here was this huge report saying patient safety stinks and needs to be fixed. I was pretty sure other medical specialties would not welcome the findings. I and other hospitalist leaders pushed very hard to say ‘we own this’—we believe the report is true and we believe it requires a new kind of physician who believes in systems thinking, teamwork, and collaboration. I still think it was a good call for hospital medicine to jump with both feet into the quality and safety field.”

The IOM report sparked a patient-safety renaissance, Dr. Wachter says. “We recognized that there is a science here—a core knowledge, a way of thinking and an understanding that we were not going to make much progress on patient safety until we understood that knowledge, learned its science, and did the research. We have since learned that fixing patient safety is tricky, and yet as you scan the landscape, you see all of the important actors are doing something to make patient care safer.”

One of the first steps to fixing the problem is “owning up” to the fact people die because of medical mistakes. Hospitals’ willingness to adopt transparency, from the first floor to the C-suite, has changed in the past decade, Dr. Wachter says.

“We have created an environment where we’re on the path to getting safer,” he says. “We’re much more open and honest about errors. We attack them with root-cause analysis and find better ways to fix the problem. For me, that’s all healthy. It leaves me with great confidence that things are safer in American hospitals than they were 10 years ago—although certainly not as safe as they need to be.”—LB

Q: How do you rate the impact of To Err is Human on the medical industry as a whole?

Dr. Cassel: The Agency for Healthcare Research and Quality, five years after the IOM report, said we hadn’t made enough progress. We have, most importantly, been able to talk about it and understand some of the approaches to safety and quality. But that’s not nearly enough, in my opinion.

Dr. Berwick: I’d give it a C-minus. There has been a change in awareness of medical safety. Before the IOM report, you just didn’t hear about it. A scientific basis for the statement of the problem was created, and we can never go back. Prototypes of what could be achieved have started to emerge, not just in this country but worldwide. The problem is that the success is just in pockets—not fundamental change in the nature of the American healthcare industry. That level of execution just is not there yet. Now it’s game time—time to take safety and quality mainstream.

Q: In retrospect, what was missed in the report?

Dr. Berwick: If we missed any boat in our analysis, the idea of “no blame” is not meant to relieve everyone of responsibility for medical errors, but to relocate responsibility for safety in the offices and work of leaders of healthcare institutions. The finger points to the executive suite. There’s more and more evidence that safety does not improve without the clear commitment of leaders.

Dr. Cassel: When we think about how we train doctors, which I spend a lot of time doing, they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change. ABIM’s new pathway for hospitalists, which will be rolled out in another year or so (see “A-Plus Achievement,” p. 1), treats questions of how … to identify patient-safety issues as core knowledge.

Q: What is the relationship of the patient-safety movement to the hospitalist movement?

Dr. Cassel: The development and growth of patient safety has paralleled the growth of hospital medicine, and I think that’s a good thing. Most of the literature on available errors focuses on the hospital because that’s the easiest place to find numbers of patients and shine a light on safety. Specialists in hospital medicine have a unique opportunity and responsibility to be leaders in continuing to advance the cause of patient safety.

Q: What should HM’s patient-safety agenda look like going forward?

Dr. Berwick: No. 1, aim for zero. There are types of injuries and infections that can be nearly eliminated in the hospital. When you look at safety-oriented efforts in other industries, they strive to get to the point where they’re no longer talking about ratios, only numerators (how many actual incidents).

Second is to broaden the focus from safety to all the other dimensions of quality. Think about reliability, processes and performance across the board.

Third is to be authentic about teamwork across professions. In the medical culture at large, there still is too much focus on turf issues between doctors and nurses. I believe in the long run new safety initiatives will be fostered by teams working at unprecedented levels of collaboration, reaching across traditional boundaries.

Dr. Cassel: The issue of diagnostic error is also emerging as another kind of medical error.

In order for patients to get the right treatment, they need to get the right diagnosis. That’s where all of your medical training, knowledge, and judgment come into play. For ABIM, that’s how we evaluate physicians’ judgment.

The next frontier in patient safety is the handoff, from ambulatory to hospital and back, but also with long-term care, which is a black box. An enlightened and energetic hospitalist movement could decide to take that issue on.

Where it would happen is at the community level, although some of the healthcare reform legislation includes ideas about innovation zones and how to create payment mechanisms to support continuity of care. TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press, 2001.
3. Moser R. Diseases of Medical Progress: A Contemporary Analysis of Illnesses Produced by Drugs and Other Therapeutic Procedures. Springfield, Ill.: Charles C. Thomas, 1959.
4. Reason, J. Human Error. Cambridge, England: Cambridge University Press, 1990.
5. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
6. United Kingdom Department of Health. An Organisation with a Memory. 2000.
7. Jerrard J. No fee for errors. The Hospitalist. 2008;(5):18.
8. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-221.

The Evolution of Patient Safety

Key milestones in the patient-safety and medical QI movement:

200 B.C. - Hippocrates, the Greek scholar and father of modern medicine, promulgates the concept primum non nocere, which translates to “first, do no harm.”

1910 - Ernest Codman, a Boston surgeon who loses his privileges at Massachusetts General Hospital for pushing his end-results system (known today as medical outcomes), establishes the “End Result Hospital” and helps found the American College of Surgeons’ Hospital Standardization Program. This program evolves into the Joint Commission.

1959 - Diseases of Medical Progress by Robert Moser argues that iatrogenic disease is both common and preventable.2

1980s-1990s - Various medical errors result in high-profile patient deaths, including that of Libby Zion at New York Hospital in 1984 and Betsy Lehman at the Dana-Farber Cancer Institute in Boston in 1994. The deaths keep medical errors in the headlines.

1985 - The Anesthesia Patient Safety Foundation is established; anesthesiology is the first specialty to dedicate resources to preventing medical error.

1990 - James Reason’s Human Error describes his theory of error as systems failure.3 It is undiscovered by healthcare until …

1994 - … Lucien Leape’s article “Error in Medicine” is published in the Journal of the American Medical Association, drawing upon advances in error prevention from fields other than medicine.4

1999- The Institute of Medicine releases its landmark patient safety report, To Err Is Human.

2000 - The National Health Service in the United Kingdom releases another major medical safety report, An Organisation with a Memory.5

2001 - Congress establishes the Agency for Healthcare Research and Quality (AHRQ) to begin an aggressive patient-safety research and improvement program.

2001 - IOM releases a follow-up safety and quality report, Crossing the Quality Chasm.2

2002 - The Joint Commission releases its first National Patient Safety Goals.

2004 - The federal government creates the Office of the National Coordinator for Healthcare Information Technology to promote systems improvements in the medical industry.

2005 - The Institute for Healthcare Improvement’s 100,000 Lives campaign begins; it encourages hospitals to adopt basic steps to reduce harm and deaths.

2006 - The National Quality Forum issues its list of “never events,” 28 medical errors that should never occur in hospitals.6

2007 - Medical checklist research spearheaded by Peter Pronovost, MD, of Johns Hopkins University, including a patient- safety project involving all ICUs in the state of Michigan, is highlighted in a widely noted New Yorker profile and elsewhere.

2009 - The American Recovery and Reinvestment Act passes Congress and is signed by President Obama. It contains $19 billion for advancing healthcare information technology.

Source: Adapted from Wachter, R. Understanding Patient Safety (Lang Clinical Medicine), McGraw-Hill: 2007, Appendix III, Selected Milestones in the Field of Patient Safety, p. 280-281, which was adapted from sources including Vincent C. Patient Safety. London; Elsevier, 2006; and Sharpe VA, Faden AI. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic illness. New York: Cambridge University Press, 1998.

Image Sources: DNY59, ZEFFSS1, AYZEK, DON BAYLEY, BECKY REED/ISTOCKPHOTO.COM

HM Leaders Weigh In

Question 1: What was hospital medicine’s contribution and role in the patient-safety movement that ensued following the IOM report?

“I believe that hospitalists have been integral to improving patient safety and reducing medical errors in those hospitals. Patients are safer and better off if there is a physician in the house ready to respond should patients have a change in health status. Hospitalists see the hospital as their office, if you will, and they focus not only on treating the patient in the bed, but treating the hospital itself by becoming engaged with quality improvement and patient-safety initiatives that improve the system of care.”—Mark Williams, MD, FHM, chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago; SHM past president; editor of the Journal of Hospital Medicine

“The role hospital medicine has filled has been as a major supplier of physicians to quality-improvement teams and other hospital teams at the front lines, prior to which physicians were conspicuously absent. If you look, for example, at nurses and other healthcare professionals, they came to the party much earlier than we did. Physicians have only recently on a broad scale become involved on these teams, and I think the major contributors have been hospitalists.”—Winthrop Whitcomb, MD, FHM, director of performance improvement, Mercy Medical Center, Springfield, Mass.; SHM co-founder

“There was a tremendous kind of synergy where hospital medicine was defining itself by its focus on systems of care, safety culture, error reporting, collaboration, interdisciplinary teams and so forth. The IOM report did a beautiful job of taking the knowledge and literature, not just from within medicine but more importantly from outside, and showing how a lot of those concepts that had been implemented successfully elsewhere were lacking in medicine in general. That really just teed it up for hospital medicine to take the impetus and framework IOM supplied and use it as a rubric for what hospital medicine could do for its part of the health system.”—Russ Cucina, MD, assistant professor of medicine and associate medical director for information technology, University of California at San Francisco

Question 2: What is the most important unfinished business for hospitalists regarding the patient-safety movement?

“I think we have made tremendous strides but there is much more to do. Although we have pockets of success, what we need to do is make those successes more uniform, so they happen in every hospital, not just some hospitals that have the right hospitalist leader or the right skill set or the right culture. We want to create the right culture and skill set and team in every hospital, and one of our challenges at SHM is to work on a mentoring program for hospitalists. That means using those who have been successful to mentor other sites and bring them on board to reproduce and replicate the good work.”—Janet Nagamine, MD, FHM, hospitalist, Kaiser Permanente Medical Center, Santa Clara, Calif.; SHM Hospital Quality/Patient Safety Committee chairwoman

“The patients who enter hospitals today are incredibly sick, with multiple organ failures and other complications. Taking care of these patients is incredibly challenging, and there are always going to be things that do not go well. Hospitalists have begun to uncover and tackle a lot of these problems, but even as they eliminate one problem, new treatments, devices, procedures and strategies for caring for patients—all designed to improve care—may have unintended consequences. It is hospitalists’ job to try to mitigate those consequences and redesign the strategies to continue to improve outcomes. But this is a long road—a marathon, not a sprint.”—Scott Flanders, MD, FHM, director of the hospitalist division, University of Michigan Health System, Ann Arbor; president of SHM

“The greatest area of unfinished business I see is preserving continuity of care for our patients as they transition in and out of the hospital. So much is happening, and there is a great need to get information quickly and communicate between the inpatient and community-based practitioner. I should say we’ve come a long way, but there’s a lot more to do in this area, and that’s why six medical societies, including SHM, came together to produce the recent Transitions of Care Consensus Statement, acknowledging that this is a crucial part of patient safety and describing what are effective transitions of care in and out of the hospital.”—Vineet Arora, MD, MA, FHM, assistant professor, Department of Medicine, University of Chicago

—LB

It’s November 1999, and the release of an advance copy of a breakthrough Institute of Medicine (IOM) report on patient safety provokes headlines around the world with its estimate that as many as 98,000 people per year die from medical errors in U.S. hospitals. The report and subsequent book, To Err is Human: Building a Safer Health System, already is labeled a landmark event for modern medicine.1 It launches a nationwide effort to systematically improve patient safety and reduce errors.

Believe it or not, the IOM report celebrates its 10th anniversary this month. Many healthcare leaders point out that the QI and patient-safety revolution birthed by the IOM report has paralleled the simultaneous—and seismic—growth of HM.

The IOM report drew upon data from Harvard Medical Practice Studies and other existing research for its shocking estimates of error-induced deaths. The report, to a large degree, focused on prescribing errors, with less emphasis on hospital-acquired infections and other safety and quality issues that have emerged since its publication. The report also proposed a comprehensive safety strategy for government, industry, consumers, and healthcare providers—a proposal that has been adopted only in pieces.

In commemorating the 10th anniversary of the IOM report, industry leaders agree that HM more than any other medical specialty will continue to play a leading role in pushing the quality and patient-safety agenda in hospitals throughout America.

IOM’s Committee on Quality of Healthcare in America, which was made up of physicians, researchers, and healthcare leaders, authored the breakthrough report on medical errors, and followed up two years later with Crossing the Quality Chasm: A New Health System for the 21st Century (www.iom.edu/?id=12736).2

The Hospitalist caught up with two of the original committee members, Donald Berwick, MD, MPP, FRCP, president and CEO of the Institute for Healthcare Improvement (IHI), and Christine Cassel, MD, president and CEO of the American Board of Internal Medicine (ABIM), to discuss how far medicine has come—and how far it has to go—in the areas of hospital quality and patient safety.

When we think about how we train doctors … they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change.

—Christine Cassel, MD, president, CEO, American Board of Internal Medicine, Philadelphia

Question: What is the legacy of the IOM report?

Dr. Berwick: It didn’t launch the patient-safety movement, but it was the most important single contributor to that movement. In one step, it took the focus on safety as a goal in medicine from a relatively fringe concern to a central issue, and a central task for health providers.

Its most important element was the focus on systems improvement, rather than exhortations to individual health professionals to do a better job with patient safety. It is a cultural norm to blame someone when something goes wrong. That hasn’t changed fundamentally. But the IOM report made the point that it’s not people who are to blame for problems in patient safety, and blame won’t get us where we need to go.

HM Jumps into Quality and Patient Safety with Both Feet

An incredible, happy coincidence: That is how Robert Wachter, MD, FHM, explains the paralleled growth of HM and patient-safety awareness in U.S. hospitals. HM had “just emerged in the mid-1990s and was still figuring out what it was about when the IOM report [To Err is Human] was published,” says Dr. Wachter, chief of the hospital medicine division, professor and associate chair of the Department of Medicine, the University of California at San Francisco, former SHM president and author of the blog “Wachter’s World,” noting concerns at the time that HM would be branded as a cost-saving measure for hospitals and health plans.

“I remember vividly when the IOM report came out. A light bulb went off for me—what a spectacular opportunity for our field,” the well-known HM pioneer recalls. “Here was this huge report saying patient safety stinks and needs to be fixed. I was pretty sure other medical specialties would not welcome the findings. I and other hospitalist leaders pushed very hard to say ‘we own this’—we believe the report is true and we believe it requires a new kind of physician who believes in systems thinking, teamwork, and collaboration. I still think it was a good call for hospital medicine to jump with both feet into the quality and safety field.”

The IOM report sparked a patient-safety renaissance, Dr. Wachter says. “We recognized that there is a science here—a core knowledge, a way of thinking and an understanding that we were not going to make much progress on patient safety until we understood that knowledge, learned its science, and did the research. We have since learned that fixing patient safety is tricky, and yet as you scan the landscape, you see all of the important actors are doing something to make patient care safer.”

One of the first steps to fixing the problem is “owning up” to the fact people die because of medical mistakes. Hospitals’ willingness to adopt transparency, from the first floor to the C-suite, has changed in the past decade, Dr. Wachter says.

“We have created an environment where we’re on the path to getting safer,” he says. “We’re much more open and honest about errors. We attack them with root-cause analysis and find better ways to fix the problem. For me, that’s all healthy. It leaves me with great confidence that things are safer in American hospitals than they were 10 years ago—although certainly not as safe as they need to be.”—LB

Q: How do you rate the impact of To Err is Human on the medical industry as a whole?

Dr. Cassel: The Agency for Healthcare Research and Quality, five years after the IOM report, said we hadn’t made enough progress. We have, most importantly, been able to talk about it and understand some of the approaches to safety and quality. But that’s not nearly enough, in my opinion.

Dr. Berwick: I’d give it a C-minus. There has been a change in awareness of medical safety. Before the IOM report, you just didn’t hear about it. A scientific basis for the statement of the problem was created, and we can never go back. Prototypes of what could be achieved have started to emerge, not just in this country but worldwide. The problem is that the success is just in pockets—not fundamental change in the nature of the American healthcare industry. That level of execution just is not there yet. Now it’s game time—time to take safety and quality mainstream.

Q: In retrospect, what was missed in the report?

Dr. Berwick: If we missed any boat in our analysis, the idea of “no blame” is not meant to relieve everyone of responsibility for medical errors, but to relocate responsibility for safety in the offices and work of leaders of healthcare institutions. The finger points to the executive suite. There’s more and more evidence that safety does not improve without the clear commitment of leaders.

Dr. Cassel: When we think about how we train doctors, which I spend a lot of time doing, they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change. ABIM’s new pathway for hospitalists, which will be rolled out in another year or so (see “A-Plus Achievement,” p. 1), treats questions of how … to identify patient-safety issues as core knowledge.

Q: What is the relationship of the patient-safety movement to the hospitalist movement?

Dr. Cassel: The development and growth of patient safety has paralleled the growth of hospital medicine, and I think that’s a good thing. Most of the literature on available errors focuses on the hospital because that’s the easiest place to find numbers of patients and shine a light on safety. Specialists in hospital medicine have a unique opportunity and responsibility to be leaders in continuing to advance the cause of patient safety.

Q: What should HM’s patient-safety agenda look like going forward?

Dr. Berwick: No. 1, aim for zero. There are types of injuries and infections that can be nearly eliminated in the hospital. When you look at safety-oriented efforts in other industries, they strive to get to the point where they’re no longer talking about ratios, only numerators (how many actual incidents).

Second is to broaden the focus from safety to all the other dimensions of quality. Think about reliability, processes and performance across the board.

Third is to be authentic about teamwork across professions. In the medical culture at large, there still is too much focus on turf issues between doctors and nurses. I believe in the long run new safety initiatives will be fostered by teams working at unprecedented levels of collaboration, reaching across traditional boundaries.

Dr. Cassel: The issue of diagnostic error is also emerging as another kind of medical error.

In order for patients to get the right treatment, they need to get the right diagnosis. That’s where all of your medical training, knowledge, and judgment come into play. For ABIM, that’s how we evaluate physicians’ judgment.

The next frontier in patient safety is the handoff, from ambulatory to hospital and back, but also with long-term care, which is a black box. An enlightened and energetic hospitalist movement could decide to take that issue on.

Where it would happen is at the community level, although some of the healthcare reform legislation includes ideas about innovation zones and how to create payment mechanisms to support continuity of care. TH

Larry Beresford is a freelance writer based in Oakland, Calif.

References

1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press, 2000.
2. Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academies Press, 2001.
3. Moser R. Diseases of Medical Progress: A Contemporary Analysis of Illnesses Produced by Drugs and Other Therapeutic Procedures. Springfield, Ill.: Charles C. Thomas, 1959.
4. Reason, J. Human Error. Cambridge, England: Cambridge University Press, 1990.
5. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
6. United Kingdom Department of Health. An Organisation with a Memory. 2000.
7. Jerrard J. No fee for errors. The Hospitalist. 2008;(5):18.
8. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-221.

The Evolution of Patient Safety

Key milestones in the patient-safety and medical QI movement:

200 B.C. - Hippocrates, the Greek scholar and father of modern medicine, promulgates the concept primum non nocere, which translates to “first, do no harm.”

1910 - Ernest Codman, a Boston surgeon who loses his privileges at Massachusetts General Hospital for pushing his end-results system (known today as medical outcomes), establishes the “End Result Hospital” and helps found the American College of Surgeons’ Hospital Standardization Program. This program evolves into the Joint Commission.

1959 - Diseases of Medical Progress by Robert Moser argues that iatrogenic disease is both common and preventable.2

1980s-1990s - Various medical errors result in high-profile patient deaths, including that of Libby Zion at New York Hospital in 1984 and Betsy Lehman at the Dana-Farber Cancer Institute in Boston in 1994. The deaths keep medical errors in the headlines.

1985 - The Anesthesia Patient Safety Foundation is established; anesthesiology is the first specialty to dedicate resources to preventing medical error.

1990 - James Reason’s Human Error describes his theory of error as systems failure.3 It is undiscovered by healthcare until …

1994 - … Lucien Leape’s article “Error in Medicine” is published in the Journal of the American Medical Association, drawing upon advances in error prevention from fields other than medicine.4

1999- The Institute of Medicine releases its landmark patient safety report, To Err Is Human.

2000 - The National Health Service in the United Kingdom releases another major medical safety report, An Organisation with a Memory.5

2001 - Congress establishes the Agency for Healthcare Research and Quality (AHRQ) to begin an aggressive patient-safety research and improvement program.

2001 - IOM releases a follow-up safety and quality report, Crossing the Quality Chasm.2

2002 - The Joint Commission releases its first National Patient Safety Goals.

2004 - The federal government creates the Office of the National Coordinator for Healthcare Information Technology to promote systems improvements in the medical industry.

2005 - The Institute for Healthcare Improvement’s 100,000 Lives campaign begins; it encourages hospitals to adopt basic steps to reduce harm and deaths.

2006 - The National Quality Forum issues its list of “never events,” 28 medical errors that should never occur in hospitals.6

2007 - Medical checklist research spearheaded by Peter Pronovost, MD, of Johns Hopkins University, including a patient- safety project involving all ICUs in the state of Michigan, is highlighted in a widely noted New Yorker profile and elsewhere.

2009 - The American Recovery and Reinvestment Act passes Congress and is signed by President Obama. It contains $19 billion for advancing healthcare information technology.

Source: Adapted from Wachter, R. Understanding Patient Safety (Lang Clinical Medicine), McGraw-Hill: 2007, Appendix III, Selected Milestones in the Field of Patient Safety, p. 280-281, which was adapted from sources including Vincent C. Patient Safety. London; Elsevier, 2006; and Sharpe VA, Faden AI. Medical Harm: Historical, Conceptual, and Ethical Dimensions of Iatrogenic illness. New York: Cambridge University Press, 1998.

Image Sources: DNY59, ZEFFSS1, AYZEK, DON BAYLEY, BECKY REED/ISTOCKPHOTO.COM

HM Leaders Weigh In

Question 1: What was hospital medicine’s contribution and role in the patient-safety movement that ensued following the IOM report?

“I believe that hospitalists have been integral to improving patient safety and reducing medical errors in those hospitals. Patients are safer and better off if there is a physician in the house ready to respond should patients have a change in health status. Hospitalists see the hospital as their office, if you will, and they focus not only on treating the patient in the bed, but treating the hospital itself by becoming engaged with quality improvement and patient-safety initiatives that improve the system of care.”—Mark Williams, MD, FHM, chief, division of hospital medicine, Northwestern University Feinberg School of Medicine, Chicago; SHM past president; editor of the Journal of Hospital Medicine

“The role hospital medicine has filled has been as a major supplier of physicians to quality-improvement teams and other hospital teams at the front lines, prior to which physicians were conspicuously absent. If you look, for example, at nurses and other healthcare professionals, they came to the party much earlier than we did. Physicians have only recently on a broad scale become involved on these teams, and I think the major contributors have been hospitalists.”—Winthrop Whitcomb, MD, FHM, director of performance improvement, Mercy Medical Center, Springfield, Mass.; SHM co-founder

“There was a tremendous kind of synergy where hospital medicine was defining itself by its focus on systems of care, safety culture, error reporting, collaboration, interdisciplinary teams and so forth. The IOM report did a beautiful job of taking the knowledge and literature, not just from within medicine but more importantly from outside, and showing how a lot of those concepts that had been implemented successfully elsewhere were lacking in medicine in general. That really just teed it up for hospital medicine to take the impetus and framework IOM supplied and use it as a rubric for what hospital medicine could do for its part of the health system.”—Russ Cucina, MD, assistant professor of medicine and associate medical director for information technology, University of California at San Francisco

Question 2: What is the most important unfinished business for hospitalists regarding the patient-safety movement?

“I think we have made tremendous strides but there is much more to do. Although we have pockets of success, what we need to do is make those successes more uniform, so they happen in every hospital, not just some hospitals that have the right hospitalist leader or the right skill set or the right culture. We want to create the right culture and skill set and team in every hospital, and one of our challenges at SHM is to work on a mentoring program for hospitalists. That means using those who have been successful to mentor other sites and bring them on board to reproduce and replicate the good work.”—Janet Nagamine, MD, FHM, hospitalist, Kaiser Permanente Medical Center, Santa Clara, Calif.; SHM Hospital Quality/Patient Safety Committee chairwoman

“The patients who enter hospitals today are incredibly sick, with multiple organ failures and other complications. Taking care of these patients is incredibly challenging, and there are always going to be things that do not go well. Hospitalists have begun to uncover and tackle a lot of these problems, but even as they eliminate one problem, new treatments, devices, procedures and strategies for caring for patients—all designed to improve care—may have unintended consequences. It is hospitalists’ job to try to mitigate those consequences and redesign the strategies to continue to improve outcomes. But this is a long road—a marathon, not a sprint.”—Scott Flanders, MD, FHM, director of the hospitalist division, University of Michigan Health System, Ann Arbor; president of SHM

“The greatest area of unfinished business I see is preserving continuity of care for our patients as they transition in and out of the hospital. So much is happening, and there is a great need to get information quickly and communicate between the inpatient and community-based practitioner. I should say we’ve come a long way, but there’s a lot more to do in this area, and that’s why six medical societies, including SHM, came together to produce the recent Transitions of Care Consensus Statement, acknowledging that this is a crucial part of patient safety and describing what are effective transitions of care in and out of the hospital.”—Vineet Arora, MD, MA, FHM, assistant professor, Department of Medicine, University of Chicago

—LB

A commentary in the Oct. 1 New England Journal of Medicine (2009;361(14):1401-1406) says physicians should be held more accountable when they violate recognized medical-safety practices. The leader of one of the nation’s largest HM companies agrees with the article's premise, although hospitalwide discipline change will be difficult to implement.

Robert Bessler, MD, president and CEO of Sound Inpatient Physicians in Tacoma, Wash., says greater accountability should be the overarching goal when the systemic causes of medical errors have been addressed and evidence-based safety processes are established. Once those definitions are in place, "if people still fail to meet recognized safety practices, there should be personal accountability," Dr. Bessler says. "I applaud the sentiments of the NEJM article, but I can see that this may be hard to implement."

Coauthors Robert Wachter, MD, FHM, professor and chief of the division of hospital medicine at the University of California at San Francisco, and Peter Pronovost, MD, PhD, director of the quality and safety group at Johns Hopkins University in Baltimore, propose balancing the "no blame" philosophy at the core of the patient-safety movement with provider performance expectations and penalties for failure to adhere to best practices. The authors offer the example of hand hygiene, which rarely rises above 30% to 70% compliance in hospitals despite evidence it prevents infections.

The biggest roadblock to making physicians accountable for practices might be the complex relationship between hospitals and medical staffs—namely, the hospital administrations' reluctance to anger the physicians who bring in patients, Dr. Bessler says. It might be easier to influence the behavior of hospitalists, he explains, because of the role they play inside the hospital.

As a contract provider of hospitalists, Dr. Bessler's company exerts influence on the behavior of its physicians through orientation, mutual performance evaluations, and the exchange of quality and performance data. "Physicians who don't share our core values wouldn't make partners, so it’s a financial and career development issue," he says. But the best "stick" for changing behavior, he adds, is sharing actual performance data with physicians, who tend to be competitive about their performance.

A commentary in the Oct. 1 New England Journal of Medicine (2009;361(14):1401-1406) says physicians should be held more accountable when they violate recognized medical-safety practices. The leader of one of the nation’s largest HM companies agrees with the article's premise, although hospitalwide discipline change will be difficult to implement.

Robert Bessler, MD, president and CEO of Sound Inpatient Physicians in Tacoma, Wash., says greater accountability should be the overarching goal when the systemic causes of medical errors have been addressed and evidence-based safety processes are established. Once those definitions are in place, "if people still fail to meet recognized safety practices, there should be personal accountability," Dr. Bessler says. "I applaud the sentiments of the NEJM article, but I can see that this may be hard to implement."

Coauthors Robert Wachter, MD, FHM, professor and chief of the division of hospital medicine at the University of California at San Francisco, and Peter Pronovost, MD, PhD, director of the quality and safety group at Johns Hopkins University in Baltimore, propose balancing the "no blame" philosophy at the core of the patient-safety movement with provider performance expectations and penalties for failure to adhere to best practices. The authors offer the example of hand hygiene, which rarely rises above 30% to 70% compliance in hospitals despite evidence it prevents infections.

The biggest roadblock to making physicians accountable for practices might be the complex relationship between hospitals and medical staffs—namely, the hospital administrations' reluctance to anger the physicians who bring in patients, Dr. Bessler says. It might be easier to influence the behavior of hospitalists, he explains, because of the role they play inside the hospital.

As a contract provider of hospitalists, Dr. Bessler's company exerts influence on the behavior of its physicians through orientation, mutual performance evaluations, and the exchange of quality and performance data. "Physicians who don't share our core values wouldn't make partners, so it’s a financial and career development issue," he says. But the best "stick" for changing behavior, he adds, is sharing actual performance data with physicians, who tend to be competitive about their performance.

A commentary in the Oct. 1 New England Journal of Medicine (2009;361(14):1401-1406) says physicians should be held more accountable when they violate recognized medical-safety practices. The leader of one of the nation’s largest HM companies agrees with the article's premise, although hospitalwide discipline change will be difficult to implement.

Robert Bessler, MD, president and CEO of Sound Inpatient Physicians in Tacoma, Wash., says greater accountability should be the overarching goal when the systemic causes of medical errors have been addressed and evidence-based safety processes are established. Once those definitions are in place, "if people still fail to meet recognized safety practices, there should be personal accountability," Dr. Bessler says. "I applaud the sentiments of the NEJM article, but I can see that this may be hard to implement."

Coauthors Robert Wachter, MD, FHM, professor and chief of the division of hospital medicine at the University of California at San Francisco, and Peter Pronovost, MD, PhD, director of the quality and safety group at Johns Hopkins University in Baltimore, propose balancing the "no blame" philosophy at the core of the patient-safety movement with provider performance expectations and penalties for failure to adhere to best practices. The authors offer the example of hand hygiene, which rarely rises above 30% to 70% compliance in hospitals despite evidence it prevents infections.

The biggest roadblock to making physicians accountable for practices might be the complex relationship between hospitals and medical staffs—namely, the hospital administrations' reluctance to anger the physicians who bring in patients, Dr. Bessler says. It might be easier to influence the behavior of hospitalists, he explains, because of the role they play inside the hospital.

As a contract provider of hospitalists, Dr. Bessler's company exerts influence on the behavior of its physicians through orientation, mutual performance evaluations, and the exchange of quality and performance data. "Physicians who don't share our core values wouldn't make partners, so it’s a financial and career development issue," he says. But the best "stick" for changing behavior, he adds, is sharing actual performance data with physicians, who tend to be competitive about their performance.

A presentation at last week's 13th annual Management of the Hospitalized Patient conference in San Francisco described various ways that hospitals, hospitalists, and HM groups can incorporate new social media into their practice routines.

Hospitalist Russell Cucina, MD, MS, associate medical director of information technology at the University of California at San Francisco, says some physicians mistakenly disclose unprofessional content through social networks. He points to a recent article in the Journal of the American Medical Association (2009;302(12):1309-1315), which shows some physicians inadvertently violate Health Insurance Portability and Accountability Act privacy rules by accepting e-mails from patients that contain protected personal health information.

But in many cases, hospitals and physicians use blogs, Twitter, Facebook, LinkedIn, and other networking sites to exchange information with colleagues, promote their practice in their communities, or recruit new physicians. Such organizations as the Mayo Clinic and SHM use Facebook to reach targeted audiences, while the Centers for Disease Control and Prevention (CDC) uses Twitter to quickly disseminate influenza updates. Dr. Cucina says he knows of 167 U.S. hospitals using the much-hyped Twitter, but he could not find an HM group that uses the quick-hit network. He also reports that Ozmosis and Sermo, networking sites reserved for physicians, have yet to catch on in a big way.

Christine Roed, MD, a hospitalist at El Camino Hospital in Mountain View, Calif., says she sees great potential for communicating within her small medical group and for tapping into public health information. "I also feel it might be quite overwhelming. I think we have to look quite carefully at which information sources are reliable and, in turn, advise the public," Dr. Roed says. "I think a lot of physicians don't really have time to sit down and figure out what they're going to do with these things."

A presentation at last week's 13th annual Management of the Hospitalized Patient conference in San Francisco described various ways that hospitals, hospitalists, and HM groups can incorporate new social media into their practice routines.

Hospitalist Russell Cucina, MD, MS, associate medical director of information technology at the University of California at San Francisco, says some physicians mistakenly disclose unprofessional content through social networks. He points to a recent article in the Journal of the American Medical Association (2009;302(12):1309-1315), which shows some physicians inadvertently violate Health Insurance Portability and Accountability Act privacy rules by accepting e-mails from patients that contain protected personal health information.

But in many cases, hospitals and physicians use blogs, Twitter, Facebook, LinkedIn, and other networking sites to exchange information with colleagues, promote their practice in their communities, or recruit new physicians. Such organizations as the Mayo Clinic and SHM use Facebook to reach targeted audiences, while the Centers for Disease Control and Prevention (CDC) uses Twitter to quickly disseminate influenza updates. Dr. Cucina says he knows of 167 U.S. hospitals using the much-hyped Twitter, but he could not find an HM group that uses the quick-hit network. He also reports that Ozmosis and Sermo, networking sites reserved for physicians, have yet to catch on in a big way.

Christine Roed, MD, a hospitalist at El Camino Hospital in Mountain View, Calif., says she sees great potential for communicating within her small medical group and for tapping into public health information. "I also feel it might be quite overwhelming. I think we have to look quite carefully at which information sources are reliable and, in turn, advise the public," Dr. Roed says. "I think a lot of physicians don't really have time to sit down and figure out what they're going to do with these things."

A presentation at last week's 13th annual Management of the Hospitalized Patient conference in San Francisco described various ways that hospitals, hospitalists, and HM groups can incorporate new social media into their practice routines.

Hospitalist Russell Cucina, MD, MS, associate medical director of information technology at the University of California at San Francisco, says some physicians mistakenly disclose unprofessional content through social networks. He points to a recent article in the Journal of the American Medical Association (2009;302(12):1309-1315), which shows some physicians inadvertently violate Health Insurance Portability and Accountability Act privacy rules by accepting e-mails from patients that contain protected personal health information.

But in many cases, hospitals and physicians use blogs, Twitter, Facebook, LinkedIn, and other networking sites to exchange information with colleagues, promote their practice in their communities, or recruit new physicians. Such organizations as the Mayo Clinic and SHM use Facebook to reach targeted audiences, while the Centers for Disease Control and Prevention (CDC) uses Twitter to quickly disseminate influenza updates. Dr. Cucina says he knows of 167 U.S. hospitals using the much-hyped Twitter, but he could not find an HM group that uses the quick-hit network. He also reports that Ozmosis and Sermo, networking sites reserved for physicians, have yet to catch on in a big way.

Christine Roed, MD, a hospitalist at El Camino Hospital in Mountain View, Calif., says she sees great potential for communicating within her small medical group and for tapping into public health information. "I also feel it might be quite overwhelming. I think we have to look quite carefully at which information sources are reliable and, in turn, advise the public," Dr. Roed says. "I think a lot of physicians don't really have time to sit down and figure out what they're going to do with these things."