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The Time to Act Is Now
It should come as no surprise to most hospitalists that healthcare-associated infections (HAIs) are among the leading causes of death in the U.S. The Centers for Disease Control and Prevention (CDC) estimates that from 5% to 10% of hospitalized patients develops an HAI, which leads to nearly 100,000 deaths every year.
The big four infection categories are catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (as well as non-ventilator-associated hospital-acquired pneumonia), central-line-associated bloodstream infections, and surgical-site infections. In addition, Clostridium difficile (C-diff) and methicillin-resistant Staphylococcus aureus (MRSA) infections add to the burden.
While the toll on patients is substantial, the financial burden is equally staggering. It is estimated that HAIs lead to $28 billion to $33 billion in excess healthcare costs each year. So what does this have to do with hospitalists? Everything.
National Efforts to Curb HAIs
The morbidity, mortality, and financial consequences of HAIs have not been lost on patients, payors, and policymakers; each group is demanding action. The Department of Health and Human Services (HHS) is coordinating a national effort addressing HAIs; it aims to bring together many of HHS’ agencies (CDC, Agency for Healthcare Research and Quality, National Institutes of Health, Centers for Medicare and Medicaid Services, etc.) and engage patients, payors, and care providers. As a show of support for these efforts, Congress provided HHS with more than $200 million to target HAIs. After much work, HHS released its action plan to prevent HAIs in January.
SHM was one of the organizations asked to comment on the prevention plan. We did.
- We supported HHS’ focus on process measures (rather than outcomes), which recognizes the inevitability of some HAIs;
- We asked to be more involved in the process of developing and implementing the action plan; and
- We specifically asked for hospitalist representation on the Healthcare Infection Control Practices Advisory Committee (HICPAC), which develops the guidelines and prioritizes national efforts targeting HAI prevention.
Wish granted. In June, I was invited to HHS’ offices in Washington, D.C., along with key stakeholders to hear details of the final plan of action and discuss implementation. The plan (www.hhs.gov/ophs/initiatives/hai/infection.html) addresses key HAIs, establishes baseline rates, and proposes five-year national targets for reductions in infections.
The National Quality Foundation (NQF) has endorsed most of the metrics. The targeted reductions seem reasonable, and they are mostly in line with current evidence on best practices.
Of note, HHS dropped ventilator-associated pneumonia as a target area because of feedback from stakeholders (e.g., SHM) who argued that current definitions of the condition were inadequate to allow accurate measurement of targeted performance improvement efforts. Also of note, SHM was offered a HICPAC seat, which will enhance our ability to further impact the development and evaluation of current and future metrics.
I was invited back to Washington in July to meet with Don Wright, MD, MPH, FAACP, HHS’ principal deputy assistant secretary for health. It’s obvious to me that HHS realizes that any effective campaign to reduce HAI incidence will require engaging hospitalists, and, interestingly, HHS has even heard from other professional societies that hospitalists are a key group to target if you plan to implement hospitalwide interventions that span the ED, hospital wards, ICUs, surgical patients, pediatrics, or any other nook or cranny in the hospital. Hospitalists and SHM appear to be at ground zero in the national effort to combat HAIs.
The Hospitalist’s Role
There are few medical conditions that impact more of SHM’s big tent of membership the way HAIs do. HAIs affect administrators, internists, family practitioners, pediatricians, physician assistants and nurse practitioners, nurses, residents, students, community practitioners, academics, and large management companies … the list goes on. Not surprisingly, efforts to combat HAIs will require teams composed of many of the groups highlighted above working together to create systems-based approaches in their own hospitals—in joint efforts to reduce the rate of preventable HAIs.
Take the most common HAI as an example: catheter-associated urinary tract infections. These infections affect patients in every hospital unit and are familiar to every care provider, regardless of background or practice setting. Administrators should care about CAUTIs in part because CMS no longer pays for a CAUTI when it complicates a hospitalization, but also because these infections adversely affect patient satisfaction. Efforts to reduce CAUTIs will need to address inappropriate catheter insertion, provide alternatives to catheter use (e.g., bladder scans), develop best practices for maintenance of necessary catheters, and facilitate timely removal of catheters no longer needed. Dealing with all of these issues will take a team-based systems approach.
I will not be surprised if hospitalists end up leading these initiatives across the country. Hospitalists will need to share best practices, collaborate in local or national initiatives, provide feedback to SHM and policymakers about what works and what doesn’t, and educate patients about HAIs and prevention. Every hospitalist in the country needs to understand the reasons HAIs develop, know strategies to prevent them, and work to implement these strategies in their hospitals.
Future Directions
Given the urgency, what can you expect next? The action plan is finalized, so HHS is turning its attention to implementation. HHS has reached out to SHM to see how we can get the word out to our members. Dissemination strategies include publication of key messages in The Hospitalist, the Journal of Hospital Medicine, Webinars, e-mail announcements, and presentations at our annual meeting.
And while HHS’ plan of action highlights the metrics, it does not provide detailed strategies to combat HAIs. Prevention tools will need to be developed, tested, and, if effective, disseminated. HHS has asked SHM to help in tool development and dissemination.
HHS will continue to work with CMS to align payment policies that incentivize prevention efforts, and SHM will need to follow these developments closely. In addition, AHRQ is dedicating substantial funds to support the development and dissemination of best practices to prevent HAIs.
HHS acknowledges we still have much to learn about HAIs and their prevention. I expect many hospitalists, as well as SHM, will be at the center of these initiatives. Healthcare-associated infections are a problem that can no longer be ignored. Prevention efforts need to be ramped up. Hospitalists around the country need to prepare to lead and champion these efforts. It is time to act. TH
Dr. Flanders is president of SHM.
It should come as no surprise to most hospitalists that healthcare-associated infections (HAIs) are among the leading causes of death in the U.S. The Centers for Disease Control and Prevention (CDC) estimates that from 5% to 10% of hospitalized patients develops an HAI, which leads to nearly 100,000 deaths every year.
The big four infection categories are catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (as well as non-ventilator-associated hospital-acquired pneumonia), central-line-associated bloodstream infections, and surgical-site infections. In addition, Clostridium difficile (C-diff) and methicillin-resistant Staphylococcus aureus (MRSA) infections add to the burden.
While the toll on patients is substantial, the financial burden is equally staggering. It is estimated that HAIs lead to $28 billion to $33 billion in excess healthcare costs each year. So what does this have to do with hospitalists? Everything.
National Efforts to Curb HAIs
The morbidity, mortality, and financial consequences of HAIs have not been lost on patients, payors, and policymakers; each group is demanding action. The Department of Health and Human Services (HHS) is coordinating a national effort addressing HAIs; it aims to bring together many of HHS’ agencies (CDC, Agency for Healthcare Research and Quality, National Institutes of Health, Centers for Medicare and Medicaid Services, etc.) and engage patients, payors, and care providers. As a show of support for these efforts, Congress provided HHS with more than $200 million to target HAIs. After much work, HHS released its action plan to prevent HAIs in January.
SHM was one of the organizations asked to comment on the prevention plan. We did.
- We supported HHS’ focus on process measures (rather than outcomes), which recognizes the inevitability of some HAIs;
- We asked to be more involved in the process of developing and implementing the action plan; and
- We specifically asked for hospitalist representation on the Healthcare Infection Control Practices Advisory Committee (HICPAC), which develops the guidelines and prioritizes national efforts targeting HAI prevention.
Wish granted. In June, I was invited to HHS’ offices in Washington, D.C., along with key stakeholders to hear details of the final plan of action and discuss implementation. The plan (www.hhs.gov/ophs/initiatives/hai/infection.html) addresses key HAIs, establishes baseline rates, and proposes five-year national targets for reductions in infections.
The National Quality Foundation (NQF) has endorsed most of the metrics. The targeted reductions seem reasonable, and they are mostly in line with current evidence on best practices.
Of note, HHS dropped ventilator-associated pneumonia as a target area because of feedback from stakeholders (e.g., SHM) who argued that current definitions of the condition were inadequate to allow accurate measurement of targeted performance improvement efforts. Also of note, SHM was offered a HICPAC seat, which will enhance our ability to further impact the development and evaluation of current and future metrics.
I was invited back to Washington in July to meet with Don Wright, MD, MPH, FAACP, HHS’ principal deputy assistant secretary for health. It’s obvious to me that HHS realizes that any effective campaign to reduce HAI incidence will require engaging hospitalists, and, interestingly, HHS has even heard from other professional societies that hospitalists are a key group to target if you plan to implement hospitalwide interventions that span the ED, hospital wards, ICUs, surgical patients, pediatrics, or any other nook or cranny in the hospital. Hospitalists and SHM appear to be at ground zero in the national effort to combat HAIs.
The Hospitalist’s Role
There are few medical conditions that impact more of SHM’s big tent of membership the way HAIs do. HAIs affect administrators, internists, family practitioners, pediatricians, physician assistants and nurse practitioners, nurses, residents, students, community practitioners, academics, and large management companies … the list goes on. Not surprisingly, efforts to combat HAIs will require teams composed of many of the groups highlighted above working together to create systems-based approaches in their own hospitals—in joint efforts to reduce the rate of preventable HAIs.
Take the most common HAI as an example: catheter-associated urinary tract infections. These infections affect patients in every hospital unit and are familiar to every care provider, regardless of background or practice setting. Administrators should care about CAUTIs in part because CMS no longer pays for a CAUTI when it complicates a hospitalization, but also because these infections adversely affect patient satisfaction. Efforts to reduce CAUTIs will need to address inappropriate catheter insertion, provide alternatives to catheter use (e.g., bladder scans), develop best practices for maintenance of necessary catheters, and facilitate timely removal of catheters no longer needed. Dealing with all of these issues will take a team-based systems approach.
I will not be surprised if hospitalists end up leading these initiatives across the country. Hospitalists will need to share best practices, collaborate in local or national initiatives, provide feedback to SHM and policymakers about what works and what doesn’t, and educate patients about HAIs and prevention. Every hospitalist in the country needs to understand the reasons HAIs develop, know strategies to prevent them, and work to implement these strategies in their hospitals.
Future Directions
Given the urgency, what can you expect next? The action plan is finalized, so HHS is turning its attention to implementation. HHS has reached out to SHM to see how we can get the word out to our members. Dissemination strategies include publication of key messages in The Hospitalist, the Journal of Hospital Medicine, Webinars, e-mail announcements, and presentations at our annual meeting.
And while HHS’ plan of action highlights the metrics, it does not provide detailed strategies to combat HAIs. Prevention tools will need to be developed, tested, and, if effective, disseminated. HHS has asked SHM to help in tool development and dissemination.
HHS will continue to work with CMS to align payment policies that incentivize prevention efforts, and SHM will need to follow these developments closely. In addition, AHRQ is dedicating substantial funds to support the development and dissemination of best practices to prevent HAIs.
HHS acknowledges we still have much to learn about HAIs and their prevention. I expect many hospitalists, as well as SHM, will be at the center of these initiatives. Healthcare-associated infections are a problem that can no longer be ignored. Prevention efforts need to be ramped up. Hospitalists around the country need to prepare to lead and champion these efforts. It is time to act. TH
Dr. Flanders is president of SHM.
It should come as no surprise to most hospitalists that healthcare-associated infections (HAIs) are among the leading causes of death in the U.S. The Centers for Disease Control and Prevention (CDC) estimates that from 5% to 10% of hospitalized patients develops an HAI, which leads to nearly 100,000 deaths every year.
The big four infection categories are catheter-associated urinary tract infections (CAUTIs), ventilator-associated pneumonia (as well as non-ventilator-associated hospital-acquired pneumonia), central-line-associated bloodstream infections, and surgical-site infections. In addition, Clostridium difficile (C-diff) and methicillin-resistant Staphylococcus aureus (MRSA) infections add to the burden.
While the toll on patients is substantial, the financial burden is equally staggering. It is estimated that HAIs lead to $28 billion to $33 billion in excess healthcare costs each year. So what does this have to do with hospitalists? Everything.
National Efforts to Curb HAIs
The morbidity, mortality, and financial consequences of HAIs have not been lost on patients, payors, and policymakers; each group is demanding action. The Department of Health and Human Services (HHS) is coordinating a national effort addressing HAIs; it aims to bring together many of HHS’ agencies (CDC, Agency for Healthcare Research and Quality, National Institutes of Health, Centers for Medicare and Medicaid Services, etc.) and engage patients, payors, and care providers. As a show of support for these efforts, Congress provided HHS with more than $200 million to target HAIs. After much work, HHS released its action plan to prevent HAIs in January.
SHM was one of the organizations asked to comment on the prevention plan. We did.
- We supported HHS’ focus on process measures (rather than outcomes), which recognizes the inevitability of some HAIs;
- We asked to be more involved in the process of developing and implementing the action plan; and
- We specifically asked for hospitalist representation on the Healthcare Infection Control Practices Advisory Committee (HICPAC), which develops the guidelines and prioritizes national efforts targeting HAI prevention.
Wish granted. In June, I was invited to HHS’ offices in Washington, D.C., along with key stakeholders to hear details of the final plan of action and discuss implementation. The plan (www.hhs.gov/ophs/initiatives/hai/infection.html) addresses key HAIs, establishes baseline rates, and proposes five-year national targets for reductions in infections.
The National Quality Foundation (NQF) has endorsed most of the metrics. The targeted reductions seem reasonable, and they are mostly in line with current evidence on best practices.
Of note, HHS dropped ventilator-associated pneumonia as a target area because of feedback from stakeholders (e.g., SHM) who argued that current definitions of the condition were inadequate to allow accurate measurement of targeted performance improvement efforts. Also of note, SHM was offered a HICPAC seat, which will enhance our ability to further impact the development and evaluation of current and future metrics.
I was invited back to Washington in July to meet with Don Wright, MD, MPH, FAACP, HHS’ principal deputy assistant secretary for health. It’s obvious to me that HHS realizes that any effective campaign to reduce HAI incidence will require engaging hospitalists, and, interestingly, HHS has even heard from other professional societies that hospitalists are a key group to target if you plan to implement hospitalwide interventions that span the ED, hospital wards, ICUs, surgical patients, pediatrics, or any other nook or cranny in the hospital. Hospitalists and SHM appear to be at ground zero in the national effort to combat HAIs.
The Hospitalist’s Role
There are few medical conditions that impact more of SHM’s big tent of membership the way HAIs do. HAIs affect administrators, internists, family practitioners, pediatricians, physician assistants and nurse practitioners, nurses, residents, students, community practitioners, academics, and large management companies … the list goes on. Not surprisingly, efforts to combat HAIs will require teams composed of many of the groups highlighted above working together to create systems-based approaches in their own hospitals—in joint efforts to reduce the rate of preventable HAIs.
Take the most common HAI as an example: catheter-associated urinary tract infections. These infections affect patients in every hospital unit and are familiar to every care provider, regardless of background or practice setting. Administrators should care about CAUTIs in part because CMS no longer pays for a CAUTI when it complicates a hospitalization, but also because these infections adversely affect patient satisfaction. Efforts to reduce CAUTIs will need to address inappropriate catheter insertion, provide alternatives to catheter use (e.g., bladder scans), develop best practices for maintenance of necessary catheters, and facilitate timely removal of catheters no longer needed. Dealing with all of these issues will take a team-based systems approach.
I will not be surprised if hospitalists end up leading these initiatives across the country. Hospitalists will need to share best practices, collaborate in local or national initiatives, provide feedback to SHM and policymakers about what works and what doesn’t, and educate patients about HAIs and prevention. Every hospitalist in the country needs to understand the reasons HAIs develop, know strategies to prevent them, and work to implement these strategies in their hospitals.
Future Directions
Given the urgency, what can you expect next? The action plan is finalized, so HHS is turning its attention to implementation. HHS has reached out to SHM to see how we can get the word out to our members. Dissemination strategies include publication of key messages in The Hospitalist, the Journal of Hospital Medicine, Webinars, e-mail announcements, and presentations at our annual meeting.
And while HHS’ plan of action highlights the metrics, it does not provide detailed strategies to combat HAIs. Prevention tools will need to be developed, tested, and, if effective, disseminated. HHS has asked SHM to help in tool development and dissemination.
HHS will continue to work with CMS to align payment policies that incentivize prevention efforts, and SHM will need to follow these developments closely. In addition, AHRQ is dedicating substantial funds to support the development and dissemination of best practices to prevent HAIs.
HHS acknowledges we still have much to learn about HAIs and their prevention. I expect many hospitalists, as well as SHM, will be at the center of these initiatives. Healthcare-associated infections are a problem that can no longer be ignored. Prevention efforts need to be ramped up. Hospitalists around the country need to prepare to lead and champion these efforts. It is time to act. TH
Dr. Flanders is president of SHM.
Life under the Big Tent
SHM prides itself on being a “big tent” organization—inclusive of care providers with different training backgrounds, from varied clinical settings, and representing a multitude of hospital roles. SHM’s diversity expands beyond care providers to include other key stakeholders, such as administrators of hospitalist programs or departments. The diversity was highlighted in the society’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” which shows that 40% of our members are hospital-employed, 20% are from academic settings, about 15% work in large multistate management companies, and the remaining 25% are equally split between multispecialty practices and local hospitalist groups. The diversity extends to internists, pediatricians, family practitioners, nurse practitioners, physician assistants, specialists—the list goes on.
All of us at SHM appreciate that diversity and routinely try to nurture it. Our board of directors includes physicians from all the aforementioned practice settings and includes dedicated seats for such key constituencies as pediatrics. We have more than 25 committees and task-force groups representing all the key factions of our membership. These groups address issues of relevance to every type of hospitalist and hospitalist group. Our annual meeting has evolved to meet the needs of this diverse membership by addressing an enormous volume of topics and incorporating a variety of tracks that cater to general hospitalists, quality experts, academics, and pediatricians.
One notable area in which we lack diversity: age. We are a young specialty; the average hospitalist is 40 years old.
SHM’s organizational diversity creates challenges; new issues surface every year. One key issue is the balance between academic hospitalists and community hospitalists. Academic hospitalists have wanted SHM to more aggressively support their interests. Community hospitalists want SHM to advocate for their interests, as well as develop programs and projects to meet their needs.
With my election as president and the recent election of another academic hospitalist to serve as SHM president in 2010-2011, there might be some concern that community hospitalists could get lost in an academic agenda. Interestingly, academic hospitalists might have raised similar concerns several years ago following the election of a second consecutive community hospitalist as society president. We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.
One Tent, Many Spikes in the Ground
The issues are more complex than simply the differences between academic and community hospitalists. Appropriately, each of our members wants their groups’ issues discussed and addressed. Although workforce might be an issue for private-practice hospitalists, academic hospitalists share these same issues—just in a different environment. Pediatricians see SHM develop core competencies for adult medicine, then want their own pediatric core competencies; SHM needs to look for a way to make this happen. Nurse practitioners (NPs), physician assistants (PAs), and administrators have looked to SHM to represent not just physicians in HM, but also their interests.
As a result, SHM has developed committees and approaches to engage the professional societies representing PAs and NPs, along with the Medical Group Management Association, to design specific projects and programs. At any point in time, there might be a group of members who see a need for SHM to pay attention to “their” issue or perceive that a current approach, while relevant to one group, falls short of the needs of another. As our diversity grows, the frequency of these situations will increase.
So, is this worrisome? Quite the contrary. I believe it is healthy.
Having an established organization with members of differing opinions and backgrounds helps challenge our assumptions. It refines our approach to complex problems, highlights issues or concerns we did not anticipate, and, most importantly, guards against “groupthink”—the tendency to agree with one another all the time. SHM’s board of directors is committed to this type of inclusive leadership.
We do need to be cautious and think quite a bit about this issue in the coming years. The big tent is filling up quickly. It’s becoming more diverse by the week. The concern is that in trying to work at a level that keeps all our constituents happy, we might please no one. If all our activities have to be justified as being relevant to every distinct group that makes up SHM, then we might dilute our effectiveness.
Alternatively, we do not currently have the bandwidth as an organization to initiate in-depth projects in areas relevant to all our members. So far, our approach has been to focus on areas core to every hospitalist: quality and safety, process improvement, leadership, practice management, care transitions, networking, and education.
As unique problems or issues arise that are relevant to only a subset of members, we will weigh the importance. In many cases, we have created task-force groups to clarify and tackle the problem. We provide the support, but the members of the group create the solution. It has worked well so far.
One Voice, One Goal
But can we stick to this strategy as the diversity of membership expands and the number of relevant issues grows? I don’t know. What I do know is that there is strength in numbers, and even though we all have different issues we deem more important, there are times when it helps to come together and speak as one very big, very loud voice.
Older specialties like endocrinology, allergy, and others have split into a variety of organizations and potentially diluted their message. SHM needs to look for creative ways to be relevant to many constituencies within the specialty. In the meantime, we must pay close attention to the big-tent issues. An academic hospitalist in leadership needs to listen to the voices of hospitalists in the community, work to understand them, and support efforts to address problems relevant to them.
In the past, SHM leadership from the community hospitalist setting has worked to help address and solve issues relevant to academic hospitalists. We need to understand and respect the diversity within SHM’s tent, and we need to work to keep us all together. I firmly believe that is the way forward, and I assure you that is the goal of SHM’s leadership.
As President Kennedy said, “If we cannot end now our differences, at least we can help make the world safe for diversity.” I pledge to keep SHM your organization, regardless of how you were trained or where you practice HM. I can’t hope to know all of your important issues, but I can commit to stand ready to hear your concerns and do what SHM has always done—give your request a thoughtful response and all of our energy.
SHM is your organization. Let me know the direction you think SHM should go. Send me an e-mail at [email protected]. TH
Dr. Flanders is president of SHM.
SHM prides itself on being a “big tent” organization—inclusive of care providers with different training backgrounds, from varied clinical settings, and representing a multitude of hospital roles. SHM’s diversity expands beyond care providers to include other key stakeholders, such as administrators of hospitalist programs or departments. The diversity was highlighted in the society’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” which shows that 40% of our members are hospital-employed, 20% are from academic settings, about 15% work in large multistate management companies, and the remaining 25% are equally split between multispecialty practices and local hospitalist groups. The diversity extends to internists, pediatricians, family practitioners, nurse practitioners, physician assistants, specialists—the list goes on.
All of us at SHM appreciate that diversity and routinely try to nurture it. Our board of directors includes physicians from all the aforementioned practice settings and includes dedicated seats for such key constituencies as pediatrics. We have more than 25 committees and task-force groups representing all the key factions of our membership. These groups address issues of relevance to every type of hospitalist and hospitalist group. Our annual meeting has evolved to meet the needs of this diverse membership by addressing an enormous volume of topics and incorporating a variety of tracks that cater to general hospitalists, quality experts, academics, and pediatricians.
One notable area in which we lack diversity: age. We are a young specialty; the average hospitalist is 40 years old.
SHM’s organizational diversity creates challenges; new issues surface every year. One key issue is the balance between academic hospitalists and community hospitalists. Academic hospitalists have wanted SHM to more aggressively support their interests. Community hospitalists want SHM to advocate for their interests, as well as develop programs and projects to meet their needs.
With my election as president and the recent election of another academic hospitalist to serve as SHM president in 2010-2011, there might be some concern that community hospitalists could get lost in an academic agenda. Interestingly, academic hospitalists might have raised similar concerns several years ago following the election of a second consecutive community hospitalist as society president. We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.
One Tent, Many Spikes in the Ground
The issues are more complex than simply the differences between academic and community hospitalists. Appropriately, each of our members wants their groups’ issues discussed and addressed. Although workforce might be an issue for private-practice hospitalists, academic hospitalists share these same issues—just in a different environment. Pediatricians see SHM develop core competencies for adult medicine, then want their own pediatric core competencies; SHM needs to look for a way to make this happen. Nurse practitioners (NPs), physician assistants (PAs), and administrators have looked to SHM to represent not just physicians in HM, but also their interests.
As a result, SHM has developed committees and approaches to engage the professional societies representing PAs and NPs, along with the Medical Group Management Association, to design specific projects and programs. At any point in time, there might be a group of members who see a need for SHM to pay attention to “their” issue or perceive that a current approach, while relevant to one group, falls short of the needs of another. As our diversity grows, the frequency of these situations will increase.
So, is this worrisome? Quite the contrary. I believe it is healthy.
Having an established organization with members of differing opinions and backgrounds helps challenge our assumptions. It refines our approach to complex problems, highlights issues or concerns we did not anticipate, and, most importantly, guards against “groupthink”—the tendency to agree with one another all the time. SHM’s board of directors is committed to this type of inclusive leadership.
We do need to be cautious and think quite a bit about this issue in the coming years. The big tent is filling up quickly. It’s becoming more diverse by the week. The concern is that in trying to work at a level that keeps all our constituents happy, we might please no one. If all our activities have to be justified as being relevant to every distinct group that makes up SHM, then we might dilute our effectiveness.
Alternatively, we do not currently have the bandwidth as an organization to initiate in-depth projects in areas relevant to all our members. So far, our approach has been to focus on areas core to every hospitalist: quality and safety, process improvement, leadership, practice management, care transitions, networking, and education.
As unique problems or issues arise that are relevant to only a subset of members, we will weigh the importance. In many cases, we have created task-force groups to clarify and tackle the problem. We provide the support, but the members of the group create the solution. It has worked well so far.
One Voice, One Goal
But can we stick to this strategy as the diversity of membership expands and the number of relevant issues grows? I don’t know. What I do know is that there is strength in numbers, and even though we all have different issues we deem more important, there are times when it helps to come together and speak as one very big, very loud voice.
Older specialties like endocrinology, allergy, and others have split into a variety of organizations and potentially diluted their message. SHM needs to look for creative ways to be relevant to many constituencies within the specialty. In the meantime, we must pay close attention to the big-tent issues. An academic hospitalist in leadership needs to listen to the voices of hospitalists in the community, work to understand them, and support efforts to address problems relevant to them.
In the past, SHM leadership from the community hospitalist setting has worked to help address and solve issues relevant to academic hospitalists. We need to understand and respect the diversity within SHM’s tent, and we need to work to keep us all together. I firmly believe that is the way forward, and I assure you that is the goal of SHM’s leadership.
As President Kennedy said, “If we cannot end now our differences, at least we can help make the world safe for diversity.” I pledge to keep SHM your organization, regardless of how you were trained or where you practice HM. I can’t hope to know all of your important issues, but I can commit to stand ready to hear your concerns and do what SHM has always done—give your request a thoughtful response and all of our energy.
SHM is your organization. Let me know the direction you think SHM should go. Send me an e-mail at [email protected]. TH
Dr. Flanders is president of SHM.
SHM prides itself on being a “big tent” organization—inclusive of care providers with different training backgrounds, from varied clinical settings, and representing a multitude of hospital roles. SHM’s diversity expands beyond care providers to include other key stakeholders, such as administrators of hospitalist programs or departments. The diversity was highlighted in the society’s 2007-2008 “Bi-annual Survey on the State of the Hospital Medicine Movement,” which shows that 40% of our members are hospital-employed, 20% are from academic settings, about 15% work in large multistate management companies, and the remaining 25% are equally split between multispecialty practices and local hospitalist groups. The diversity extends to internists, pediatricians, family practitioners, nurse practitioners, physician assistants, specialists—the list goes on.
All of us at SHM appreciate that diversity and routinely try to nurture it. Our board of directors includes physicians from all the aforementioned practice settings and includes dedicated seats for such key constituencies as pediatrics. We have more than 25 committees and task-force groups representing all the key factions of our membership. These groups address issues of relevance to every type of hospitalist and hospitalist group. Our annual meeting has evolved to meet the needs of this diverse membership by addressing an enormous volume of topics and incorporating a variety of tracks that cater to general hospitalists, quality experts, academics, and pediatricians.
One notable area in which we lack diversity: age. We are a young specialty; the average hospitalist is 40 years old.
SHM’s organizational diversity creates challenges; new issues surface every year. One key issue is the balance between academic hospitalists and community hospitalists. Academic hospitalists have wanted SHM to more aggressively support their interests. Community hospitalists want SHM to advocate for their interests, as well as develop programs and projects to meet their needs.
With my election as president and the recent election of another academic hospitalist to serve as SHM president in 2010-2011, there might be some concern that community hospitalists could get lost in an academic agenda. Interestingly, academic hospitalists might have raised similar concerns several years ago following the election of a second consecutive community hospitalist as society president. We have been fortunate to have leaders who can see the whole HM picture, regardless of their professional backgrounds.
One Tent, Many Spikes in the Ground
The issues are more complex than simply the differences between academic and community hospitalists. Appropriately, each of our members wants their groups’ issues discussed and addressed. Although workforce might be an issue for private-practice hospitalists, academic hospitalists share these same issues—just in a different environment. Pediatricians see SHM develop core competencies for adult medicine, then want their own pediatric core competencies; SHM needs to look for a way to make this happen. Nurse practitioners (NPs), physician assistants (PAs), and administrators have looked to SHM to represent not just physicians in HM, but also their interests.
As a result, SHM has developed committees and approaches to engage the professional societies representing PAs and NPs, along with the Medical Group Management Association, to design specific projects and programs. At any point in time, there might be a group of members who see a need for SHM to pay attention to “their” issue or perceive that a current approach, while relevant to one group, falls short of the needs of another. As our diversity grows, the frequency of these situations will increase.
So, is this worrisome? Quite the contrary. I believe it is healthy.
Having an established organization with members of differing opinions and backgrounds helps challenge our assumptions. It refines our approach to complex problems, highlights issues or concerns we did not anticipate, and, most importantly, guards against “groupthink”—the tendency to agree with one another all the time. SHM’s board of directors is committed to this type of inclusive leadership.
We do need to be cautious and think quite a bit about this issue in the coming years. The big tent is filling up quickly. It’s becoming more diverse by the week. The concern is that in trying to work at a level that keeps all our constituents happy, we might please no one. If all our activities have to be justified as being relevant to every distinct group that makes up SHM, then we might dilute our effectiveness.
Alternatively, we do not currently have the bandwidth as an organization to initiate in-depth projects in areas relevant to all our members. So far, our approach has been to focus on areas core to every hospitalist: quality and safety, process improvement, leadership, practice management, care transitions, networking, and education.
As unique problems or issues arise that are relevant to only a subset of members, we will weigh the importance. In many cases, we have created task-force groups to clarify and tackle the problem. We provide the support, but the members of the group create the solution. It has worked well so far.
One Voice, One Goal
But can we stick to this strategy as the diversity of membership expands and the number of relevant issues grows? I don’t know. What I do know is that there is strength in numbers, and even though we all have different issues we deem more important, there are times when it helps to come together and speak as one very big, very loud voice.
Older specialties like endocrinology, allergy, and others have split into a variety of organizations and potentially diluted their message. SHM needs to look for creative ways to be relevant to many constituencies within the specialty. In the meantime, we must pay close attention to the big-tent issues. An academic hospitalist in leadership needs to listen to the voices of hospitalists in the community, work to understand them, and support efforts to address problems relevant to them.
In the past, SHM leadership from the community hospitalist setting has worked to help address and solve issues relevant to academic hospitalists. We need to understand and respect the diversity within SHM’s tent, and we need to work to keep us all together. I firmly believe that is the way forward, and I assure you that is the goal of SHM’s leadership.
As President Kennedy said, “If we cannot end now our differences, at least we can help make the world safe for diversity.” I pledge to keep SHM your organization, regardless of how you were trained or where you practice HM. I can’t hope to know all of your important issues, but I can commit to stand ready to hear your concerns and do what SHM has always done—give your request a thoughtful response and all of our energy.
SHM is your organization. Let me know the direction you think SHM should go. Send me an e-mail at [email protected]. TH
Dr. Flanders is president of SHM.