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A Patient's Perspective on Readmissions
Years into the national discourse on reducing readmissions, hospitals and providers are still struggling with how to sustainably reduce 30‐day readmissions.[1] All‐cause hospital readmission rates for Medicare benificiaries averaged 19% from 2007 through 2011 and showed only a modest improvement to 18.4% in 2012.[2] A review of 43 studies in 2011 concluded that no single intervention was reliably associated with reducing readmission rates.[3] However, although no institution has found a magic bullet for reducing readmissions, progress has been made. A 2014 meta‐analysis of randomized trials aimed at preventing 30‐day readmissions found that overall readmission interventions are effective, and that the most successful interventions are more complex in nature and focus on empowering patients to engage in self‐care after discharge.[4] Readmission reduction efforts for patients with specific diagnoses have also made gains. Among patients with heart failure, for instance, higher rates of early outpatient follow‐up and care‐transition interventions for high‐risk patients have been shown to reduce 30‐day readmissions.[5, 6]
An emerging, yet still underexplored, area in readmissions is the importance of evaluating patient perspectives. The patient has intimate knowledge of the circumstances surrounding their readmission and can be a valuable resource. This is particularly true given evidence that patient perspectives do not always align with those of providers.[7, 8] Coleman's Care Transitions Intervention was one of the earliest care‐transition models demonstrating value in engaging patients to become actively involved in their care.[9] Since then, others have begun to analyze transitions of care from the patient perspective, identifying patient‐reported needs in anticipation of discharge and after they are home.[10, 11, 12, 13, 14] However, still only a few studies have endeavored to gain a thorough understanding of the readmitted patient perspective.[7, 15, 16] These studies have already identified important issues such as lack of patient readiness for discharge and the need for additional advanced care planning and caregiver resources. A few smaller studies have interviewed readmitted patients with specific diagnoses and have also shed light on disease‐specific issues.[17, 18, 19, 20] Outside the field of readmissions, improving patient‐centered communication has been shown to reduce expenditures on diagnostic tests,[21, 22] increase adherence to treatment,[23] and improve health outcomes.[24, 25] It is time for us to incorporate the patient voice into all areas of care.
In 2014, our group published the results of a study aimed at understanding the patient perspective surrounding readmissions. In this study, 27% of patients believed their readmission could have been prevented. This opinion was associated with not feeling ready for discharge, not having a follow‐up appointment scheduled, and poor satisfaction with the discharging team.[7] A key observation in these initial interviews was that patients often expressed sentiments of relief rather than frustration when they returned to the hospital. With the results of this previous study in mind, we designed a more comprehensive evaluation to investigate why patients felt unprepared for discharge, explore reasons for and attitudes surrounding readmissions, and identify patient‐centered interventions that could prevent future readmissions.
METHODS
Study Design and Recruitment
We designed the study as an in‐person survey of readmitted patients. Over a 7‐month period (February 11, 2014September 8, 2014), we identified all patients readmitted within 30 days to general medicine and cardiology services through daily queries from the electronic health record. The study took place in a 540‐bed tertiary academic medical center, as well as a 266‐bed affiliated community hospital. We reviewed the discharge summary from the index admission and the history and physical documentation from the readmission for exclusion criteria. Patients were excluded if they were: (1) readmitted to the intensive care unit, (2) had a planned readmission, (3) received an organ transplant in the preceding 3 months, (4) did not speak English, or (5) had a physical or mental incapacity preventing interview and no family member or caregiver was available to interview.
Patient Interviews
Five trained study volunteers approached all eligible patients for an interview starting the day after the patient was readmitted. Prior to the start of the interview, we obtained verbal consent from all patients. Interviews typically lasted 10 to 30 minutes in the patient's hospital room. Caregivers and/or family members were allowed to respond to interview questions if the patient granted them permission or if the patient was unable to participate. The interviewers were not part of the patient's medical team and the patients could refuse the interview at any time. According to the University of California Los Angeles (UCLA) Institutional Review Board, this work met criteria for quality‐improvement activities and was deemed to be exempt.
The survey was comprised of 24 questions addressing causes, preventability, and attitudes toward readmissions, readiness for discharge, quality of the discharge process, outpatient resources, and follow‐up care (see Supporting Information in the online version of this article). These areas of focus were chosen based on a pilot study of 98 patient interviews in which these topics emerged as worthy of further investigation.[7] With regard to patient readiness for discharge, we investigated correlations between patient readiness and symptom resolution, pain control, discharge location, level of support at home, and concerns about independent self‐care after discharge.
Data Analysis
We administered the surveys, collected and managed the data using REDCap (Research Electronic Data Capture) hosted at UCLA.[26] We collected demographic data, including race, ethnicity, and insurance status retrospectively though automated chart abstraction.
We summarized descriptive characteristics by mean and standard deviation (SD) for continuous variables (except for length of stay, which was summarized by median and range) and by proportions for categorical variables. To compare demographic variables between interviewed participants and those not interviewed (not available, not approached, refused, or excluded) we used Pearson 2 tests and Fisher exact tests for categorical variables and Student t tests for the only continuous variable, age. In evaluating patient readiness for discharge, we divided patients into groups of ready and not ready as determined by interview responses, then performed Pearson 2 tests and Fisher exact tests where appropriate.
For comparing the extent of burden and relief patients endorsed upon being readmitted, we subtracted the burden score (110) from the relief score (110) for each patient, resulting in a net relief score. We then performed a 1‐sample t test to determine whether the net relief was significantly different from 0. A P value of<0.05 was considered to be statistically significant. All statistical analyses were performed using R version 3.0.2 (
RESULTS
Patient Characteristics
Eight hundred nineteen patients were readmitted to general medicine and cardiology services over the 7‐month study period at both institutions. Two hundred thirty‐five patients (29%) were excluded based on the predetermined exclusion criteria, and 105 patients (13%) were not approached for interview due to time constraints. Of the 479 eligible patients approached for interview, 164 patients (34%) could not be interviewed because they were unavailable, and 85 patients (18%) refused. We interviewed 230 patients (48%). We conducted 115 interviews at our academic medical center and 115 at our community affiliate. The only significant demographic difference between interviewed and not‐interviewed patients was race (P=0.004).
Interviewed patients had a mean (SD) age of 63 (SD 20) years, and 45% were male. Sixty‐three percent of interviewees were white, 21% black, 8% Asian, and 8% other. The index admission median length of stay was 4 days, and the average time between admission and readmission was 13 days (Table 1). Seventy‐nine percent of the interviews were performed directly with the patient, and 21% were conducted predominantly with the patient's caregiver.
| Characteristic | Value |
|---|---|
| |
| Age, y, mean (SD) | 62.9 (20.2) |
| Female, n (%) | 127 (55.2) |
| Insurance status, n (%) | |
| Commercial | 36 (16.3) |
| Medi‐Cal/Medicaid | 31 (14.0) |
| Medicare | 123 (55.7) |
| Other | 5 (2.3) |
| UCLA managed care | 26 (11.8) |
| Missing | 9 |
| Race, n (%) | |
| Asian | 18 (7.9) |
| Black or African American | 48 (21.1) |
| Other/refused | 19 (8.3) |
| White or Caucasian | 143 (62.7) |
| Missing | 2 |
| Index length of stay, d, median (maximum, minimum) | 4 (1, 49) |
| Time between discharge and readmission, d, mean (SD) | 13 (9) |
| Discharge location following index admission, n (%) | |
| Home | 202 (88.2) |
| Skilled nursing facility | 3 (1.3) |
| Acute rehab facility | 17 (7.4) |
| Assisted living facility | 2 (0.9) |
| Other | 5 (2.2) |
| Missing | 1 |
Patient Readiness
Twenty‐eight percent of patients reported feeling unready for discharge from their index admission. Patients who felt that their readmission was preventable were significantly more likely to report feeling unready at the time of discharge compared to those who did not classify their readmission as preventable (53% vs 17%, P<0.01). Among patients who did not feel ready for discharge, over two‐thirds felt their symptoms were not adequately resolved. Conversely, among patients who did feel ready for discharge, only 8% felt their symptoms were not resolved (P<0.01). Patients who felt they were not ready for discharge were also significantly more likely to endorse poor pain control (43% vs 7%, P<0.01). The location of discharge (ie, home, rehab facility, or skilled nursing facility) and having someone to help take care of them at home did not significantly correlate with patient readiness. Over 80% of patients in both groups reported having someone to help at home, but patients who felt unready for discharge were significantly more likely to have concerns about taking care of themselves at home (54% vs 25%, P<0.001) (Table 2).
| All Participants, n=230 | Ready, n=164 | Not Ready, n=65 | P Value | |
|---|---|---|---|---|
| Symptoms were resolved enough to leave the hospital, n=227 | 170 (74.9%) | 149 (92.0%) | 21 (32.3%) | <0.01 |
| Felt pain was under control when left the hospital, n=229 | 190 (83.0%) | 153 (93.3%) | 37 (56.9%) | <0.01 |
| Discharged to home following index admission, n=229 | 202 (88.2%) | 146 (89.6%) | 56 (86.2%) | 0.62 |
| If discharged home, had someone at home able to help, n=202 | 178 (88.1%) | 132 (90.4%) | 46 (82.1%) | 0.17 |
| If discharged home, had concerns about being able to take of themselves at home or not being strong enough to go home, n=202 | 67 (33.2%) | 37 (25.3%) | 30 (53.6%) | <0.01 |
| Thought something could have been done to prevent them from coming back to the hospital, n=228 | 75 (32.9%) | 35 (21.6%) | 39 (60.0%) | <0.01 |
Discharge Instructions
Twenty‐nine percent of patients did not recall a physician talking to them about their discharge, and 35% did not remember receiving and reviewing the discharge paperwork. Of those who read the discharge paperwork, 23% noted difficulty identifying contact phone numbers, and 22% could not locate warning symptoms indicating when to seek medical attention. Patients were able to identify medications and follow‐up appointments on the discharge paperwork a majority of the time (92% and 85%, respectively).
Ambulatory Resources and Utilization
Patients were asked about their access to outpatient resources as well as their reason(s) for returning to the hospital. Eighty‐five percent of patients reported having a primary care doctor that they would feel comfortable calling if their symptoms worsened at home. Of the patients who indicated that they were given a contact number by their discharging team, only 56% contacted a doctor before returning to the emergency room. One‐third of patients reported knowing where to obtain urgent or same‐day care besides the emergency room. Among those who did report knowledge of same‐day care centers, 89% still chose not to utilize them.
Attitudes About Readmission
To investigate the patient experience with readmissions, patients were asked to rate the extent of the burden they felt upon returning to the hospital on a scale of 1 to 10, where 1 was no burden and 10 was extreme burden. Patients were also asked to evaluate the extent of relief they felt upon readmission using the same scale. On average, patients rated their sense of relief 1.8 points higher than their sense of burden upon readmission to the hospital (7.7 [SD 2.8] vs 5.9 [SD 3.4], P<0.001). The relief of readmission was rated as equal to or greater than the burden of readmission in 79% of cases. Lastly, patients' mean (SD) overall satisfaction with their medical care was 8.5 (SD 2.0) on a scale of 1 to 10, where 1 was the least satisfied and 10 was the most satisfied a patient could imagine.
DISCUSSION
This study performs a comprehensive evaluation of the patient perspective on 30‐day readmissions. Our previous work indicated that patients associate preventable readmissions with lack of preparedness at the time of discharge.[7] This study further evaluates the basis of this association. We found that nearly 1 in 3 readmitted patients did not feel ready to leave the hospital at the time of initial discharge. Feelings of inadequate symptom resolution and poor pain control appear to be major contributors to this sentiment. Furthermore, although 88% of patients endorse having a caretaker at home, patients with concerns about taking care of themselves are more likely to feel unready at discharge. Presumably, when healthcare providers discharge patients, they believe that the patient is ready to be discharged. However, our findings suggest that often patients do not agree, highlighting a gap between the beliefs of patients and those of healthcare providers. Creating patient‐centered education on symptom management and engaging patients in developing skills for independent self‐care may minimize this gap and allow patients to feel more prepared at discharge. Future research investigating provider opinions and the steps providers take when there is a disagreement over discharge readiness would also be useful.
One way to enhance education at the time of discharge is through improvements in printed discharge instructions. Jha et al. previously showed that chart documentation of providing discharge instructions does not correlate with patients reporting receiving discharge instructions.[27] Our study echoes this finding, with only 65% of the patients remembering receiving and reviewing the discharge paperwork. Horwitz et al. have also previously demonstrated poor comprehension of discharge planning and postdischarge care among patients discharged from an academic medical center.[28] Ensuring that all patients understand and retain their discharge instructions is an essential step in improving the patient experience and potentially decreasing readmissions. Our surveys have illuminated potential shortcomings in our own center's discharge instructions. Interventions aimed at clarifying critical pieces of information on the discharge paperwork, such as warning symptoms, contact phone numbers and follow‐up appointments, could be especially helpful.
After discharge, our findings suggest that only about half of patients will call a physician before returning to the hospital. Furthermore, there is limited knowledge and poor utilization of same‐day treatment centers besides the emergency room. In previous studies, Long et al. found that frequently readmitted patients self‐triage to the emergency room because they believe primary care clinics cannot treat acute illness.[11] Another study concluded that low‐income patients prefer hospital care to ambulatory care because of a greater sense of trust in inpatient care.[29]
Our patients' attitudes about readmission may also be different from those of providers. For patients, coming back to the hospital is not a significant burden, and satisfaction with their medical care remains high despite readmission. Additional research is needed to further explore the complex emotions patients have when coming back to the hospital and why patients may not be as upset with returning to the hospital as providers may expect. Ultimately, if patients continue to feel more comfortable being hospitalized, there are few incentives for patients to stay out of the hospital, and readmission rates will remain elevated.
Based on our survey results we have hypothesized a potential framework for studying readmissions from a patient‐centered approach (Figure 1). This figure is not meant to imply causality, but rather to highlight a potential journey from discharge to readmission for a patient who does not feel ready to go home. This schema principally applies to patients who are worried about symptom management and/or self‐care before discharge and may not apply to everyone. Each asterisk in this framework represents an area where an intervention could be designed to improve the patient experience and possibly reduce readmissions. Such interventions should be centered around increasing patient education about symptom management and self‐care at the time of discharge, improving printed discharge instructions, increasing patient awareness of outpatient resources, enhancing communication after discharge, and changing patients' attitudes about readmissions.
This study's limitations include that it is a single‐institution study focusing on patients admitted to a large academic medical center and its partner community hospital. Only English‐speaking patients were included, and thus our results may not be generalizable to other populations. All patients were interviewed at the time of readmission, potentially introducing recall bias regarding their prior discharge. For example, patients might be more likely to state they were not ready for discharge once they have been readmitted to the hospital. Lastly, because there are only a few prior studies interviewing readmitted patients, our survey instrument was not previously validated. Nevertheless, we believe this study offers a unique view on 30‐day readmissions from the patient perspective, with a focus on identifying areas for quality‐improvement interventions.
In conclusion, this study has enabled us to understand readmissions from a patient‐centered perspective. This perspective helps to challenge provider assumptions and gives much‐needed insight into the patient experience. For example, prior to surveying patients, one might assume that if a patient has a caregiver at home, they are unlikely to have concerns about taking care of themselves. We now know this is not the case. Similarly, we have discovered sections of our discharge paperwork that are confusing. Additionally, this study has revealed that patient attitudes regarding readmission can vary significantly from provider attitudes. By exploring the patient perspective and creating a new transition framework, we have identified specific target areas for interventions that would be meaningful to patients. As the nation continues to strive to identify sustainable solutions to reduce readmissions, the way to redesign care must always start and end with the patient.
Acknowledgements
The authors acknowledge Puneet Rana, James Haggerty‐Skeans, Jae Kim, Rhea Mathew, and Anna Do (UCLA volunteers) for helping to perform the patient interviews. We acknowledge Sandy Berry, MA (Senior Behavioral Scientist at RAND Corporation) for her help in reviewing our patient interview script. Additionally Anna Dermenchyan, RN, BSN (Senior Clinical Quality Specialist in the Department of Medicine at UCLA) provided significant administrative support.
Disclosures: This project was supported by a Patient Experience Grant from the Beryl Institute awarded to Jessica Howard‐Anderson, Sarah Lonowski, Ashley Busuttil, and Nasim Afsar‐manesh. Dr. Howard‐Anderson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All coauthors have seen and agree with the contents of the article. The article is not under review by any other publication. An earlier version of this work was written as a research report (not peer reviewed) for the Beryl Institute (available at:
- , . What will it take to move the needle on hospital readmissions? Am J Med Qual. 2013;29(4):357–359.
- , , , , , . Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2):E1–E12.
- , , , , . Interventions to reduce 30‐day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–528.
- , , , et al. Preventing 30‐day hospital readmissions: a systematic review and meta‐analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095–1107.
- , , , et al. Relationship between early physician follow‐up and 30‐day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716–1722.
- , , , et al. Allocating scarce resources in real‐time to reduce heart failure readmissions: a prospective, controlled study. BMJ Qual Saf. 2013;22(12):998–1005.
- , , , , , . Readmissions in the era of patient engagement. JAMA Intern Med. 2014;174(11):1870–1872.
- , , , et al. Comparing perspectives of patients, caregivers, and clinicians on heart failure management [published online October 23, 2015]. J Card Fail. doi: 10.1016/j.cardfail.2015.10.011.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.
- , , . Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization? J Hosp Med. 2007;2(5):297–304.
- , , . Reasons for readmission in an underserved high‐risk population: a qualitative analysis of a series of inpatient interviews. BMJ Open. 2013;3(9):e003212.
- , , , , , . Improving care transitions: the patient perspective. J Health Commun. 2012;17(suppl 3):312–324.
- , , , et al. Challenges faced by patients with low socioeconomic status during the post‐hospital transition. J Gen Intern Med. 2014;29(2):283–289.
- , , , et al. “Missing pieces”—functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014;62(8):1556–1561.
- , , , , , . Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. 2012;7(9):709–712.
- , , , et al. Factors contributing to all‐cause 30‐day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599–605.
- , , . Reasons for readmission in heart failure: perspectives of patients, caregivers, cardiologists, and heart failure nurses. Heart Lung. 2009;38(5):427–434.
- , , , et al. Patient‐identified factors related to heart failure readmissions. Circ Cardiovasc Qual Outcomes. 2013;6(2):171–177.
- , , , , . Early readmission among patients with diabetes: a qualitative assessment of contributing factors. J Diabetes Complications. 2014;28(6):869–873.
- , , , , . “Because I was sick”: seriously ill veterans' perspectives on reason for 30‐day readmissions. J Am Geriatr Soc. 2015;63(3):537–542.
- , , , et al. The impact of patient‐centered care on outcomes. J Fam Pract. 2000;49(9):796–804.
- , , , et al. Patient‐centered communication and diagnostic testing. Ann Fam Med. 2005;3(5):415–421.
- , . Physician communication and patient adherence to treatment: a meta‐analysis. Med Care. 2009;47(8):826–834.
- , , , et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90.
- , , , , . Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3(5):448–457.
- , , , , , . Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
- , , . Public reporting of discharge planning and rates of readmissions. N Engl J Med. 2009;361(27):2637–2645.
- , , , et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013;173(18):1715–1722
- , , , , , . Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff (Millwood). 2013;32(7):1196–1203.
Years into the national discourse on reducing readmissions, hospitals and providers are still struggling with how to sustainably reduce 30‐day readmissions.[1] All‐cause hospital readmission rates for Medicare benificiaries averaged 19% from 2007 through 2011 and showed only a modest improvement to 18.4% in 2012.[2] A review of 43 studies in 2011 concluded that no single intervention was reliably associated with reducing readmission rates.[3] However, although no institution has found a magic bullet for reducing readmissions, progress has been made. A 2014 meta‐analysis of randomized trials aimed at preventing 30‐day readmissions found that overall readmission interventions are effective, and that the most successful interventions are more complex in nature and focus on empowering patients to engage in self‐care after discharge.[4] Readmission reduction efforts for patients with specific diagnoses have also made gains. Among patients with heart failure, for instance, higher rates of early outpatient follow‐up and care‐transition interventions for high‐risk patients have been shown to reduce 30‐day readmissions.[5, 6]
An emerging, yet still underexplored, area in readmissions is the importance of evaluating patient perspectives. The patient has intimate knowledge of the circumstances surrounding their readmission and can be a valuable resource. This is particularly true given evidence that patient perspectives do not always align with those of providers.[7, 8] Coleman's Care Transitions Intervention was one of the earliest care‐transition models demonstrating value in engaging patients to become actively involved in their care.[9] Since then, others have begun to analyze transitions of care from the patient perspective, identifying patient‐reported needs in anticipation of discharge and after they are home.[10, 11, 12, 13, 14] However, still only a few studies have endeavored to gain a thorough understanding of the readmitted patient perspective.[7, 15, 16] These studies have already identified important issues such as lack of patient readiness for discharge and the need for additional advanced care planning and caregiver resources. A few smaller studies have interviewed readmitted patients with specific diagnoses and have also shed light on disease‐specific issues.[17, 18, 19, 20] Outside the field of readmissions, improving patient‐centered communication has been shown to reduce expenditures on diagnostic tests,[21, 22] increase adherence to treatment,[23] and improve health outcomes.[24, 25] It is time for us to incorporate the patient voice into all areas of care.
In 2014, our group published the results of a study aimed at understanding the patient perspective surrounding readmissions. In this study, 27% of patients believed their readmission could have been prevented. This opinion was associated with not feeling ready for discharge, not having a follow‐up appointment scheduled, and poor satisfaction with the discharging team.[7] A key observation in these initial interviews was that patients often expressed sentiments of relief rather than frustration when they returned to the hospital. With the results of this previous study in mind, we designed a more comprehensive evaluation to investigate why patients felt unprepared for discharge, explore reasons for and attitudes surrounding readmissions, and identify patient‐centered interventions that could prevent future readmissions.
METHODS
Study Design and Recruitment
We designed the study as an in‐person survey of readmitted patients. Over a 7‐month period (February 11, 2014September 8, 2014), we identified all patients readmitted within 30 days to general medicine and cardiology services through daily queries from the electronic health record. The study took place in a 540‐bed tertiary academic medical center, as well as a 266‐bed affiliated community hospital. We reviewed the discharge summary from the index admission and the history and physical documentation from the readmission for exclusion criteria. Patients were excluded if they were: (1) readmitted to the intensive care unit, (2) had a planned readmission, (3) received an organ transplant in the preceding 3 months, (4) did not speak English, or (5) had a physical or mental incapacity preventing interview and no family member or caregiver was available to interview.
Patient Interviews
Five trained study volunteers approached all eligible patients for an interview starting the day after the patient was readmitted. Prior to the start of the interview, we obtained verbal consent from all patients. Interviews typically lasted 10 to 30 minutes in the patient's hospital room. Caregivers and/or family members were allowed to respond to interview questions if the patient granted them permission or if the patient was unable to participate. The interviewers were not part of the patient's medical team and the patients could refuse the interview at any time. According to the University of California Los Angeles (UCLA) Institutional Review Board, this work met criteria for quality‐improvement activities and was deemed to be exempt.
The survey was comprised of 24 questions addressing causes, preventability, and attitudes toward readmissions, readiness for discharge, quality of the discharge process, outpatient resources, and follow‐up care (see Supporting Information in the online version of this article). These areas of focus were chosen based on a pilot study of 98 patient interviews in which these topics emerged as worthy of further investigation.[7] With regard to patient readiness for discharge, we investigated correlations between patient readiness and symptom resolution, pain control, discharge location, level of support at home, and concerns about independent self‐care after discharge.
Data Analysis
We administered the surveys, collected and managed the data using REDCap (Research Electronic Data Capture) hosted at UCLA.[26] We collected demographic data, including race, ethnicity, and insurance status retrospectively though automated chart abstraction.
We summarized descriptive characteristics by mean and standard deviation (SD) for continuous variables (except for length of stay, which was summarized by median and range) and by proportions for categorical variables. To compare demographic variables between interviewed participants and those not interviewed (not available, not approached, refused, or excluded) we used Pearson 2 tests and Fisher exact tests for categorical variables and Student t tests for the only continuous variable, age. In evaluating patient readiness for discharge, we divided patients into groups of ready and not ready as determined by interview responses, then performed Pearson 2 tests and Fisher exact tests where appropriate.
For comparing the extent of burden and relief patients endorsed upon being readmitted, we subtracted the burden score (110) from the relief score (110) for each patient, resulting in a net relief score. We then performed a 1‐sample t test to determine whether the net relief was significantly different from 0. A P value of<0.05 was considered to be statistically significant. All statistical analyses were performed using R version 3.0.2 (
RESULTS
Patient Characteristics
Eight hundred nineteen patients were readmitted to general medicine and cardiology services over the 7‐month study period at both institutions. Two hundred thirty‐five patients (29%) were excluded based on the predetermined exclusion criteria, and 105 patients (13%) were not approached for interview due to time constraints. Of the 479 eligible patients approached for interview, 164 patients (34%) could not be interviewed because they were unavailable, and 85 patients (18%) refused. We interviewed 230 patients (48%). We conducted 115 interviews at our academic medical center and 115 at our community affiliate. The only significant demographic difference between interviewed and not‐interviewed patients was race (P=0.004).
Interviewed patients had a mean (SD) age of 63 (SD 20) years, and 45% were male. Sixty‐three percent of interviewees were white, 21% black, 8% Asian, and 8% other. The index admission median length of stay was 4 days, and the average time between admission and readmission was 13 days (Table 1). Seventy‐nine percent of the interviews were performed directly with the patient, and 21% were conducted predominantly with the patient's caregiver.
| Characteristic | Value |
|---|---|
| |
| Age, y, mean (SD) | 62.9 (20.2) |
| Female, n (%) | 127 (55.2) |
| Insurance status, n (%) | |
| Commercial | 36 (16.3) |
| Medi‐Cal/Medicaid | 31 (14.0) |
| Medicare | 123 (55.7) |
| Other | 5 (2.3) |
| UCLA managed care | 26 (11.8) |
| Missing | 9 |
| Race, n (%) | |
| Asian | 18 (7.9) |
| Black or African American | 48 (21.1) |
| Other/refused | 19 (8.3) |
| White or Caucasian | 143 (62.7) |
| Missing | 2 |
| Index length of stay, d, median (maximum, minimum) | 4 (1, 49) |
| Time between discharge and readmission, d, mean (SD) | 13 (9) |
| Discharge location following index admission, n (%) | |
| Home | 202 (88.2) |
| Skilled nursing facility | 3 (1.3) |
| Acute rehab facility | 17 (7.4) |
| Assisted living facility | 2 (0.9) |
| Other | 5 (2.2) |
| Missing | 1 |
Patient Readiness
Twenty‐eight percent of patients reported feeling unready for discharge from their index admission. Patients who felt that their readmission was preventable were significantly more likely to report feeling unready at the time of discharge compared to those who did not classify their readmission as preventable (53% vs 17%, P<0.01). Among patients who did not feel ready for discharge, over two‐thirds felt their symptoms were not adequately resolved. Conversely, among patients who did feel ready for discharge, only 8% felt their symptoms were not resolved (P<0.01). Patients who felt they were not ready for discharge were also significantly more likely to endorse poor pain control (43% vs 7%, P<0.01). The location of discharge (ie, home, rehab facility, or skilled nursing facility) and having someone to help take care of them at home did not significantly correlate with patient readiness. Over 80% of patients in both groups reported having someone to help at home, but patients who felt unready for discharge were significantly more likely to have concerns about taking care of themselves at home (54% vs 25%, P<0.001) (Table 2).
| All Participants, n=230 | Ready, n=164 | Not Ready, n=65 | P Value | |
|---|---|---|---|---|
| Symptoms were resolved enough to leave the hospital, n=227 | 170 (74.9%) | 149 (92.0%) | 21 (32.3%) | <0.01 |
| Felt pain was under control when left the hospital, n=229 | 190 (83.0%) | 153 (93.3%) | 37 (56.9%) | <0.01 |
| Discharged to home following index admission, n=229 | 202 (88.2%) | 146 (89.6%) | 56 (86.2%) | 0.62 |
| If discharged home, had someone at home able to help, n=202 | 178 (88.1%) | 132 (90.4%) | 46 (82.1%) | 0.17 |
| If discharged home, had concerns about being able to take of themselves at home or not being strong enough to go home, n=202 | 67 (33.2%) | 37 (25.3%) | 30 (53.6%) | <0.01 |
| Thought something could have been done to prevent them from coming back to the hospital, n=228 | 75 (32.9%) | 35 (21.6%) | 39 (60.0%) | <0.01 |
Discharge Instructions
Twenty‐nine percent of patients did not recall a physician talking to them about their discharge, and 35% did not remember receiving and reviewing the discharge paperwork. Of those who read the discharge paperwork, 23% noted difficulty identifying contact phone numbers, and 22% could not locate warning symptoms indicating when to seek medical attention. Patients were able to identify medications and follow‐up appointments on the discharge paperwork a majority of the time (92% and 85%, respectively).
Ambulatory Resources and Utilization
Patients were asked about their access to outpatient resources as well as their reason(s) for returning to the hospital. Eighty‐five percent of patients reported having a primary care doctor that they would feel comfortable calling if their symptoms worsened at home. Of the patients who indicated that they were given a contact number by their discharging team, only 56% contacted a doctor before returning to the emergency room. One‐third of patients reported knowing where to obtain urgent or same‐day care besides the emergency room. Among those who did report knowledge of same‐day care centers, 89% still chose not to utilize them.
Attitudes About Readmission
To investigate the patient experience with readmissions, patients were asked to rate the extent of the burden they felt upon returning to the hospital on a scale of 1 to 10, where 1 was no burden and 10 was extreme burden. Patients were also asked to evaluate the extent of relief they felt upon readmission using the same scale. On average, patients rated their sense of relief 1.8 points higher than their sense of burden upon readmission to the hospital (7.7 [SD 2.8] vs 5.9 [SD 3.4], P<0.001). The relief of readmission was rated as equal to or greater than the burden of readmission in 79% of cases. Lastly, patients' mean (SD) overall satisfaction with their medical care was 8.5 (SD 2.0) on a scale of 1 to 10, where 1 was the least satisfied and 10 was the most satisfied a patient could imagine.
DISCUSSION
This study performs a comprehensive evaluation of the patient perspective on 30‐day readmissions. Our previous work indicated that patients associate preventable readmissions with lack of preparedness at the time of discharge.[7] This study further evaluates the basis of this association. We found that nearly 1 in 3 readmitted patients did not feel ready to leave the hospital at the time of initial discharge. Feelings of inadequate symptom resolution and poor pain control appear to be major contributors to this sentiment. Furthermore, although 88% of patients endorse having a caretaker at home, patients with concerns about taking care of themselves are more likely to feel unready at discharge. Presumably, when healthcare providers discharge patients, they believe that the patient is ready to be discharged. However, our findings suggest that often patients do not agree, highlighting a gap between the beliefs of patients and those of healthcare providers. Creating patient‐centered education on symptom management and engaging patients in developing skills for independent self‐care may minimize this gap and allow patients to feel more prepared at discharge. Future research investigating provider opinions and the steps providers take when there is a disagreement over discharge readiness would also be useful.
One way to enhance education at the time of discharge is through improvements in printed discharge instructions. Jha et al. previously showed that chart documentation of providing discharge instructions does not correlate with patients reporting receiving discharge instructions.[27] Our study echoes this finding, with only 65% of the patients remembering receiving and reviewing the discharge paperwork. Horwitz et al. have also previously demonstrated poor comprehension of discharge planning and postdischarge care among patients discharged from an academic medical center.[28] Ensuring that all patients understand and retain their discharge instructions is an essential step in improving the patient experience and potentially decreasing readmissions. Our surveys have illuminated potential shortcomings in our own center's discharge instructions. Interventions aimed at clarifying critical pieces of information on the discharge paperwork, such as warning symptoms, contact phone numbers and follow‐up appointments, could be especially helpful.
After discharge, our findings suggest that only about half of patients will call a physician before returning to the hospital. Furthermore, there is limited knowledge and poor utilization of same‐day treatment centers besides the emergency room. In previous studies, Long et al. found that frequently readmitted patients self‐triage to the emergency room because they believe primary care clinics cannot treat acute illness.[11] Another study concluded that low‐income patients prefer hospital care to ambulatory care because of a greater sense of trust in inpatient care.[29]
Our patients' attitudes about readmission may also be different from those of providers. For patients, coming back to the hospital is not a significant burden, and satisfaction with their medical care remains high despite readmission. Additional research is needed to further explore the complex emotions patients have when coming back to the hospital and why patients may not be as upset with returning to the hospital as providers may expect. Ultimately, if patients continue to feel more comfortable being hospitalized, there are few incentives for patients to stay out of the hospital, and readmission rates will remain elevated.
Based on our survey results we have hypothesized a potential framework for studying readmissions from a patient‐centered approach (Figure 1). This figure is not meant to imply causality, but rather to highlight a potential journey from discharge to readmission for a patient who does not feel ready to go home. This schema principally applies to patients who are worried about symptom management and/or self‐care before discharge and may not apply to everyone. Each asterisk in this framework represents an area where an intervention could be designed to improve the patient experience and possibly reduce readmissions. Such interventions should be centered around increasing patient education about symptom management and self‐care at the time of discharge, improving printed discharge instructions, increasing patient awareness of outpatient resources, enhancing communication after discharge, and changing patients' attitudes about readmissions.
This study's limitations include that it is a single‐institution study focusing on patients admitted to a large academic medical center and its partner community hospital. Only English‐speaking patients were included, and thus our results may not be generalizable to other populations. All patients were interviewed at the time of readmission, potentially introducing recall bias regarding their prior discharge. For example, patients might be more likely to state they were not ready for discharge once they have been readmitted to the hospital. Lastly, because there are only a few prior studies interviewing readmitted patients, our survey instrument was not previously validated. Nevertheless, we believe this study offers a unique view on 30‐day readmissions from the patient perspective, with a focus on identifying areas for quality‐improvement interventions.
In conclusion, this study has enabled us to understand readmissions from a patient‐centered perspective. This perspective helps to challenge provider assumptions and gives much‐needed insight into the patient experience. For example, prior to surveying patients, one might assume that if a patient has a caregiver at home, they are unlikely to have concerns about taking care of themselves. We now know this is not the case. Similarly, we have discovered sections of our discharge paperwork that are confusing. Additionally, this study has revealed that patient attitudes regarding readmission can vary significantly from provider attitudes. By exploring the patient perspective and creating a new transition framework, we have identified specific target areas for interventions that would be meaningful to patients. As the nation continues to strive to identify sustainable solutions to reduce readmissions, the way to redesign care must always start and end with the patient.
Acknowledgements
The authors acknowledge Puneet Rana, James Haggerty‐Skeans, Jae Kim, Rhea Mathew, and Anna Do (UCLA volunteers) for helping to perform the patient interviews. We acknowledge Sandy Berry, MA (Senior Behavioral Scientist at RAND Corporation) for her help in reviewing our patient interview script. Additionally Anna Dermenchyan, RN, BSN (Senior Clinical Quality Specialist in the Department of Medicine at UCLA) provided significant administrative support.
Disclosures: This project was supported by a Patient Experience Grant from the Beryl Institute awarded to Jessica Howard‐Anderson, Sarah Lonowski, Ashley Busuttil, and Nasim Afsar‐manesh. Dr. Howard‐Anderson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All coauthors have seen and agree with the contents of the article. The article is not under review by any other publication. An earlier version of this work was written as a research report (not peer reviewed) for the Beryl Institute (available at:
Years into the national discourse on reducing readmissions, hospitals and providers are still struggling with how to sustainably reduce 30‐day readmissions.[1] All‐cause hospital readmission rates for Medicare benificiaries averaged 19% from 2007 through 2011 and showed only a modest improvement to 18.4% in 2012.[2] A review of 43 studies in 2011 concluded that no single intervention was reliably associated with reducing readmission rates.[3] However, although no institution has found a magic bullet for reducing readmissions, progress has been made. A 2014 meta‐analysis of randomized trials aimed at preventing 30‐day readmissions found that overall readmission interventions are effective, and that the most successful interventions are more complex in nature and focus on empowering patients to engage in self‐care after discharge.[4] Readmission reduction efforts for patients with specific diagnoses have also made gains. Among patients with heart failure, for instance, higher rates of early outpatient follow‐up and care‐transition interventions for high‐risk patients have been shown to reduce 30‐day readmissions.[5, 6]
An emerging, yet still underexplored, area in readmissions is the importance of evaluating patient perspectives. The patient has intimate knowledge of the circumstances surrounding their readmission and can be a valuable resource. This is particularly true given evidence that patient perspectives do not always align with those of providers.[7, 8] Coleman's Care Transitions Intervention was one of the earliest care‐transition models demonstrating value in engaging patients to become actively involved in their care.[9] Since then, others have begun to analyze transitions of care from the patient perspective, identifying patient‐reported needs in anticipation of discharge and after they are home.[10, 11, 12, 13, 14] However, still only a few studies have endeavored to gain a thorough understanding of the readmitted patient perspective.[7, 15, 16] These studies have already identified important issues such as lack of patient readiness for discharge and the need for additional advanced care planning and caregiver resources. A few smaller studies have interviewed readmitted patients with specific diagnoses and have also shed light on disease‐specific issues.[17, 18, 19, 20] Outside the field of readmissions, improving patient‐centered communication has been shown to reduce expenditures on diagnostic tests,[21, 22] increase adherence to treatment,[23] and improve health outcomes.[24, 25] It is time for us to incorporate the patient voice into all areas of care.
In 2014, our group published the results of a study aimed at understanding the patient perspective surrounding readmissions. In this study, 27% of patients believed their readmission could have been prevented. This opinion was associated with not feeling ready for discharge, not having a follow‐up appointment scheduled, and poor satisfaction with the discharging team.[7] A key observation in these initial interviews was that patients often expressed sentiments of relief rather than frustration when they returned to the hospital. With the results of this previous study in mind, we designed a more comprehensive evaluation to investigate why patients felt unprepared for discharge, explore reasons for and attitudes surrounding readmissions, and identify patient‐centered interventions that could prevent future readmissions.
METHODS
Study Design and Recruitment
We designed the study as an in‐person survey of readmitted patients. Over a 7‐month period (February 11, 2014September 8, 2014), we identified all patients readmitted within 30 days to general medicine and cardiology services through daily queries from the electronic health record. The study took place in a 540‐bed tertiary academic medical center, as well as a 266‐bed affiliated community hospital. We reviewed the discharge summary from the index admission and the history and physical documentation from the readmission for exclusion criteria. Patients were excluded if they were: (1) readmitted to the intensive care unit, (2) had a planned readmission, (3) received an organ transplant in the preceding 3 months, (4) did not speak English, or (5) had a physical or mental incapacity preventing interview and no family member or caregiver was available to interview.
Patient Interviews
Five trained study volunteers approached all eligible patients for an interview starting the day after the patient was readmitted. Prior to the start of the interview, we obtained verbal consent from all patients. Interviews typically lasted 10 to 30 minutes in the patient's hospital room. Caregivers and/or family members were allowed to respond to interview questions if the patient granted them permission or if the patient was unable to participate. The interviewers were not part of the patient's medical team and the patients could refuse the interview at any time. According to the University of California Los Angeles (UCLA) Institutional Review Board, this work met criteria for quality‐improvement activities and was deemed to be exempt.
The survey was comprised of 24 questions addressing causes, preventability, and attitudes toward readmissions, readiness for discharge, quality of the discharge process, outpatient resources, and follow‐up care (see Supporting Information in the online version of this article). These areas of focus were chosen based on a pilot study of 98 patient interviews in which these topics emerged as worthy of further investigation.[7] With regard to patient readiness for discharge, we investigated correlations between patient readiness and symptom resolution, pain control, discharge location, level of support at home, and concerns about independent self‐care after discharge.
Data Analysis
We administered the surveys, collected and managed the data using REDCap (Research Electronic Data Capture) hosted at UCLA.[26] We collected demographic data, including race, ethnicity, and insurance status retrospectively though automated chart abstraction.
We summarized descriptive characteristics by mean and standard deviation (SD) for continuous variables (except for length of stay, which was summarized by median and range) and by proportions for categorical variables. To compare demographic variables between interviewed participants and those not interviewed (not available, not approached, refused, or excluded) we used Pearson 2 tests and Fisher exact tests for categorical variables and Student t tests for the only continuous variable, age. In evaluating patient readiness for discharge, we divided patients into groups of ready and not ready as determined by interview responses, then performed Pearson 2 tests and Fisher exact tests where appropriate.
For comparing the extent of burden and relief patients endorsed upon being readmitted, we subtracted the burden score (110) from the relief score (110) for each patient, resulting in a net relief score. We then performed a 1‐sample t test to determine whether the net relief was significantly different from 0. A P value of<0.05 was considered to be statistically significant. All statistical analyses were performed using R version 3.0.2 (
RESULTS
Patient Characteristics
Eight hundred nineteen patients were readmitted to general medicine and cardiology services over the 7‐month study period at both institutions. Two hundred thirty‐five patients (29%) were excluded based on the predetermined exclusion criteria, and 105 patients (13%) were not approached for interview due to time constraints. Of the 479 eligible patients approached for interview, 164 patients (34%) could not be interviewed because they were unavailable, and 85 patients (18%) refused. We interviewed 230 patients (48%). We conducted 115 interviews at our academic medical center and 115 at our community affiliate. The only significant demographic difference between interviewed and not‐interviewed patients was race (P=0.004).
Interviewed patients had a mean (SD) age of 63 (SD 20) years, and 45% were male. Sixty‐three percent of interviewees were white, 21% black, 8% Asian, and 8% other. The index admission median length of stay was 4 days, and the average time between admission and readmission was 13 days (Table 1). Seventy‐nine percent of the interviews were performed directly with the patient, and 21% were conducted predominantly with the patient's caregiver.
| Characteristic | Value |
|---|---|
| |
| Age, y, mean (SD) | 62.9 (20.2) |
| Female, n (%) | 127 (55.2) |
| Insurance status, n (%) | |
| Commercial | 36 (16.3) |
| Medi‐Cal/Medicaid | 31 (14.0) |
| Medicare | 123 (55.7) |
| Other | 5 (2.3) |
| UCLA managed care | 26 (11.8) |
| Missing | 9 |
| Race, n (%) | |
| Asian | 18 (7.9) |
| Black or African American | 48 (21.1) |
| Other/refused | 19 (8.3) |
| White or Caucasian | 143 (62.7) |
| Missing | 2 |
| Index length of stay, d, median (maximum, minimum) | 4 (1, 49) |
| Time between discharge and readmission, d, mean (SD) | 13 (9) |
| Discharge location following index admission, n (%) | |
| Home | 202 (88.2) |
| Skilled nursing facility | 3 (1.3) |
| Acute rehab facility | 17 (7.4) |
| Assisted living facility | 2 (0.9) |
| Other | 5 (2.2) |
| Missing | 1 |
Patient Readiness
Twenty‐eight percent of patients reported feeling unready for discharge from their index admission. Patients who felt that their readmission was preventable were significantly more likely to report feeling unready at the time of discharge compared to those who did not classify their readmission as preventable (53% vs 17%, P<0.01). Among patients who did not feel ready for discharge, over two‐thirds felt their symptoms were not adequately resolved. Conversely, among patients who did feel ready for discharge, only 8% felt their symptoms were not resolved (P<0.01). Patients who felt they were not ready for discharge were also significantly more likely to endorse poor pain control (43% vs 7%, P<0.01). The location of discharge (ie, home, rehab facility, or skilled nursing facility) and having someone to help take care of them at home did not significantly correlate with patient readiness. Over 80% of patients in both groups reported having someone to help at home, but patients who felt unready for discharge were significantly more likely to have concerns about taking care of themselves at home (54% vs 25%, P<0.001) (Table 2).
| All Participants, n=230 | Ready, n=164 | Not Ready, n=65 | P Value | |
|---|---|---|---|---|
| Symptoms were resolved enough to leave the hospital, n=227 | 170 (74.9%) | 149 (92.0%) | 21 (32.3%) | <0.01 |
| Felt pain was under control when left the hospital, n=229 | 190 (83.0%) | 153 (93.3%) | 37 (56.9%) | <0.01 |
| Discharged to home following index admission, n=229 | 202 (88.2%) | 146 (89.6%) | 56 (86.2%) | 0.62 |
| If discharged home, had someone at home able to help, n=202 | 178 (88.1%) | 132 (90.4%) | 46 (82.1%) | 0.17 |
| If discharged home, had concerns about being able to take of themselves at home or not being strong enough to go home, n=202 | 67 (33.2%) | 37 (25.3%) | 30 (53.6%) | <0.01 |
| Thought something could have been done to prevent them from coming back to the hospital, n=228 | 75 (32.9%) | 35 (21.6%) | 39 (60.0%) | <0.01 |
Discharge Instructions
Twenty‐nine percent of patients did not recall a physician talking to them about their discharge, and 35% did not remember receiving and reviewing the discharge paperwork. Of those who read the discharge paperwork, 23% noted difficulty identifying contact phone numbers, and 22% could not locate warning symptoms indicating when to seek medical attention. Patients were able to identify medications and follow‐up appointments on the discharge paperwork a majority of the time (92% and 85%, respectively).
Ambulatory Resources and Utilization
Patients were asked about their access to outpatient resources as well as their reason(s) for returning to the hospital. Eighty‐five percent of patients reported having a primary care doctor that they would feel comfortable calling if their symptoms worsened at home. Of the patients who indicated that they were given a contact number by their discharging team, only 56% contacted a doctor before returning to the emergency room. One‐third of patients reported knowing where to obtain urgent or same‐day care besides the emergency room. Among those who did report knowledge of same‐day care centers, 89% still chose not to utilize them.
Attitudes About Readmission
To investigate the patient experience with readmissions, patients were asked to rate the extent of the burden they felt upon returning to the hospital on a scale of 1 to 10, where 1 was no burden and 10 was extreme burden. Patients were also asked to evaluate the extent of relief they felt upon readmission using the same scale. On average, patients rated their sense of relief 1.8 points higher than their sense of burden upon readmission to the hospital (7.7 [SD 2.8] vs 5.9 [SD 3.4], P<0.001). The relief of readmission was rated as equal to or greater than the burden of readmission in 79% of cases. Lastly, patients' mean (SD) overall satisfaction with their medical care was 8.5 (SD 2.0) on a scale of 1 to 10, where 1 was the least satisfied and 10 was the most satisfied a patient could imagine.
DISCUSSION
This study performs a comprehensive evaluation of the patient perspective on 30‐day readmissions. Our previous work indicated that patients associate preventable readmissions with lack of preparedness at the time of discharge.[7] This study further evaluates the basis of this association. We found that nearly 1 in 3 readmitted patients did not feel ready to leave the hospital at the time of initial discharge. Feelings of inadequate symptom resolution and poor pain control appear to be major contributors to this sentiment. Furthermore, although 88% of patients endorse having a caretaker at home, patients with concerns about taking care of themselves are more likely to feel unready at discharge. Presumably, when healthcare providers discharge patients, they believe that the patient is ready to be discharged. However, our findings suggest that often patients do not agree, highlighting a gap between the beliefs of patients and those of healthcare providers. Creating patient‐centered education on symptom management and engaging patients in developing skills for independent self‐care may minimize this gap and allow patients to feel more prepared at discharge. Future research investigating provider opinions and the steps providers take when there is a disagreement over discharge readiness would also be useful.
One way to enhance education at the time of discharge is through improvements in printed discharge instructions. Jha et al. previously showed that chart documentation of providing discharge instructions does not correlate with patients reporting receiving discharge instructions.[27] Our study echoes this finding, with only 65% of the patients remembering receiving and reviewing the discharge paperwork. Horwitz et al. have also previously demonstrated poor comprehension of discharge planning and postdischarge care among patients discharged from an academic medical center.[28] Ensuring that all patients understand and retain their discharge instructions is an essential step in improving the patient experience and potentially decreasing readmissions. Our surveys have illuminated potential shortcomings in our own center's discharge instructions. Interventions aimed at clarifying critical pieces of information on the discharge paperwork, such as warning symptoms, contact phone numbers and follow‐up appointments, could be especially helpful.
After discharge, our findings suggest that only about half of patients will call a physician before returning to the hospital. Furthermore, there is limited knowledge and poor utilization of same‐day treatment centers besides the emergency room. In previous studies, Long et al. found that frequently readmitted patients self‐triage to the emergency room because they believe primary care clinics cannot treat acute illness.[11] Another study concluded that low‐income patients prefer hospital care to ambulatory care because of a greater sense of trust in inpatient care.[29]
Our patients' attitudes about readmission may also be different from those of providers. For patients, coming back to the hospital is not a significant burden, and satisfaction with their medical care remains high despite readmission. Additional research is needed to further explore the complex emotions patients have when coming back to the hospital and why patients may not be as upset with returning to the hospital as providers may expect. Ultimately, if patients continue to feel more comfortable being hospitalized, there are few incentives for patients to stay out of the hospital, and readmission rates will remain elevated.
Based on our survey results we have hypothesized a potential framework for studying readmissions from a patient‐centered approach (Figure 1). This figure is not meant to imply causality, but rather to highlight a potential journey from discharge to readmission for a patient who does not feel ready to go home. This schema principally applies to patients who are worried about symptom management and/or self‐care before discharge and may not apply to everyone. Each asterisk in this framework represents an area where an intervention could be designed to improve the patient experience and possibly reduce readmissions. Such interventions should be centered around increasing patient education about symptom management and self‐care at the time of discharge, improving printed discharge instructions, increasing patient awareness of outpatient resources, enhancing communication after discharge, and changing patients' attitudes about readmissions.
This study's limitations include that it is a single‐institution study focusing on patients admitted to a large academic medical center and its partner community hospital. Only English‐speaking patients were included, and thus our results may not be generalizable to other populations. All patients were interviewed at the time of readmission, potentially introducing recall bias regarding their prior discharge. For example, patients might be more likely to state they were not ready for discharge once they have been readmitted to the hospital. Lastly, because there are only a few prior studies interviewing readmitted patients, our survey instrument was not previously validated. Nevertheless, we believe this study offers a unique view on 30‐day readmissions from the patient perspective, with a focus on identifying areas for quality‐improvement interventions.
In conclusion, this study has enabled us to understand readmissions from a patient‐centered perspective. This perspective helps to challenge provider assumptions and gives much‐needed insight into the patient experience. For example, prior to surveying patients, one might assume that if a patient has a caregiver at home, they are unlikely to have concerns about taking care of themselves. We now know this is not the case. Similarly, we have discovered sections of our discharge paperwork that are confusing. Additionally, this study has revealed that patient attitudes regarding readmission can vary significantly from provider attitudes. By exploring the patient perspective and creating a new transition framework, we have identified specific target areas for interventions that would be meaningful to patients. As the nation continues to strive to identify sustainable solutions to reduce readmissions, the way to redesign care must always start and end with the patient.
Acknowledgements
The authors acknowledge Puneet Rana, James Haggerty‐Skeans, Jae Kim, Rhea Mathew, and Anna Do (UCLA volunteers) for helping to perform the patient interviews. We acknowledge Sandy Berry, MA (Senior Behavioral Scientist at RAND Corporation) for her help in reviewing our patient interview script. Additionally Anna Dermenchyan, RN, BSN (Senior Clinical Quality Specialist in the Department of Medicine at UCLA) provided significant administrative support.
Disclosures: This project was supported by a Patient Experience Grant from the Beryl Institute awarded to Jessica Howard‐Anderson, Sarah Lonowski, Ashley Busuttil, and Nasim Afsar‐manesh. Dr. Howard‐Anderson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All coauthors have seen and agree with the contents of the article. The article is not under review by any other publication. An earlier version of this work was written as a research report (not peer reviewed) for the Beryl Institute (available at:
- , . What will it take to move the needle on hospital readmissions? Am J Med Qual. 2013;29(4):357–359.
- , , , , , . Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2):E1–E12.
- , , , , . Interventions to reduce 30‐day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–528.
- , , , et al. Preventing 30‐day hospital readmissions: a systematic review and meta‐analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095–1107.
- , , , et al. Relationship between early physician follow‐up and 30‐day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716–1722.
- , , , et al. Allocating scarce resources in real‐time to reduce heart failure readmissions: a prospective, controlled study. BMJ Qual Saf. 2013;22(12):998–1005.
- , , , , , . Readmissions in the era of patient engagement. JAMA Intern Med. 2014;174(11):1870–1872.
- , , , et al. Comparing perspectives of patients, caregivers, and clinicians on heart failure management [published online October 23, 2015]. J Card Fail. doi: 10.1016/j.cardfail.2015.10.011.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.
- , , . Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization? J Hosp Med. 2007;2(5):297–304.
- , , . Reasons for readmission in an underserved high‐risk population: a qualitative analysis of a series of inpatient interviews. BMJ Open. 2013;3(9):e003212.
- , , , , , . Improving care transitions: the patient perspective. J Health Commun. 2012;17(suppl 3):312–324.
- , , , et al. Challenges faced by patients with low socioeconomic status during the post‐hospital transition. J Gen Intern Med. 2014;29(2):283–289.
- , , , et al. “Missing pieces”—functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014;62(8):1556–1561.
- , , , , , . Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. 2012;7(9):709–712.
- , , , et al. Factors contributing to all‐cause 30‐day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599–605.
- , , . Reasons for readmission in heart failure: perspectives of patients, caregivers, cardiologists, and heart failure nurses. Heart Lung. 2009;38(5):427–434.
- , , , et al. Patient‐identified factors related to heart failure readmissions. Circ Cardiovasc Qual Outcomes. 2013;6(2):171–177.
- , , , , . Early readmission among patients with diabetes: a qualitative assessment of contributing factors. J Diabetes Complications. 2014;28(6):869–873.
- , , , , . “Because I was sick”: seriously ill veterans' perspectives on reason for 30‐day readmissions. J Am Geriatr Soc. 2015;63(3):537–542.
- , , , et al. The impact of patient‐centered care on outcomes. J Fam Pract. 2000;49(9):796–804.
- , , , et al. Patient‐centered communication and diagnostic testing. Ann Fam Med. 2005;3(5):415–421.
- , . Physician communication and patient adherence to treatment: a meta‐analysis. Med Care. 2009;47(8):826–834.
- , , , et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90.
- , , , , . Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3(5):448–457.
- , , , , , . Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
- , , . Public reporting of discharge planning and rates of readmissions. N Engl J Med. 2009;361(27):2637–2645.
- , , , et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013;173(18):1715–1722
- , , , , , . Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff (Millwood). 2013;32(7):1196–1203.
- , . What will it take to move the needle on hospital readmissions? Am J Med Qual. 2013;29(4):357–359.
- , , , , , . Medicare readmission rates showed meaningful decline in 2012. Medicare Medicaid Res Rev. 2013;3(2):E1–E12.
- , , , , . Interventions to reduce 30‐day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–528.
- , , , et al. Preventing 30‐day hospital readmissions: a systematic review and meta‐analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095–1107.
- , , , et al. Relationship between early physician follow‐up and 30‐day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA. 2010;303(17):1716–1722.
- , , , et al. Allocating scarce resources in real‐time to reduce heart failure readmissions: a prospective, controlled study. BMJ Qual Saf. 2013;22(12):998–1005.
- , , , , , . Readmissions in the era of patient engagement. JAMA Intern Med. 2014;174(11):1870–1872.
- , , , et al. Comparing perspectives of patients, caregivers, and clinicians on heart failure management [published online October 23, 2015]. J Card Fail. doi: 10.1016/j.cardfail.2015.10.011.
- , , , . The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–1828.
- , , . Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization? J Hosp Med. 2007;2(5):297–304.
- , , . Reasons for readmission in an underserved high‐risk population: a qualitative analysis of a series of inpatient interviews. BMJ Open. 2013;3(9):e003212.
- , , , , , . Improving care transitions: the patient perspective. J Health Commun. 2012;17(suppl 3):312–324.
- , , , et al. Challenges faced by patients with low socioeconomic status during the post‐hospital transition. J Gen Intern Med. 2014;29(2):283–289.
- , , , et al. “Missing pieces”—functional, social, and environmental barriers to recovery for vulnerable older adults transitioning from hospital to home. J Am Geriatr Soc. 2014;62(8):1556–1561.
- , , , , , . Perceptions of readmitted patients on the transition from hospital to home. J Hosp Med. 2012;7(9):709–712.
- , , , et al. Factors contributing to all‐cause 30‐day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599–605.
- , , . Reasons for readmission in heart failure: perspectives of patients, caregivers, cardiologists, and heart failure nurses. Heart Lung. 2009;38(5):427–434.
- , , , et al. Patient‐identified factors related to heart failure readmissions. Circ Cardiovasc Qual Outcomes. 2013;6(2):171–177.
- , , , , . Early readmission among patients with diabetes: a qualitative assessment of contributing factors. J Diabetes Complications. 2014;28(6):869–873.
- , , , , . “Because I was sick”: seriously ill veterans' perspectives on reason for 30‐day readmissions. J Am Geriatr Soc. 2015;63(3):537–542.
- , , , et al. The impact of patient‐centered care on outcomes. J Fam Pract. 2000;49(9):796–804.
- , , , et al. Patient‐centered communication and diagnostic testing. Ann Fam Med. 2005;3(5):415–421.
- , . Physician communication and patient adherence to treatment: a meta‐analysis. Med Care. 2009;47(8):826–834.
- , , , et al. Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003;163(1):83–90.
- , , , , . Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3(5):448–457.
- , , , , , . Research electronic data capture (REDCap)—a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377–381.
- , , . Public reporting of discharge planning and rates of readmissions. N Engl J Med. 2009;361(27):2637–2645.
- , , , et al. Quality of discharge practices and patient understanding at an academic medical center. JAMA Intern Med. 2013;173(18):1715–1722
- , , , , , . Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff (Millwood). 2013;32(7):1196–1203.
© 2016 Society of Hospital Medicine
HQPS Competencies
Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10
Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16
The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.
Development of The Hospital Quality and Patient Safety Competencies
The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.
The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.
Description of The Competencies
The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.
| Competency | Basic | Intermediate | Advanced |
|---|---|---|---|
| |||
| Quality measurement and stakeholder interests | Define structure, process, and outcome measures | Compare and contrast relative benefits of using one type of measure vs another | Anticipate and respond to stakeholders' needs and interests |
| Define stakeholders and understand their interests related to healthcare quality | Explain measures as defined by stakeholders (Center for Medicare and Medicaid Services, Leapfrog, etc) | Anticipate and respond to changes in quality measures and incentive programs | |
| Identify measures as defined by stakeholders (Center for Medicare and Medicaid Services, Leapfrog, etc) | Appreciate variation in quality and utilization performance | Lead efforts to reduce variation in care delivery (see also quality improvement methods) | |
| Describe potential unintended consequences of quality measurement and incentive programs | Avoid unintended consequences of quality measurement and incentive programs | ||
| Data acquisition and interpretation | Interpret simple statistical methods to compare populations within a sample (chi‐square, t tests, etc) | Describe sources of data for quality measurement | Acquire data from internal and external sources |
| Define basic terms used to describe continuous and categorical data (mean, median, standard deviation, interquartile range, percentages, rates, etc) | Identify potential pitfalls in administrative data | Create visual representations of data (Bar, Pareto, and Control Charts) | |
| Summarize basic principles of statistical process control | Explain variation in data | Use simple statistical methods to compare populations within a sample (chi‐square, t tests, etc) | |
| Interpret data displayed in Pareto and Control Charts | Administer and interpret a survey | ||
| Summarize basic survey techniques (including methods to maximize response, minimize bias, and use of ordinal response scales) | |||
| Use appropriate terms to describe continuous and categorical data (mean, median, standard deviation, interquartile range, percentages, rates, etc) | |||
| Organizational knowledge and leadership skills | Describe the organizational structure of one's institution | Define interests of internal and external stakeholders | Effectively negotiate with stakeholders |
| Define leaders within the organization and describe their roles | Collaborate as an effective team member of a quality improvement project | Assemble a quality improvement project team and effectively lead meetings (setting agendas, hold members accountable, etc) | |
| Exemplify the importance of leading by example | Explain principles of change management and how it can positively or negatively impact quality improvement project implementation | Motivate change and create vision for ideal state | |
| Effectively communicate quality or safety issues identified during routine patient care to the appropriate parties | Communicate effectively in a variety of settings (lead a meeting, public speaking, etc) | ||
| Serve as a resource and/or mentor for less‐experienced team members | |||
| Patient safety principles | Identify potential sources of error encountered during routine patient care | Compare methods to measure errors and adverse events, including administrative data analysis, chart review, and incident reporting systems | Lead efforts to appropriately measure medical error and/or adverse events |
| Compare and contrast medical error with adverse event | Identify and explain how human factors can contribute to medical errors | Lead efforts to redesign systems to reduce errors from occurring; this may include the facilitation of a hospital, departmental, or divisional Root Cause Analysis | |
| Describe how the systems approach to medical error is more productive than assigning individual blame | Know the difference between a strong vs a weak action plan for improvement (ie, brief education intervention is weak; skills training with deliberate practice or physical changes are stronger) | Lead efforts to advance the culture of patient safety in the hospital | |
| Differentiate among types of error (knowledge/judgment vs systems vs procedural/technical; latent vs active) | |||
| Explain the role that incident reporting plays in quality improvement efforts and how reporting can foster a culture of safety | |||
| Describe principles of medical error disclosure | |||
| Teamwork and communication | Explain how poor teamwork and communication failures contribute to adverse events | Collaborate on administration and interpretation of teamwork and safety culture measures | Lead efforts to improve teamwork and safety culture |
| Identify the potential for errors during transitions within and between healthcare settings (handoffs, transfers, discharge) | Describe the principles of effective teamwork and identify behaviors consistent with effective teamwork | Lead efforts to improve teamwork in specific settings (intensive care, medical‐surgical unit, etc) | |
| Identify deficiencies in transitions within and between healthcare settings (handoffs, transfers, discharge) | Successfully improve the safety of transitions within and between healthcare settings (handoffs, transfers, discharge) | ||
| Quality and safety improvement methods and tools | Define the quality improvement methods used and infrastructure in place at one's hospital | Compare and contrast various quality improvement methods, including six sigma, lean, and PDSA | Lead a quality improvement project using six sigma, lean, or PDSA methodology |
| Summarize the basic principles and use of Root Cause Analysis as a tool to evaluate medical error | Collaborate on a quality improvement project using six sigma, lean, or PDSA | Use high level process mapping, fishbone diagrams, etc, to identify areas for opportunity in evaluating a process | |
| Describe and collaborate on Failure Mode and Effects Analysis | Lead the development and implementation of clinical protocols to standardize care delivery when appropriate | ||
| Actively participate in a Root Cause Analysis | Conduct Failure Mode and Effects Analysis | ||
| Conduct Root Cause Analysis | |||
| Health information systems | Identify the potential for information systems to reduce as well as contribute to medical error | Define types of clinical decision support | Lead or co‐lead efforts to leverage information systems in quality measurement |
| Describe how information systems fit into provider workflow and care delivery | Collaborate on the design of health information systems | Lead or co‐lead efforts to leverage information systems to reduce error and/or improve delivery of effective care | |
| Anticipate and prevent unintended consequences of implementation or revision of information systems | |||
| Lead or co‐lead efforts to leverage clinical decision support to improve quality and safety | |||
| Patient centeredness | Explain the clinical benefits of a patient‐centered approach | Explain benefits and potential limitations of patient satisfaction surveys | Interpret data from patient satisfaction surveys and lead efforts to improve patient satisfaction |
| Identify system barriers to effective and safe care from the patient's perspective | Identify clinical areas with suboptimal efficiency and/or timeliness from the patient's perspective | Lead effort to reduce inefficiency and/or improve timeliness from the patient's perspective | |
| Describe the value of patient satisfaction surveys and patient and family partnership in care | Promote patient and caregiver education including use of effective education tools | Lead efforts to eliminate system barriers to effective and safe care from the patient's perspective | |
| Lead efforts to improve patent and caregiver education including development or implementation of effective education tools | |||
| Lead efforts to actively involve patients and families in the redesign of healthcare delivery systems and processes | |||
Recommended Use of The Competencies
The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.
Professional Development
Since residency programs historically have not trained their graduates to achieve a basic level of competence, practicing hospitalists will need to seek out professional development opportunities. Some educational opportunities which already exist include the Quality Track sessions during the SHM Annual Meeting, and the SHM Quality Improvement Pre‐Course. Hospitalist leaders are currently using the HQPS Competencies to review and revise annual meeting and pre‐course objectives and content in an effort to meet the expected level of competence for SHM members. Similarly, local SHM Chapter and regional hospital medicine leaders should look to the competencies to help select topics and objectives for future presentations. Additionally, the SHM Web site offers tools to develop skills, including a resource room and quality improvement primer.26 Mentored‐implementation programs, supported by SHM, can help hospitalists' acquire more advanced experiential training in quality improvement.
New educational opportunities are being developed, including a comprehensive set of Internet‐based modules designed to help practicing hospitalists achieve a basic level of competence. Hospitalists will be able to achieve continuing medical education (CME) credit upon completion of individual modules. Plans are underway to provide Certification in Hospital Quality and Patient Safety, reflecting an advanced level of competence, upon completion of the entire set, and demonstration of knowledge and skill application through an approved quality improvement project. The certification process will leverage the success of the SHM Leadership Academies and Mentored Implementation projects to help hospitalists apply their new skills in a real world setting.
HQPS Competencies and Focused Practice in Hospital Medicine
Recently, the American Board of Internal Medicine (ABIM) has recognized the field of hospital medicine by developing a new program that provides hospitalists the opportunity to earn Maintenance of Certification (MOC) in Internal Medicine with a Focused Practice in Hospital Medicine.27 Appropriately, hospital quality and patient safety content is included among the knowledge questions on the secure exam, and completion of a practice improvement module (commonly known as PIM) is required for the certification. The SHM Education Committee has developed a Self‐Evaluation of Medical Knowledge module related to hospital quality and patient safety for use in the MOC process. ABIM recertification with Focused Practice in Hospital Medicine is an important and visible step for the Hospital Medicine movement; the content of both the secure exam and the MOC reaffirms the notion that the acquisition of knowledge, skills, and attitudes in hospital quality and patient safety is essential to the practice of hospital medicine.
Medical Education
Because teaching hospitalists frequently serve in important roles as educators and physician leaders in quality improvement, they are often responsible for medical student and resident training in healthcare quality and patient safety. Medical schools and residency programs have struggled to integrate healthcare quality and patient safety into their curricula.11, 12, 28 Hospitalists can play a major role in academic medical centers by helping to develop curricular materials and evaluations related to healthcare quality. Though intended primarily for future and current hospitalists, the HQPS Competencies and standards for the basic level may be adapted to provide educational targets for many learners in undergraduate and graduate medical education. Teaching hospitalists may use these standards to evaluate current educational efforts and design new curricula in collaboration with their medical school and residency program leaders.
Beyond the basic level of training in healthcare quality required for all, many residents will benefit from more advanced training experiences, including opportunities to apply knowledge and develop skills related to quality improvement. A recent report from the ACGME concluded that role models and mentors were essential for engaging residents in quality improvement efforts.29 Hospitalists are ideally suited to serve as role models during residents' experiential learning opportunities related to hospital quality. Several residency programs have begun to implement hospitalist tracks13 and quality improvement rotations.3032 Additionally, some academic medical centers have begun to develop and offer fellowship training in Hospital Medicine.33 These hospitalist‐led educational programs are an ideal opportunity to teach the intermediate and advanced training components, of healthcare quality and patient safety, to residents and fellows that wish to incorporate activity or leadership in quality improvement and patient safety science into their generalist or subspecialty careers. Teaching hospitalists should use the HQPS competency standards to define learning objectives for trainees at this stage of development.
To address the enormous educational needs in quality and safety for future physicians, a cadre of expert teachers in quality and safety will need to be developed. In collaboration with the Alliance for Academic Internal Medicine (AAIM), SHM is developing a Quality and Safety Educators Academy which will target academic hospitalists and other medical educators interested in developing advanced skills in quality improvement and patient safety education.
Assessment of Competence
An essential component of a rigorous faculty development program or medical education initiative is the assessment of whether these endeavors are achieving their stated aims. Published literature provides examples of useful assessment methods applicable to the HQPS Competencies. Knowledge in several areas of HQPS competence may be assessed with the use of multiple choice tests.34, 35 Knowledge of quality improvement methods may be assessed using the Quality Improvement Knowledge Application Tool (QIKAT), an instrument in which the learner responds to each of 3 scenarios with an aim, outcome and process measures, and ideas for changes which may result in improved performance.36 Teamwork and communication skills may be assessed using 360‐degree evaluations3739 and direct observation using behaviorally anchored rating scales.4043 Objective structured clinical examinations have been used to assess knowledge and skills related to patient safety principles.44, 45 Notably, few studies have rigorously assessed the validity and reliability of tools designed to evaluate competence related to healthcare quality.46 Additionally, to our knowledge, no prior research has evaluated assessment specifically for hospitalists. Thus, the development and validation of new assessment tools based on the HQPS Competencies for learners at each level is a crucial next step in the educational process. Additionally, evaluation of educational initiatives should include analyses of clinical benefit, as the ultimate goal of these efforts is to improve patient care.47, 48
Conclusion
Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.
- Crossing the Quality Chasm: A New Health System for the Twenty‐first Century.Washington, DC:Institute of Medicine;2001.
- ,,,.Care in U.S. hospitals—the Hospital Quality Alliance program.N Engl J Med.2005;353(3):265–274.
- ,.Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.JAMA.2003;290(14):1868–1874.
- Hospital Compare—A quality tool provided by Medicare. Available at: http://www.hospitalcompare.hhs.gov/. Accessed April 23,2010.
- The Leapfrog Group: Hospital Quality Ratings. Available at: http://www.leapfroggroup.org/cp. Accessed April 30,2010.
- Why Not the Best? A Healthcare Quality Improvement Resource. Available at: http://www.whynotthebest.org/. Accessed April 30,2010.
- The Joint Commission: Facts about ORYX for hospitals (National Hospital Quality Measures). Available at: http://www.jointcommission.org/accreditationprograms/hospitals/oryx/oryx_facts.htm. Accessed August 19,2010.
- The Joint Commission: National Patient Safety Goals. Available at: http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/. Accessed August 9,2010.
- Hospital Acquired Conditions: Overview. Available at: http://www.cms.gov/HospitalAcqCond/01_Overview.asp. Accessed April 30,2010.
- Report to Congress:Plan to Implement a Medicare Hospital Value‐based Purchasing Program. Washington, DC: US Department of Health and Human Services, Center for Medicare and Medicaid Services;2007.
- Unmet Needs: Teaching Physicians to Provide Safe Patient Care.Boston, MA:Lucian Leape Institute at the National Patient Safety Foundation;2010.
- ,,,,.Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey.Acad Med.2009;84(12):1672–1676.
- ,,,,.Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs.J Gen Intern Med.2008;23(7):1110–1115.
- ,,,.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111(3):247–254.
- ,,,,.Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.Ann Intern Med.2006;144(12):920–926.
- ,,.Redesigning training for internal medicine.Ann Intern Med.2006;144(12):927–932.
- ,,,,.Core competencies in hospital medicine: development and methodology.J Hosp Med.2006;1(1):48–56.
- Intermountain Healthcare. 20‐Day Course for Executives 2001.
- ,,,.Curriculum Development for Medical Education: A Six‐step Approach.Baltimore, MD:Johns Hopkins Press;1998.
- Society of Hospital Medicine Quality Improvement Basics. Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/QualityImprovement/QIPrimer/QI_Primer_Landing_Pa.htm. Accessed June 4,2010.
- American Board of Internal Medicine: Questions and Answers Regarding ABIM's Maintenance of Certification in Internal Medicine With a Focused Practice in Hospital Medicine Program. Available at: http://www.abim.org/news/news/focused‐practice‐hospital‐medicine‐qa.aspx. Accessed August 9,2010.
- ,,.Assessing the needs of residency program directors to meet the ACGME general competencies.Acad Med.2002;77(7):750.
- .Accreditation Council for Graduate Medical Education and Institute for Healthcare Improvement 90‐Day Project. Involving Residents in Quality Improvement: Contrasting “Top‐Down” and “Bottom‐Up” Approaches.Chicago, IL;ACGME;2008.
- ,,,.Teaching internal medicine residents quality improvement techniques using the ABIM's practice improvement modules.J Gen Intern Med.2008;23(7):927–930.
- ,,,,.A self‐instructional model to teach systems‐based practice and practice‐based learning and improvement.J Gen Intern Med.2008;23(7):931–936.
- ,,,,.Creating a quality improvement elective for medical house officers.J Gen Intern Med.2004;19(8):861–867.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119(1):72.e1‐e7.
- ,,,.Web‐based education in systems‐based practice: a randomized trial.Arch Intern Med.2007;167(4):361–366.
- ,,,,.A self‐instructional model to teach systems‐based practice and practice‐based learning and improvement.J Gen Intern Med.2008;23(7):931–936.
- ,,,.The quality improvement knowledge application tool: an instrument to assess knowledge application in practice‐based learning and improvement.J Gen Intern Med.2003;18(suppl 1):250.
- ,,, et al.Effect of multisource feedback on resident communication skills and professionalism: a randomized controlled trial.Arch Pediatr Adolesc Med.2007;161(1):44–49.
- ,.Reliability of a 360‐degree evaluation to assess resident competence.Am J Phys Med Rehabil.2007;86(10):845–852.
- ,,,.Pilot study of a 360‐degree assessment instrument for physical medicine 82(5):394–402.
- ,,,,,.Anaesthetists' non‐technical skills (ANTS): evaluation of a behavioural marker system.Br J Anaesth.2003;90(5):580–588.
- ,,, et al.The Mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills.Simul Healthc.2007;2(1):4–10.
- ,,,,,.Reliability of a revised NOTECHS scale for use in surgical teams.Am J Surg.2008;196(2):184–190.
- ,,,,,.Observational teamwork assessment for surgery: construct validation with expert versus novice raters.Ann Surg.2009;249(6):1047–1051.
- ,,,,,.A patient safety objective structured clinical examination.J Patient Saf.2009;5(2):55–60.
- ,.The Objective Structured Clinical Examination as an educational tool in patient safety.Jt Comm J Qual Patient Saf.2007;33(1):48–53.
- ,,.Measurement of the general competencies of the Accreditation Council for Graduate Medical Education: a systematic review.Acad Med.2009;84(3):301–309.
- ,,,,,.Effectiveness of teaching quality improvement to clinicians: a systematic review.JAMA.2007;298(9):1023–1037.
- ,,,,.Methodological rigor of quality improvement curricula for physician trainees: a systematic review and recommendations for change.Acad Med.2009;84(12):1677–1692.
Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10
Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16
The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.
Development of The Hospital Quality and Patient Safety Competencies
The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.
The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.
Description of The Competencies
The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.
| Competency | Basic | Intermediate | Advanced |
|---|---|---|---|
| |||
| Quality measurement and stakeholder interests | Define structure, process, and outcome measures | Compare and contrast relative benefits of using one type of measure vs another | Anticipate and respond to stakeholders' needs and interests |
| Define stakeholders and understand their interests related to healthcare quality | Explain measures as defined by stakeholders (Center for Medicare and Medicaid Services, Leapfrog, etc) | Anticipate and respond to changes in quality measures and incentive programs | |
| Identify measures as defined by stakeholders (Center for Medicare and Medicaid Services, Leapfrog, etc) | Appreciate variation in quality and utilization performance | Lead efforts to reduce variation in care delivery (see also quality improvement methods) | |
| Describe potential unintended consequences of quality measurement and incentive programs | Avoid unintended consequences of quality measurement and incentive programs | ||
| Data acquisition and interpretation | Interpret simple statistical methods to compare populations within a sample (chi‐square, t tests, etc) | Describe sources of data for quality measurement | Acquire data from internal and external sources |
| Define basic terms used to describe continuous and categorical data (mean, median, standard deviation, interquartile range, percentages, rates, etc) | Identify potential pitfalls in administrative data | Create visual representations of data (Bar, Pareto, and Control Charts) | |
| Summarize basic principles of statistical process control | Explain variation in data | Use simple statistical methods to compare populations within a sample (chi‐square, t tests, etc) | |
| Interpret data displayed in Pareto and Control Charts | Administer and interpret a survey | ||
| Summarize basic survey techniques (including methods to maximize response, minimize bias, and use of ordinal response scales) | |||
| Use appropriate terms to describe continuous and categorical data (mean, median, standard deviation, interquartile range, percentages, rates, etc) | |||
| Organizational knowledge and leadership skills | Describe the organizational structure of one's institution | Define interests of internal and external stakeholders | Effectively negotiate with stakeholders |
| Define leaders within the organization and describe their roles | Collaborate as an effective team member of a quality improvement project | Assemble a quality improvement project team and effectively lead meetings (setting agendas, hold members accountable, etc) | |
| Exemplify the importance of leading by example | Explain principles of change management and how it can positively or negatively impact quality improvement project implementation | Motivate change and create vision for ideal state | |
| Effectively communicate quality or safety issues identified during routine patient care to the appropriate parties | Communicate effectively in a variety of settings (lead a meeting, public speaking, etc) | ||
| Serve as a resource and/or mentor for less‐experienced team members | |||
| Patient safety principles | Identify potential sources of error encountered during routine patient care | Compare methods to measure errors and adverse events, including administrative data analysis, chart review, and incident reporting systems | Lead efforts to appropriately measure medical error and/or adverse events |
| Compare and contrast medical error with adverse event | Identify and explain how human factors can contribute to medical errors | Lead efforts to redesign systems to reduce errors from occurring; this may include the facilitation of a hospital, departmental, or divisional Root Cause Analysis | |
| Describe how the systems approach to medical error is more productive than assigning individual blame | Know the difference between a strong vs a weak action plan for improvement (ie, brief education intervention is weak; skills training with deliberate practice or physical changes are stronger) | Lead efforts to advance the culture of patient safety in the hospital | |
| Differentiate among types of error (knowledge/judgment vs systems vs procedural/technical; latent vs active) | |||
| Explain the role that incident reporting plays in quality improvement efforts and how reporting can foster a culture of safety | |||
| Describe principles of medical error disclosure | |||
| Teamwork and communication | Explain how poor teamwork and communication failures contribute to adverse events | Collaborate on administration and interpretation of teamwork and safety culture measures | Lead efforts to improve teamwork and safety culture |
| Identify the potential for errors during transitions within and between healthcare settings (handoffs, transfers, discharge) | Describe the principles of effective teamwork and identify behaviors consistent with effective teamwork | Lead efforts to improve teamwork in specific settings (intensive care, medical‐surgical unit, etc) | |
| Identify deficiencies in transitions within and between healthcare settings (handoffs, transfers, discharge) | Successfully improve the safety of transitions within and between healthcare settings (handoffs, transfers, discharge) | ||
| Quality and safety improvement methods and tools | Define the quality improvement methods used and infrastructure in place at one's hospital | Compare and contrast various quality improvement methods, including six sigma, lean, and PDSA | Lead a quality improvement project using six sigma, lean, or PDSA methodology |
| Summarize the basic principles and use of Root Cause Analysis as a tool to evaluate medical error | Collaborate on a quality improvement project using six sigma, lean, or PDSA | Use high level process mapping, fishbone diagrams, etc, to identify areas for opportunity in evaluating a process | |
| Describe and collaborate on Failure Mode and Effects Analysis | Lead the development and implementation of clinical protocols to standardize care delivery when appropriate | ||
| Actively participate in a Root Cause Analysis | Conduct Failure Mode and Effects Analysis | ||
| Conduct Root Cause Analysis | |||
| Health information systems | Identify the potential for information systems to reduce as well as contribute to medical error | Define types of clinical decision support | Lead or co‐lead efforts to leverage information systems in quality measurement |
| Describe how information systems fit into provider workflow and care delivery | Collaborate on the design of health information systems | Lead or co‐lead efforts to leverage information systems to reduce error and/or improve delivery of effective care | |
| Anticipate and prevent unintended consequences of implementation or revision of information systems | |||
| Lead or co‐lead efforts to leverage clinical decision support to improve quality and safety | |||
| Patient centeredness | Explain the clinical benefits of a patient‐centered approach | Explain benefits and potential limitations of patient satisfaction surveys | Interpret data from patient satisfaction surveys and lead efforts to improve patient satisfaction |
| Identify system barriers to effective and safe care from the patient's perspective | Identify clinical areas with suboptimal efficiency and/or timeliness from the patient's perspective | Lead effort to reduce inefficiency and/or improve timeliness from the patient's perspective | |
| Describe the value of patient satisfaction surveys and patient and family partnership in care | Promote patient and caregiver education including use of effective education tools | Lead efforts to eliminate system barriers to effective and safe care from the patient's perspective | |
| Lead efforts to improve patent and caregiver education including development or implementation of effective education tools | |||
| Lead efforts to actively involve patients and families in the redesign of healthcare delivery systems and processes | |||
Recommended Use of The Competencies
The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.
Professional Development
Since residency programs historically have not trained their graduates to achieve a basic level of competence, practicing hospitalists will need to seek out professional development opportunities. Some educational opportunities which already exist include the Quality Track sessions during the SHM Annual Meeting, and the SHM Quality Improvement Pre‐Course. Hospitalist leaders are currently using the HQPS Competencies to review and revise annual meeting and pre‐course objectives and content in an effort to meet the expected level of competence for SHM members. Similarly, local SHM Chapter and regional hospital medicine leaders should look to the competencies to help select topics and objectives for future presentations. Additionally, the SHM Web site offers tools to develop skills, including a resource room and quality improvement primer.26 Mentored‐implementation programs, supported by SHM, can help hospitalists' acquire more advanced experiential training in quality improvement.
New educational opportunities are being developed, including a comprehensive set of Internet‐based modules designed to help practicing hospitalists achieve a basic level of competence. Hospitalists will be able to achieve continuing medical education (CME) credit upon completion of individual modules. Plans are underway to provide Certification in Hospital Quality and Patient Safety, reflecting an advanced level of competence, upon completion of the entire set, and demonstration of knowledge and skill application through an approved quality improvement project. The certification process will leverage the success of the SHM Leadership Academies and Mentored Implementation projects to help hospitalists apply their new skills in a real world setting.
HQPS Competencies and Focused Practice in Hospital Medicine
Recently, the American Board of Internal Medicine (ABIM) has recognized the field of hospital medicine by developing a new program that provides hospitalists the opportunity to earn Maintenance of Certification (MOC) in Internal Medicine with a Focused Practice in Hospital Medicine.27 Appropriately, hospital quality and patient safety content is included among the knowledge questions on the secure exam, and completion of a practice improvement module (commonly known as PIM) is required for the certification. The SHM Education Committee has developed a Self‐Evaluation of Medical Knowledge module related to hospital quality and patient safety for use in the MOC process. ABIM recertification with Focused Practice in Hospital Medicine is an important and visible step for the Hospital Medicine movement; the content of both the secure exam and the MOC reaffirms the notion that the acquisition of knowledge, skills, and attitudes in hospital quality and patient safety is essential to the practice of hospital medicine.
Medical Education
Because teaching hospitalists frequently serve in important roles as educators and physician leaders in quality improvement, they are often responsible for medical student and resident training in healthcare quality and patient safety. Medical schools and residency programs have struggled to integrate healthcare quality and patient safety into their curricula.11, 12, 28 Hospitalists can play a major role in academic medical centers by helping to develop curricular materials and evaluations related to healthcare quality. Though intended primarily for future and current hospitalists, the HQPS Competencies and standards for the basic level may be adapted to provide educational targets for many learners in undergraduate and graduate medical education. Teaching hospitalists may use these standards to evaluate current educational efforts and design new curricula in collaboration with their medical school and residency program leaders.
Beyond the basic level of training in healthcare quality required for all, many residents will benefit from more advanced training experiences, including opportunities to apply knowledge and develop skills related to quality improvement. A recent report from the ACGME concluded that role models and mentors were essential for engaging residents in quality improvement efforts.29 Hospitalists are ideally suited to serve as role models during residents' experiential learning opportunities related to hospital quality. Several residency programs have begun to implement hospitalist tracks13 and quality improvement rotations.3032 Additionally, some academic medical centers have begun to develop and offer fellowship training in Hospital Medicine.33 These hospitalist‐led educational programs are an ideal opportunity to teach the intermediate and advanced training components, of healthcare quality and patient safety, to residents and fellows that wish to incorporate activity or leadership in quality improvement and patient safety science into their generalist or subspecialty careers. Teaching hospitalists should use the HQPS competency standards to define learning objectives for trainees at this stage of development.
To address the enormous educational needs in quality and safety for future physicians, a cadre of expert teachers in quality and safety will need to be developed. In collaboration with the Alliance for Academic Internal Medicine (AAIM), SHM is developing a Quality and Safety Educators Academy which will target academic hospitalists and other medical educators interested in developing advanced skills in quality improvement and patient safety education.
Assessment of Competence
An essential component of a rigorous faculty development program or medical education initiative is the assessment of whether these endeavors are achieving their stated aims. Published literature provides examples of useful assessment methods applicable to the HQPS Competencies. Knowledge in several areas of HQPS competence may be assessed with the use of multiple choice tests.34, 35 Knowledge of quality improvement methods may be assessed using the Quality Improvement Knowledge Application Tool (QIKAT), an instrument in which the learner responds to each of 3 scenarios with an aim, outcome and process measures, and ideas for changes which may result in improved performance.36 Teamwork and communication skills may be assessed using 360‐degree evaluations3739 and direct observation using behaviorally anchored rating scales.4043 Objective structured clinical examinations have been used to assess knowledge and skills related to patient safety principles.44, 45 Notably, few studies have rigorously assessed the validity and reliability of tools designed to evaluate competence related to healthcare quality.46 Additionally, to our knowledge, no prior research has evaluated assessment specifically for hospitalists. Thus, the development and validation of new assessment tools based on the HQPS Competencies for learners at each level is a crucial next step in the educational process. Additionally, evaluation of educational initiatives should include analyses of clinical benefit, as the ultimate goal of these efforts is to improve patient care.47, 48
Conclusion
Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.
Healthcare quality is defined as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.1 Delivering high quality care to patients in the hospital setting is especially challenging, given the rapid pace of clinical care, the severity and multitude of patient conditions, and the interdependence of complex processes within the hospital system. Research has shown that hospitalized patients do not consistently receive recommended care2 and are at risk for experiencing preventable harm.3 In an effort to stimulate improvement, stakeholders have called for increased accountability, including enhanced transparency and differential payment based on performance. A growing number of hospital process and outcome measures are readily available to the public via the Internet.46 The Joint Commission, which accredits US hospitals, requires the collection of core quality measure data7 and sets the expectation that National Patient Safety Goals be met to maintain accreditation.8 Moreover, the Center for Medicare and Medicaid Services (CMS) has developed a Value‐Based Purchasing (VBP) plan intended to adjust hospital payment based on quality measures and the occurrence of certain hospital‐acquired conditions.9, 10
Because of their clinical expertise, understanding of hospital clinical operations, leadership of multidisciplinary inpatient teams, and vested interest to improve the systems in which they work, hospitalists are perfectly positioned to collaborate with their institutions to improve the quality of care delivered to inpatients. However, many hospitalists are inadequately prepared to engage in efforts to improve quality, because medical schools and residency programs have not traditionally included or emphasized healthcare quality and patient safety in their curricula.1113 In a survey of 389 internal medicine‐trained hospitalists, significant educational deficiencies were identified in the area of systems‐based practice.14 Specifically, the topics of quality improvement, team management, practice guideline development, health information systems management, and coordination of care between healthcare settings were listed as essential skills for hospitalist practice but underemphasized in residency training. Recognizing the gap between the needs of practicing physicians and current medical education provided in healthcare quality, professional societies have recently published position papers calling for increased training in quality, safety, and systems, both in medical school11 and residency training.15, 16
The Society of Hospital Medicine (SHM) convened a Quality Summit in December 2008 to develop strategic plans related to healthcare quality. Summit attendees felt that most hospitalists lack the formal training necessary to evaluate, implement, and sustain system changes within the hospital. In response, the SHM Hospital Quality and Patient Safety (HQPS) Committee formed a Quality Improvement Education (QIE) subcommittee in 2009 to assess the needs of hospitalists with respect to hospital quality and patient safety, and to evaluate and expand upon existing educational programs in this area. Membership of the QIE subcommittee consisted of hospitalists with extensive experience in healthcare quality and medical education. The QIE subcommittee refined and expanded upon the healthcare quality and patient safety‐related competencies initially described in the Core Competencies in Hospital Medicine.17 The purpose of this report is to describe the development, provide definitions, and make recommendations on the use of the Hospital Quality and Patient Safety (HQPS) Competencies.
Development of The Hospital Quality and Patient Safety Competencies
The multistep process used by the SHM QIE subcommittee to develop the HQPS Competencies is summarized in Figure 1. We performed an in‐depth evaluation of current educational materials and offerings, including a review of the Core Competencies in Hospital Medicine, past annual SHM Quality Improvement Pre‐Course objectives, and the content of training courses offered by other organizations.1722 Throughout our analysis, we emphasized the identification of gaps in content relevant to hospitalists. We then used the Institute of Medicine's (IOM) 6 aims for healthcare quality as a foundation for developing the HQPS Competencies.1 Specifically, the IOM states that healthcare should be safe, effective, patient‐centered, timely, efficient, and equitable. Additionally, we reviewed and integrated elements of the Practice‐Based Learning and Improvement (PBLI) and Systems‐Based Practice (SBP) competencies as defined by the Accreditation Council for Graduate Medical Education (ACGME).23 We defined general areas of competence and specific standards for knowledge, skills, and attitudes within each area. Subcommittee members reflected on their own experience, as clinicians, educators, and leaders in healthcare quality and patient safety, to inform and refine the competency definitions and standards. Acknowledging that some hospitalists may serve as collaborators or clinical content experts, while others may serve as leaders of hospital quality initiatives, 3 levels of expertise were established: basic, intermediate, and advanced.
The QIE subcommittee presented a draft version of the HQPS Competencies to the HQPS Committee in the fall of 2009 and incorporated suggested revisions. The revised set of competencies was then reviewed by members of the Leadership and Education Committees during the winter of 2009‐2010, and additional recommendations were included in the final version now described.
Description of The Competencies
The 8 areas of competence include: Quality Measurement and Stakeholder Interests, Data Acquisition and Interpretation, Organizational Knowledge and Leadership Skills, Patient Safety Principles, Teamwork and Communication, Quality and Safety Improvement Methods, Health Information Systems, and Patient Centeredness. Three levels of competence and standards within each level and area are defined in Table 1. Standards use carefully selected action verbs to reflect educational goals for hospitalists at each level.24 The basic level represents a minimum level of competency for all practicing hospitalists. The intermediate level represents a hospitalist who is prepared to meaningfully engage and collaborate with his or her institution in quality improvement efforts. A hospitalist at this level may also lead uncomplicated improvement projects for his or her medical center and/or hospital medicine group. The advanced level represents a hospitalist prepared to lead quality improvement efforts for his or her institution and/or hospital medicine group. Many hospitalists at this level will have, or will be prepared to have, leadership positions in quality and patient safety at their institutions. Advanced level hospitalists will also have the expertise to teach and mentor other individuals in their quality improvement efforts.
| Competency | Basic | Intermediate | Advanced |
|---|---|---|---|
| |||
| Quality measurement and stakeholder interests | Define structure, process, and outcome measures | Compare and contrast relative benefits of using one type of measure vs another | Anticipate and respond to stakeholders' needs and interests |
| Define stakeholders and understand their interests related to healthcare quality | Explain measures as defined by stakeholders (Center for Medicare and Medicaid Services, Leapfrog, etc) | Anticipate and respond to changes in quality measures and incentive programs | |
| Identify measures as defined by stakeholders (Center for Medicare and Medicaid Services, Leapfrog, etc) | Appreciate variation in quality and utilization performance | Lead efforts to reduce variation in care delivery (see also quality improvement methods) | |
| Describe potential unintended consequences of quality measurement and incentive programs | Avoid unintended consequences of quality measurement and incentive programs | ||
| Data acquisition and interpretation | Interpret simple statistical methods to compare populations within a sample (chi‐square, t tests, etc) | Describe sources of data for quality measurement | Acquire data from internal and external sources |
| Define basic terms used to describe continuous and categorical data (mean, median, standard deviation, interquartile range, percentages, rates, etc) | Identify potential pitfalls in administrative data | Create visual representations of data (Bar, Pareto, and Control Charts) | |
| Summarize basic principles of statistical process control | Explain variation in data | Use simple statistical methods to compare populations within a sample (chi‐square, t tests, etc) | |
| Interpret data displayed in Pareto and Control Charts | Administer and interpret a survey | ||
| Summarize basic survey techniques (including methods to maximize response, minimize bias, and use of ordinal response scales) | |||
| Use appropriate terms to describe continuous and categorical data (mean, median, standard deviation, interquartile range, percentages, rates, etc) | |||
| Organizational knowledge and leadership skills | Describe the organizational structure of one's institution | Define interests of internal and external stakeholders | Effectively negotiate with stakeholders |
| Define leaders within the organization and describe their roles | Collaborate as an effective team member of a quality improvement project | Assemble a quality improvement project team and effectively lead meetings (setting agendas, hold members accountable, etc) | |
| Exemplify the importance of leading by example | Explain principles of change management and how it can positively or negatively impact quality improvement project implementation | Motivate change and create vision for ideal state | |
| Effectively communicate quality or safety issues identified during routine patient care to the appropriate parties | Communicate effectively in a variety of settings (lead a meeting, public speaking, etc) | ||
| Serve as a resource and/or mentor for less‐experienced team members | |||
| Patient safety principles | Identify potential sources of error encountered during routine patient care | Compare methods to measure errors and adverse events, including administrative data analysis, chart review, and incident reporting systems | Lead efforts to appropriately measure medical error and/or adverse events |
| Compare and contrast medical error with adverse event | Identify and explain how human factors can contribute to medical errors | Lead efforts to redesign systems to reduce errors from occurring; this may include the facilitation of a hospital, departmental, or divisional Root Cause Analysis | |
| Describe how the systems approach to medical error is more productive than assigning individual blame | Know the difference between a strong vs a weak action plan for improvement (ie, brief education intervention is weak; skills training with deliberate practice or physical changes are stronger) | Lead efforts to advance the culture of patient safety in the hospital | |
| Differentiate among types of error (knowledge/judgment vs systems vs procedural/technical; latent vs active) | |||
| Explain the role that incident reporting plays in quality improvement efforts and how reporting can foster a culture of safety | |||
| Describe principles of medical error disclosure | |||
| Teamwork and communication | Explain how poor teamwork and communication failures contribute to adverse events | Collaborate on administration and interpretation of teamwork and safety culture measures | Lead efforts to improve teamwork and safety culture |
| Identify the potential for errors during transitions within and between healthcare settings (handoffs, transfers, discharge) | Describe the principles of effective teamwork and identify behaviors consistent with effective teamwork | Lead efforts to improve teamwork in specific settings (intensive care, medical‐surgical unit, etc) | |
| Identify deficiencies in transitions within and between healthcare settings (handoffs, transfers, discharge) | Successfully improve the safety of transitions within and between healthcare settings (handoffs, transfers, discharge) | ||
| Quality and safety improvement methods and tools | Define the quality improvement methods used and infrastructure in place at one's hospital | Compare and contrast various quality improvement methods, including six sigma, lean, and PDSA | Lead a quality improvement project using six sigma, lean, or PDSA methodology |
| Summarize the basic principles and use of Root Cause Analysis as a tool to evaluate medical error | Collaborate on a quality improvement project using six sigma, lean, or PDSA | Use high level process mapping, fishbone diagrams, etc, to identify areas for opportunity in evaluating a process | |
| Describe and collaborate on Failure Mode and Effects Analysis | Lead the development and implementation of clinical protocols to standardize care delivery when appropriate | ||
| Actively participate in a Root Cause Analysis | Conduct Failure Mode and Effects Analysis | ||
| Conduct Root Cause Analysis | |||
| Health information systems | Identify the potential for information systems to reduce as well as contribute to medical error | Define types of clinical decision support | Lead or co‐lead efforts to leverage information systems in quality measurement |
| Describe how information systems fit into provider workflow and care delivery | Collaborate on the design of health information systems | Lead or co‐lead efforts to leverage information systems to reduce error and/or improve delivery of effective care | |
| Anticipate and prevent unintended consequences of implementation or revision of information systems | |||
| Lead or co‐lead efforts to leverage clinical decision support to improve quality and safety | |||
| Patient centeredness | Explain the clinical benefits of a patient‐centered approach | Explain benefits and potential limitations of patient satisfaction surveys | Interpret data from patient satisfaction surveys and lead efforts to improve patient satisfaction |
| Identify system barriers to effective and safe care from the patient's perspective | Identify clinical areas with suboptimal efficiency and/or timeliness from the patient's perspective | Lead effort to reduce inefficiency and/or improve timeliness from the patient's perspective | |
| Describe the value of patient satisfaction surveys and patient and family partnership in care | Promote patient and caregiver education including use of effective education tools | Lead efforts to eliminate system barriers to effective and safe care from the patient's perspective | |
| Lead efforts to improve patent and caregiver education including development or implementation of effective education tools | |||
| Lead efforts to actively involve patients and families in the redesign of healthcare delivery systems and processes | |||
Recommended Use of The Competencies
The HQPS Competencies provide a framework for curricula and other professional development experiences in healthcare quality and patient safety. We recommend a step‐wise approach to curriculum development which includes conducting a targeted needs assessment, defining goals and specific learning objectives, and evaluation of the curriculum.25 The HQPS Competencies can be used at each step and provide educational targets for learners across a range of interest and experience.
Professional Development
Since residency programs historically have not trained their graduates to achieve a basic level of competence, practicing hospitalists will need to seek out professional development opportunities. Some educational opportunities which already exist include the Quality Track sessions during the SHM Annual Meeting, and the SHM Quality Improvement Pre‐Course. Hospitalist leaders are currently using the HQPS Competencies to review and revise annual meeting and pre‐course objectives and content in an effort to meet the expected level of competence for SHM members. Similarly, local SHM Chapter and regional hospital medicine leaders should look to the competencies to help select topics and objectives for future presentations. Additionally, the SHM Web site offers tools to develop skills, including a resource room and quality improvement primer.26 Mentored‐implementation programs, supported by SHM, can help hospitalists' acquire more advanced experiential training in quality improvement.
New educational opportunities are being developed, including a comprehensive set of Internet‐based modules designed to help practicing hospitalists achieve a basic level of competence. Hospitalists will be able to achieve continuing medical education (CME) credit upon completion of individual modules. Plans are underway to provide Certification in Hospital Quality and Patient Safety, reflecting an advanced level of competence, upon completion of the entire set, and demonstration of knowledge and skill application through an approved quality improvement project. The certification process will leverage the success of the SHM Leadership Academies and Mentored Implementation projects to help hospitalists apply their new skills in a real world setting.
HQPS Competencies and Focused Practice in Hospital Medicine
Recently, the American Board of Internal Medicine (ABIM) has recognized the field of hospital medicine by developing a new program that provides hospitalists the opportunity to earn Maintenance of Certification (MOC) in Internal Medicine with a Focused Practice in Hospital Medicine.27 Appropriately, hospital quality and patient safety content is included among the knowledge questions on the secure exam, and completion of a practice improvement module (commonly known as PIM) is required for the certification. The SHM Education Committee has developed a Self‐Evaluation of Medical Knowledge module related to hospital quality and patient safety for use in the MOC process. ABIM recertification with Focused Practice in Hospital Medicine is an important and visible step for the Hospital Medicine movement; the content of both the secure exam and the MOC reaffirms the notion that the acquisition of knowledge, skills, and attitudes in hospital quality and patient safety is essential to the practice of hospital medicine.
Medical Education
Because teaching hospitalists frequently serve in important roles as educators and physician leaders in quality improvement, they are often responsible for medical student and resident training in healthcare quality and patient safety. Medical schools and residency programs have struggled to integrate healthcare quality and patient safety into their curricula.11, 12, 28 Hospitalists can play a major role in academic medical centers by helping to develop curricular materials and evaluations related to healthcare quality. Though intended primarily for future and current hospitalists, the HQPS Competencies and standards for the basic level may be adapted to provide educational targets for many learners in undergraduate and graduate medical education. Teaching hospitalists may use these standards to evaluate current educational efforts and design new curricula in collaboration with their medical school and residency program leaders.
Beyond the basic level of training in healthcare quality required for all, many residents will benefit from more advanced training experiences, including opportunities to apply knowledge and develop skills related to quality improvement. A recent report from the ACGME concluded that role models and mentors were essential for engaging residents in quality improvement efforts.29 Hospitalists are ideally suited to serve as role models during residents' experiential learning opportunities related to hospital quality. Several residency programs have begun to implement hospitalist tracks13 and quality improvement rotations.3032 Additionally, some academic medical centers have begun to develop and offer fellowship training in Hospital Medicine.33 These hospitalist‐led educational programs are an ideal opportunity to teach the intermediate and advanced training components, of healthcare quality and patient safety, to residents and fellows that wish to incorporate activity or leadership in quality improvement and patient safety science into their generalist or subspecialty careers. Teaching hospitalists should use the HQPS competency standards to define learning objectives for trainees at this stage of development.
To address the enormous educational needs in quality and safety for future physicians, a cadre of expert teachers in quality and safety will need to be developed. In collaboration with the Alliance for Academic Internal Medicine (AAIM), SHM is developing a Quality and Safety Educators Academy which will target academic hospitalists and other medical educators interested in developing advanced skills in quality improvement and patient safety education.
Assessment of Competence
An essential component of a rigorous faculty development program or medical education initiative is the assessment of whether these endeavors are achieving their stated aims. Published literature provides examples of useful assessment methods applicable to the HQPS Competencies. Knowledge in several areas of HQPS competence may be assessed with the use of multiple choice tests.34, 35 Knowledge of quality improvement methods may be assessed using the Quality Improvement Knowledge Application Tool (QIKAT), an instrument in which the learner responds to each of 3 scenarios with an aim, outcome and process measures, and ideas for changes which may result in improved performance.36 Teamwork and communication skills may be assessed using 360‐degree evaluations3739 and direct observation using behaviorally anchored rating scales.4043 Objective structured clinical examinations have been used to assess knowledge and skills related to patient safety principles.44, 45 Notably, few studies have rigorously assessed the validity and reliability of tools designed to evaluate competence related to healthcare quality.46 Additionally, to our knowledge, no prior research has evaluated assessment specifically for hospitalists. Thus, the development and validation of new assessment tools based on the HQPS Competencies for learners at each level is a crucial next step in the educational process. Additionally, evaluation of educational initiatives should include analyses of clinical benefit, as the ultimate goal of these efforts is to improve patient care.47, 48
Conclusion
Hospitalists are poised to have a tremendous impact on improving the quality of care for hospitalized patients. The lack of training in quality improvement in traditional medical education programs, in which most current hospitalists were trained, can be overcome through appropriate use of the HQPS Competencies. Formal incorporation of the HQPS Competencies into professional development programs, and innovative educational initiatives and curricula, will help provide current hospitalists and the next generations of hospitalists with the needed skills to be successful.
- Crossing the Quality Chasm: A New Health System for the Twenty‐first Century.Washington, DC:Institute of Medicine;2001.
- ,,,.Care in U.S. hospitals—the Hospital Quality Alliance program.N Engl J Med.2005;353(3):265–274.
- ,.Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.JAMA.2003;290(14):1868–1874.
- Hospital Compare—A quality tool provided by Medicare. Available at: http://www.hospitalcompare.hhs.gov/. Accessed April 23,2010.
- The Leapfrog Group: Hospital Quality Ratings. Available at: http://www.leapfroggroup.org/cp. Accessed April 30,2010.
- Why Not the Best? A Healthcare Quality Improvement Resource. Available at: http://www.whynotthebest.org/. Accessed April 30,2010.
- The Joint Commission: Facts about ORYX for hospitals (National Hospital Quality Measures). Available at: http://www.jointcommission.org/accreditationprograms/hospitals/oryx/oryx_facts.htm. Accessed August 19,2010.
- The Joint Commission: National Patient Safety Goals. Available at: http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/. Accessed August 9,2010.
- Hospital Acquired Conditions: Overview. Available at: http://www.cms.gov/HospitalAcqCond/01_Overview.asp. Accessed April 30,2010.
- Report to Congress:Plan to Implement a Medicare Hospital Value‐based Purchasing Program. Washington, DC: US Department of Health and Human Services, Center for Medicare and Medicaid Services;2007.
- Unmet Needs: Teaching Physicians to Provide Safe Patient Care.Boston, MA:Lucian Leape Institute at the National Patient Safety Foundation;2010.
- ,,,,.Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey.Acad Med.2009;84(12):1672–1676.
- ,,,,.Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs.J Gen Intern Med.2008;23(7):1110–1115.
- ,,,.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111(3):247–254.
- ,,,,.Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.Ann Intern Med.2006;144(12):920–926.
- ,,.Redesigning training for internal medicine.Ann Intern Med.2006;144(12):927–932.
- ,,,,.Core competencies in hospital medicine: development and methodology.J Hosp Med.2006;1(1):48–56.
- Intermountain Healthcare. 20‐Day Course for Executives 2001.
- ,,,.Curriculum Development for Medical Education: A Six‐step Approach.Baltimore, MD:Johns Hopkins Press;1998.
- Society of Hospital Medicine Quality Improvement Basics. Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/QualityImprovement/QIPrimer/QI_Primer_Landing_Pa.htm. Accessed June 4,2010.
- American Board of Internal Medicine: Questions and Answers Regarding ABIM's Maintenance of Certification in Internal Medicine With a Focused Practice in Hospital Medicine Program. Available at: http://www.abim.org/news/news/focused‐practice‐hospital‐medicine‐qa.aspx. Accessed August 9,2010.
- ,,.Assessing the needs of residency program directors to meet the ACGME general competencies.Acad Med.2002;77(7):750.
- .Accreditation Council for Graduate Medical Education and Institute for Healthcare Improvement 90‐Day Project. Involving Residents in Quality Improvement: Contrasting “Top‐Down” and “Bottom‐Up” Approaches.Chicago, IL;ACGME;2008.
- ,,,.Teaching internal medicine residents quality improvement techniques using the ABIM's practice improvement modules.J Gen Intern Med.2008;23(7):927–930.
- ,,,,.A self‐instructional model to teach systems‐based practice and practice‐based learning and improvement.J Gen Intern Med.2008;23(7):931–936.
- ,,,,.Creating a quality improvement elective for medical house officers.J Gen Intern Med.2004;19(8):861–867.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119(1):72.e1‐e7.
- ,,,.Web‐based education in systems‐based practice: a randomized trial.Arch Intern Med.2007;167(4):361–366.
- ,,,,.A self‐instructional model to teach systems‐based practice and practice‐based learning and improvement.J Gen Intern Med.2008;23(7):931–936.
- ,,,.The quality improvement knowledge application tool: an instrument to assess knowledge application in practice‐based learning and improvement.J Gen Intern Med.2003;18(suppl 1):250.
- ,,, et al.Effect of multisource feedback on resident communication skills and professionalism: a randomized controlled trial.Arch Pediatr Adolesc Med.2007;161(1):44–49.
- ,.Reliability of a 360‐degree evaluation to assess resident competence.Am J Phys Med Rehabil.2007;86(10):845–852.
- ,,,.Pilot study of a 360‐degree assessment instrument for physical medicine 82(5):394–402.
- ,,,,,.Anaesthetists' non‐technical skills (ANTS): evaluation of a behavioural marker system.Br J Anaesth.2003;90(5):580–588.
- ,,, et al.The Mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills.Simul Healthc.2007;2(1):4–10.
- ,,,,,.Reliability of a revised NOTECHS scale for use in surgical teams.Am J Surg.2008;196(2):184–190.
- ,,,,,.Observational teamwork assessment for surgery: construct validation with expert versus novice raters.Ann Surg.2009;249(6):1047–1051.
- ,,,,,.A patient safety objective structured clinical examination.J Patient Saf.2009;5(2):55–60.
- ,.The Objective Structured Clinical Examination as an educational tool in patient safety.Jt Comm J Qual Patient Saf.2007;33(1):48–53.
- ,,.Measurement of the general competencies of the Accreditation Council for Graduate Medical Education: a systematic review.Acad Med.2009;84(3):301–309.
- ,,,,,.Effectiveness of teaching quality improvement to clinicians: a systematic review.JAMA.2007;298(9):1023–1037.
- ,,,,.Methodological rigor of quality improvement curricula for physician trainees: a systematic review and recommendations for change.Acad Med.2009;84(12):1677–1692.
- Crossing the Quality Chasm: A New Health System for the Twenty‐first Century.Washington, DC:Institute of Medicine;2001.
- ,,,.Care in U.S. hospitals—the Hospital Quality Alliance program.N Engl J Med.2005;353(3):265–274.
- ,.Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.JAMA.2003;290(14):1868–1874.
- Hospital Compare—A quality tool provided by Medicare. Available at: http://www.hospitalcompare.hhs.gov/. Accessed April 23,2010.
- The Leapfrog Group: Hospital Quality Ratings. Available at: http://www.leapfroggroup.org/cp. Accessed April 30,2010.
- Why Not the Best? A Healthcare Quality Improvement Resource. Available at: http://www.whynotthebest.org/. Accessed April 30,2010.
- The Joint Commission: Facts about ORYX for hospitals (National Hospital Quality Measures). Available at: http://www.jointcommission.org/accreditationprograms/hospitals/oryx/oryx_facts.htm. Accessed August 19,2010.
- The Joint Commission: National Patient Safety Goals. Available at: http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/. Accessed August 9,2010.
- Hospital Acquired Conditions: Overview. Available at: http://www.cms.gov/HospitalAcqCond/01_Overview.asp. Accessed April 30,2010.
- Report to Congress:Plan to Implement a Medicare Hospital Value‐based Purchasing Program. Washington, DC: US Department of Health and Human Services, Center for Medicare and Medicaid Services;2007.
- Unmet Needs: Teaching Physicians to Provide Safe Patient Care.Boston, MA:Lucian Leape Institute at the National Patient Safety Foundation;2010.
- ,,,,.Patient safety education at U.S. and Canadian medical schools: results from the 2006 Clerkship Directors in Internal Medicine survey.Acad Med.2009;84(12):1672–1676.
- ,,,,.Fulfilling the promise of hospital medicine: tailoring internal medicine training to address hospitalists' needs.J Gen Intern Med.2008;23(7):1110–1115.
- ,,,.Hospitalists' perceptions of their residency training needs: results of a national survey.Am J Med.2001;111(3):247–254.
- ,,,,.Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine.Ann Intern Med.2006;144(12):920–926.
- ,,.Redesigning training for internal medicine.Ann Intern Med.2006;144(12):927–932.
- ,,,,.Core competencies in hospital medicine: development and methodology.J Hosp Med.2006;1(1):48–56.
- Intermountain Healthcare. 20‐Day Course for Executives 2001.
- ,,,.Curriculum Development for Medical Education: A Six‐step Approach.Baltimore, MD:Johns Hopkins Press;1998.
- Society of Hospital Medicine Quality Improvement Basics. Available at: http://www.hospitalmedicine.org/Content/NavigationMenu/QualityImprovement/QIPrimer/QI_Primer_Landing_Pa.htm. Accessed June 4,2010.
- American Board of Internal Medicine: Questions and Answers Regarding ABIM's Maintenance of Certification in Internal Medicine With a Focused Practice in Hospital Medicine Program. Available at: http://www.abim.org/news/news/focused‐practice‐hospital‐medicine‐qa.aspx. Accessed August 9,2010.
- ,,.Assessing the needs of residency program directors to meet the ACGME general competencies.Acad Med.2002;77(7):750.
- .Accreditation Council for Graduate Medical Education and Institute for Healthcare Improvement 90‐Day Project. Involving Residents in Quality Improvement: Contrasting “Top‐Down” and “Bottom‐Up” Approaches.Chicago, IL;ACGME;2008.
- ,,,.Teaching internal medicine residents quality improvement techniques using the ABIM's practice improvement modules.J Gen Intern Med.2008;23(7):927–930.
- ,,,,.A self‐instructional model to teach systems‐based practice and practice‐based learning and improvement.J Gen Intern Med.2008;23(7):931–936.
- ,,,,.Creating a quality improvement elective for medical house officers.J Gen Intern Med.2004;19(8):861–867.
- ,,,.Hospital medicine fellowships: works in progress.Am J Med.2006;119(1):72.e1‐e7.
- ,,,.Web‐based education in systems‐based practice: a randomized trial.Arch Intern Med.2007;167(4):361–366.
- ,,,,.A self‐instructional model to teach systems‐based practice and practice‐based learning and improvement.J Gen Intern Med.2008;23(7):931–936.
- ,,,.The quality improvement knowledge application tool: an instrument to assess knowledge application in practice‐based learning and improvement.J Gen Intern Med.2003;18(suppl 1):250.
- ,,, et al.Effect of multisource feedback on resident communication skills and professionalism: a randomized controlled trial.Arch Pediatr Adolesc Med.2007;161(1):44–49.
- ,.Reliability of a 360‐degree evaluation to assess resident competence.Am J Phys Med Rehabil.2007;86(10):845–852.
- ,,,.Pilot study of a 360‐degree assessment instrument for physical medicine 82(5):394–402.
- ,,,,,.Anaesthetists' non‐technical skills (ANTS): evaluation of a behavioural marker system.Br J Anaesth.2003;90(5):580–588.
- ,,, et al.The Mayo high performance teamwork scale: reliability and validity for evaluating key crew resource management skills.Simul Healthc.2007;2(1):4–10.
- ,,,,,.Reliability of a revised NOTECHS scale for use in surgical teams.Am J Surg.2008;196(2):184–190.
- ,,,,,.Observational teamwork assessment for surgery: construct validation with expert versus novice raters.Ann Surg.2009;249(6):1047–1051.
- ,,,,,.A patient safety objective structured clinical examination.J Patient Saf.2009;5(2):55–60.
- ,.The Objective Structured Clinical Examination as an educational tool in patient safety.Jt Comm J Qual Patient Saf.2007;33(1):48–53.
- ,,.Measurement of the general competencies of the Accreditation Council for Graduate Medical Education: a systematic review.Acad Med.2009;84(3):301–309.
- ,,,,,.Effectiveness of teaching quality improvement to clinicians: a systematic review.JAMA.2007;298(9):1023–1037.
- ,,,,.Methodological rigor of quality improvement curricula for physician trainees: a systematic review and recommendations for change.Acad Med.2009;84(12):1677–1692.
PRESsed for time
A 36‐year‐old woman was admitted after new‐onset Hseizures. She had been diagnosed with breast cancer 5 years prior to admission. At that time, she underwent left radical mastectomy and lymph node dissection. Lymph nodes were positive for metastatic disease with negative HER‐2‐Neu and positive estrogen and progesterone receptors. She was treated with docetaxel and tamoxifen but subsequently developed metastatic left hip lesions and was treated with letrozole and anastrozole. Three years later, scans revealed further metastatic disease to the liver, lung, and vertebral column. She was subsequently treated with capecitabine, until further disease progression led to the use of carboplatin and paclitaxel. Seven months prior to admission, her cancer was progressing and she was switched to doxorubicin, gemcitabine, and bevacizumab. Six weeks prior to admission, both positron emission tomography (PET) and computed tomography (CT) scan of her whole body and magnetic resonance imaging (MRI) of the brain illustrated significant improvement. Her last dose of bevacizumab was given 3 weeks prior to her admission.
Two weeks prior to admission, patient reported new‐onset daily headache. These were often localized in the occipital region. She reported some associated nausea and occasional emesis. Subsequently, she developed photophobia and phonophobia. On seeking outpatient treatment for her headache, it was noted that her systolic blood pressure had increased from a baseline of 100 mm Hg to 170 mm Hg. On the day prior to admission, she reported severe headache and several episodes of emesis and later that evening had a witnessed tonic‐clonic seizure.
The patient presented to an outside hospital and had an unremarkable noncontrast CT scan of her brain. An examination of her cerebrospinal fluid revealed negative gram stain, and a normal white blood cell count and protein level. She was treated with lorazepam, phenytoin, and decadron. On becoming more alert, she insisted on going home, where she later developed recurrent headache and presented to our emergency room.
On admission to our service, she was noted to be confused and irritable, and unable to provide any history. Her exam revealed a blood pressure of 143/102 mmHg. No localizing neurologic signs were noted and her laboratory values were normal. After sedation, MRI of the brain was obtained (Figure 1). This revealed diffuse and patchy gyriform hyperintensity of the white matter, most consistent with posterior reversible encephalopathy syndrome (PRES).
Upon reflection, the patient had new onset hypertension that coincided with the initiation and dosing of bevacizumab. Bevacizumab, an antineoplastic agent, is a recombinant humanized monoclonal antibody that binds to and neutralizes vascular endothelial growth factor, thereby preventing angiogenesis.1 It is known to cause grade 3 hypertension in a minority of patients. Therefore, it was postulated that the patient's persistent blood pressure elevation resulted in vasogenic brain edema, precipitating her seizure. Subsequent to the diagnosis, her blood pressure was aggressively controlled with oral enalapril, metoprolol, triamterene/hydrochlorothiazide, and hydralazine. By hospital day 7, her headache had subsided and her altered mental status had resolved. She had no further episodes of seizures and bevacizumab was discontinued.
PRES has a distinct constellation of clinical symptoms and radiologic findings. The name PRES is a misnomer, as this syndrome is not always reversible, nor is it restricted to the white matter or to the posterior areas of the brain.2 It is hypothesized that a sudden rise in blood pressure leads to elevations in intracranial pressure, which exceeds the brain's autoregulatory mechanisms. This subsequently leads to transudation of fluid into the brain parenchyma. Interestingly, it appears that it is not the absolute level of systolic blood pressure that is critical in the development of PRES, but the rate of change in blood pressure. Hence, patients with chronic hypertension have developed adaptive vascular changes that protect them from this type of parenchymal damage.
PRES has gained increasing recognition due to the use of immunosuppressive and chemotherapeutic medications in organ transplant and oncology patients. Drugs such as cyclosporine, tacrolimus, fludarabine, vincristine, cisplatin, cytarabine, interferon‐alpha, interleukin, antiretroviral therapy, erythropoietin, granulocyte stimulating factor, and intravenous immunoglobulin have all been implicated.3 In addition to increasing blood pressure, these agents likely cause direct toxic injury to the brain, disrupting the blood‐brain barrier and resulting in subsequent edema. Other conditions associated with PRES include renal disease, vasculitis, endocrine disorders, porphyria, cocaine or amphetamine abuse, and stimulant abuse.
Clinically, PRES can present as headache, altered mental status, confusion, drowsiness progressing to stupor, emesis, abnormal visual perceptions, visual neglect, cortical blindness, difficulty with memory and concentration, brisk deep tendon reflexes, weakness, ataxia, and seizure activity. PRES has a characteristic appearance on neuroimaging that differentiates it from other forms of hypertensive encephalopathy. Edema of the white or gray matter in the posterior cerebral hemispheres, particularly the bilateral parietooccipital regions, is seen. PRES can also diffusely involve the brain stem, cerebellum, basal ganglia, and the frontal lobes. Abnormalities on neuroimaging are often symmetric but clinical manifestations can be asymmetric. MRI and CT scans can both be utilized for characterization of PRES.4
There are currently no published guidelines for the management of PRES. Expert opinion suggests removing the underlying cause and aggressively treating the hypertension.5 Furthermore, initiation and duration of antiepileptics remains controversial. After aggressive blood pressure control, resolution of findings on neuroimaging studies are expected anywhere from 8 days to 17 months.
Timely recognition of PRES is critical for prevention of further neurologic compromise. Immediate discontinuation of offending agents, as well as aggressive treatment of blood pressure, is the cornerstone treatment for PRES. In the future, a better understanding of the pathophysiology of PRES can lead to improved diagnostic and management options.
- ,,.Reversible posterior leukoencephalopathy syndrome and bevacizumab.N Engl J Med.2006;354(9):980–982.
- ,,, et al.A reversible posterior leukoencephalopathy syndrome.N Engl J Med.1996;334(8):494–500.
- ,,,,,.Reversible posterior leukoencephalopathy syndrome complicating cytotoxic chemotherapy for hematologic malignancies.Am J Hematol.2004;77(1):72–76.
- ,,, et al.Posterior leukoencephalopathy without severe hypertension: utility of diffusion‐weighted MRI.Neurology.1998;51(5):1369–1376.
- .Posterior leukoencephalopathy syndrome.Postgrad Med J.2001;77(903):24–28.
A 36‐year‐old woman was admitted after new‐onset Hseizures. She had been diagnosed with breast cancer 5 years prior to admission. At that time, she underwent left radical mastectomy and lymph node dissection. Lymph nodes were positive for metastatic disease with negative HER‐2‐Neu and positive estrogen and progesterone receptors. She was treated with docetaxel and tamoxifen but subsequently developed metastatic left hip lesions and was treated with letrozole and anastrozole. Three years later, scans revealed further metastatic disease to the liver, lung, and vertebral column. She was subsequently treated with capecitabine, until further disease progression led to the use of carboplatin and paclitaxel. Seven months prior to admission, her cancer was progressing and she was switched to doxorubicin, gemcitabine, and bevacizumab. Six weeks prior to admission, both positron emission tomography (PET) and computed tomography (CT) scan of her whole body and magnetic resonance imaging (MRI) of the brain illustrated significant improvement. Her last dose of bevacizumab was given 3 weeks prior to her admission.
Two weeks prior to admission, patient reported new‐onset daily headache. These were often localized in the occipital region. She reported some associated nausea and occasional emesis. Subsequently, she developed photophobia and phonophobia. On seeking outpatient treatment for her headache, it was noted that her systolic blood pressure had increased from a baseline of 100 mm Hg to 170 mm Hg. On the day prior to admission, she reported severe headache and several episodes of emesis and later that evening had a witnessed tonic‐clonic seizure.
The patient presented to an outside hospital and had an unremarkable noncontrast CT scan of her brain. An examination of her cerebrospinal fluid revealed negative gram stain, and a normal white blood cell count and protein level. She was treated with lorazepam, phenytoin, and decadron. On becoming more alert, she insisted on going home, where she later developed recurrent headache and presented to our emergency room.
On admission to our service, she was noted to be confused and irritable, and unable to provide any history. Her exam revealed a blood pressure of 143/102 mmHg. No localizing neurologic signs were noted and her laboratory values were normal. After sedation, MRI of the brain was obtained (Figure 1). This revealed diffuse and patchy gyriform hyperintensity of the white matter, most consistent with posterior reversible encephalopathy syndrome (PRES).
Upon reflection, the patient had new onset hypertension that coincided with the initiation and dosing of bevacizumab. Bevacizumab, an antineoplastic agent, is a recombinant humanized monoclonal antibody that binds to and neutralizes vascular endothelial growth factor, thereby preventing angiogenesis.1 It is known to cause grade 3 hypertension in a minority of patients. Therefore, it was postulated that the patient's persistent blood pressure elevation resulted in vasogenic brain edema, precipitating her seizure. Subsequent to the diagnosis, her blood pressure was aggressively controlled with oral enalapril, metoprolol, triamterene/hydrochlorothiazide, and hydralazine. By hospital day 7, her headache had subsided and her altered mental status had resolved. She had no further episodes of seizures and bevacizumab was discontinued.
PRES has a distinct constellation of clinical symptoms and radiologic findings. The name PRES is a misnomer, as this syndrome is not always reversible, nor is it restricted to the white matter or to the posterior areas of the brain.2 It is hypothesized that a sudden rise in blood pressure leads to elevations in intracranial pressure, which exceeds the brain's autoregulatory mechanisms. This subsequently leads to transudation of fluid into the brain parenchyma. Interestingly, it appears that it is not the absolute level of systolic blood pressure that is critical in the development of PRES, but the rate of change in blood pressure. Hence, patients with chronic hypertension have developed adaptive vascular changes that protect them from this type of parenchymal damage.
PRES has gained increasing recognition due to the use of immunosuppressive and chemotherapeutic medications in organ transplant and oncology patients. Drugs such as cyclosporine, tacrolimus, fludarabine, vincristine, cisplatin, cytarabine, interferon‐alpha, interleukin, antiretroviral therapy, erythropoietin, granulocyte stimulating factor, and intravenous immunoglobulin have all been implicated.3 In addition to increasing blood pressure, these agents likely cause direct toxic injury to the brain, disrupting the blood‐brain barrier and resulting in subsequent edema. Other conditions associated with PRES include renal disease, vasculitis, endocrine disorders, porphyria, cocaine or amphetamine abuse, and stimulant abuse.
Clinically, PRES can present as headache, altered mental status, confusion, drowsiness progressing to stupor, emesis, abnormal visual perceptions, visual neglect, cortical blindness, difficulty with memory and concentration, brisk deep tendon reflexes, weakness, ataxia, and seizure activity. PRES has a characteristic appearance on neuroimaging that differentiates it from other forms of hypertensive encephalopathy. Edema of the white or gray matter in the posterior cerebral hemispheres, particularly the bilateral parietooccipital regions, is seen. PRES can also diffusely involve the brain stem, cerebellum, basal ganglia, and the frontal lobes. Abnormalities on neuroimaging are often symmetric but clinical manifestations can be asymmetric. MRI and CT scans can both be utilized for characterization of PRES.4
There are currently no published guidelines for the management of PRES. Expert opinion suggests removing the underlying cause and aggressively treating the hypertension.5 Furthermore, initiation and duration of antiepileptics remains controversial. After aggressive blood pressure control, resolution of findings on neuroimaging studies are expected anywhere from 8 days to 17 months.
Timely recognition of PRES is critical for prevention of further neurologic compromise. Immediate discontinuation of offending agents, as well as aggressive treatment of blood pressure, is the cornerstone treatment for PRES. In the future, a better understanding of the pathophysiology of PRES can lead to improved diagnostic and management options.
A 36‐year‐old woman was admitted after new‐onset Hseizures. She had been diagnosed with breast cancer 5 years prior to admission. At that time, she underwent left radical mastectomy and lymph node dissection. Lymph nodes were positive for metastatic disease with negative HER‐2‐Neu and positive estrogen and progesterone receptors. She was treated with docetaxel and tamoxifen but subsequently developed metastatic left hip lesions and was treated with letrozole and anastrozole. Three years later, scans revealed further metastatic disease to the liver, lung, and vertebral column. She was subsequently treated with capecitabine, until further disease progression led to the use of carboplatin and paclitaxel. Seven months prior to admission, her cancer was progressing and she was switched to doxorubicin, gemcitabine, and bevacizumab. Six weeks prior to admission, both positron emission tomography (PET) and computed tomography (CT) scan of her whole body and magnetic resonance imaging (MRI) of the brain illustrated significant improvement. Her last dose of bevacizumab was given 3 weeks prior to her admission.
Two weeks prior to admission, patient reported new‐onset daily headache. These were often localized in the occipital region. She reported some associated nausea and occasional emesis. Subsequently, she developed photophobia and phonophobia. On seeking outpatient treatment for her headache, it was noted that her systolic blood pressure had increased from a baseline of 100 mm Hg to 170 mm Hg. On the day prior to admission, she reported severe headache and several episodes of emesis and later that evening had a witnessed tonic‐clonic seizure.
The patient presented to an outside hospital and had an unremarkable noncontrast CT scan of her brain. An examination of her cerebrospinal fluid revealed negative gram stain, and a normal white blood cell count and protein level. She was treated with lorazepam, phenytoin, and decadron. On becoming more alert, she insisted on going home, where she later developed recurrent headache and presented to our emergency room.
On admission to our service, she was noted to be confused and irritable, and unable to provide any history. Her exam revealed a blood pressure of 143/102 mmHg. No localizing neurologic signs were noted and her laboratory values were normal. After sedation, MRI of the brain was obtained (Figure 1). This revealed diffuse and patchy gyriform hyperintensity of the white matter, most consistent with posterior reversible encephalopathy syndrome (PRES).
Upon reflection, the patient had new onset hypertension that coincided with the initiation and dosing of bevacizumab. Bevacizumab, an antineoplastic agent, is a recombinant humanized monoclonal antibody that binds to and neutralizes vascular endothelial growth factor, thereby preventing angiogenesis.1 It is known to cause grade 3 hypertension in a minority of patients. Therefore, it was postulated that the patient's persistent blood pressure elevation resulted in vasogenic brain edema, precipitating her seizure. Subsequent to the diagnosis, her blood pressure was aggressively controlled with oral enalapril, metoprolol, triamterene/hydrochlorothiazide, and hydralazine. By hospital day 7, her headache had subsided and her altered mental status had resolved. She had no further episodes of seizures and bevacizumab was discontinued.
PRES has a distinct constellation of clinical symptoms and radiologic findings. The name PRES is a misnomer, as this syndrome is not always reversible, nor is it restricted to the white matter or to the posterior areas of the brain.2 It is hypothesized that a sudden rise in blood pressure leads to elevations in intracranial pressure, which exceeds the brain's autoregulatory mechanisms. This subsequently leads to transudation of fluid into the brain parenchyma. Interestingly, it appears that it is not the absolute level of systolic blood pressure that is critical in the development of PRES, but the rate of change in blood pressure. Hence, patients with chronic hypertension have developed adaptive vascular changes that protect them from this type of parenchymal damage.
PRES has gained increasing recognition due to the use of immunosuppressive and chemotherapeutic medications in organ transplant and oncology patients. Drugs such as cyclosporine, tacrolimus, fludarabine, vincristine, cisplatin, cytarabine, interferon‐alpha, interleukin, antiretroviral therapy, erythropoietin, granulocyte stimulating factor, and intravenous immunoglobulin have all been implicated.3 In addition to increasing blood pressure, these agents likely cause direct toxic injury to the brain, disrupting the blood‐brain barrier and resulting in subsequent edema. Other conditions associated with PRES include renal disease, vasculitis, endocrine disorders, porphyria, cocaine or amphetamine abuse, and stimulant abuse.
Clinically, PRES can present as headache, altered mental status, confusion, drowsiness progressing to stupor, emesis, abnormal visual perceptions, visual neglect, cortical blindness, difficulty with memory and concentration, brisk deep tendon reflexes, weakness, ataxia, and seizure activity. PRES has a characteristic appearance on neuroimaging that differentiates it from other forms of hypertensive encephalopathy. Edema of the white or gray matter in the posterior cerebral hemispheres, particularly the bilateral parietooccipital regions, is seen. PRES can also diffusely involve the brain stem, cerebellum, basal ganglia, and the frontal lobes. Abnormalities on neuroimaging are often symmetric but clinical manifestations can be asymmetric. MRI and CT scans can both be utilized for characterization of PRES.4
There are currently no published guidelines for the management of PRES. Expert opinion suggests removing the underlying cause and aggressively treating the hypertension.5 Furthermore, initiation and duration of antiepileptics remains controversial. After aggressive blood pressure control, resolution of findings on neuroimaging studies are expected anywhere from 8 days to 17 months.
Timely recognition of PRES is critical for prevention of further neurologic compromise. Immediate discontinuation of offending agents, as well as aggressive treatment of blood pressure, is the cornerstone treatment for PRES. In the future, a better understanding of the pathophysiology of PRES can lead to improved diagnostic and management options.
- ,,.Reversible posterior leukoencephalopathy syndrome and bevacizumab.N Engl J Med.2006;354(9):980–982.
- ,,, et al.A reversible posterior leukoencephalopathy syndrome.N Engl J Med.1996;334(8):494–500.
- ,,,,,.Reversible posterior leukoencephalopathy syndrome complicating cytotoxic chemotherapy for hematologic malignancies.Am J Hematol.2004;77(1):72–76.
- ,,, et al.Posterior leukoencephalopathy without severe hypertension: utility of diffusion‐weighted MRI.Neurology.1998;51(5):1369–1376.
- .Posterior leukoencephalopathy syndrome.Postgrad Med J.2001;77(903):24–28.
- ,,.Reversible posterior leukoencephalopathy syndrome and bevacizumab.N Engl J Med.2006;354(9):980–982.
- ,,, et al.A reversible posterior leukoencephalopathy syndrome.N Engl J Med.1996;334(8):494–500.
- ,,,,,.Reversible posterior leukoencephalopathy syndrome complicating cytotoxic chemotherapy for hematologic malignancies.Am J Hematol.2004;77(1):72–76.
- ,,, et al.Posterior leukoencephalopathy without severe hypertension: utility of diffusion‐weighted MRI.Neurology.1998;51(5):1369–1376.
- .Posterior leukoencephalopathy syndrome.Postgrad Med J.2001;77(903):24–28.
