Sylvia McKean, MD

The burden of dissatisfaction among medical professionals concerns both physicians and policy makers, especially given the potential ramifications on the work force.1, 2 Abundant research documents a strong relationship between low levels of physician satisfaction and burnout,37 intention to leave,6, 815 and job turnover.13, 1618 Moreover, low physician satisfaction is associated with self‐reported psychiatric symptoms1921 and poorer perceived mental health.22 Not surprisingly, dissatisfied physicians are less likely to recommend to medical students that they pursue their specialty.23

Importantly, physician satisfaction appears to benefit patients. Several studies show a positive relationship between higher physician satisfaction and patient satisfaction and outcomes.2426 Patients cared for by satisfied physicians declare more trust and confidence in their physicians, have better continuity, higher ratings of their care,26, 27 lower no‐show rates,25 and enhanced adherence to their medical care.28 There is also some evidence that higher job satisfaction is associated with lower likelihood of patient errors and suboptimal patient care.29

Physician satisfaction can be influenced by factors intrinsic to the individual physician (age, gender, race, and specialty) and extrinsic to the physician (work environment, practice setting, patient characteristics, and income).22, 30 In this way, satisfaction is not a static property in any physician or physician group, but reflects a dynamic interplay among the expectations and environments within which they work. Although each physician, physician group, and specialty has distinct factors that affect satisfaction, none are immune to potential dissatisfaction.

Given the documented impact of physician satisfaction on multiple aspects of healthcare delivery, we undertook a systematic review of the existing literature to achieve a greater understanding of the current state of U.S. physician satisfaction. In addition, we sought to identify the major survey tools used to measure satisfaction and the characteristics intrinsic and extrinsic to the physician that are associated with satisfaction. We conclude by suggesting needed additional research.

Materials and Methods

We performed a literature search of MEDLINE (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed) for articles from 1970 through 2007 to identify studies that provide a quantitative assessment of U.S. physician satisfaction and/or the factors associated with satisfaction. With assistance from a medical librarian with expertise in search coordination, we chose the following Medical Subject Heading (MeSH) phrases: (physicians OR physician's role OR physician's, women) AND (job satisfaction OR career satisfaction OR burnout). The search was further limited to humans and abstracts with no language restriction. The reviewers also searched reference lists to identify other relevant studies not in the search, as well as available online abstracts from the national meetings of the Society of Hospital Medicine (20022005) and the Society of General Internal Medicine (20052007). All of the abstracts were reviewed by 2 independent reviewers (D.S. and S.M.) for inclusion into the study. Study inclusion was limited to articles that reported physician satisfaction (career, professional, work, practice, job satisfaction, or overall satisfaction) or factors associated with physician satisfaction. Disagreements were resolved by consensus. After exclusions, 97 articles were included for review (Figure 1). Each study was listed by physician type sampled, whether the information was derived from a previously conducted (larger) sample, the sample size and response rate, the satisfaction measurement/subale, and satisfaction results (Appendix 1). Thirty‐seven studies that utilized multivariate analyses to report factors independently associated with satisfaction are listed in Appendix 2, along with the direction and strength of association. Confounders controlled for in these studies are listed in Appendix 3. Studies that extracted data from 1 of the 4 nationally representative studies (Community Tracking Studies [CTS], Physician Worklife Study [PWS], Women Physician Health Study [WPHS], and Robert Wood Johnson Studies [RWJS]) were considered of higher quality and generalizability than the small cross‐sectional studies. Due to the heterogeneity in physician type sampled and multiple satisfaction measurements used, a meta‐analysis of the literature was not performed, and a qualitative analysis is reported.

Figure 1

Results

Of the 97 studies, 69 were cross‐sectional (distributed to purposive and often convenience samples of physicians) with sampling sizes ranging from 39 to 6441 and response rates ranging from 31% to 97% (Appendix 1). The other 28 were from larger nationally representative studies (Table 1), including the CTS (n = 92, 45, 71, 74, 91, 102, 104106), RWJS (n = 81, 18, 3334, 39, 40, 60, 61), PWS (n = 711, 22, 23, 55, 83, 92, 99), and WPHS (n = 444, 4951). Fourteen articles reported information from longitudinal (n = 2)18, 86 or repeated cross‐sectional studies (n = 12)1, 2, 39, 73, 76, 79, 85, 91, 96, 97, 102, 110 to help determine satisfaction trends. The survey instruments from the 4 national physician surveys are outlined in Table 1. The types of satisfaction reported are outlined in Figure 2.

Figure 2

Major Characteristics Associated with Physician Satisfaction

Both factors intrinsic to the physician and characteristics of the job influence physician satisfaction (Figure 3). Intrinsic physician factors are typically not changeable when developing strategies to improve satisfaction. However, they do significantly affect what physicians consider important when choosing a job, and influence how physicians respond to changes in the job. Job characteristics, or extrinsic factors, are generally considered more modifiable when developing institutional strategies to improve satisfaction. Although the intrinsic factors are seemingly unmodifiable, one must take them into account when assessing satisfaction in order to determine the independent effects that the more modifiable extrinsic factors have on satisfaction. The next section describes the variables associated with satisfaction, from the 37 studies that utilized multivariate analyses (Appendix 2) to control for other factors (Appendix 3).

Figure 3

Physician Factors

Job Factors

Other Physician Factors

Board certification may be modestly positively associated with satisfaction, and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.9, 45, 74, 98, 104, 106 Other physician characteristics, such as personal matters (marital status, home stress, mental health, personal satisfaction), work matters (amount of charity care they provide and history of work harassment), and personality (reform mindedness and tolerance for uncertainty) require further research.50, 56, 88, 98, 104

Discussion

Our review of satisfaction trends for U.S. physicians revealed relative stability except for a slight decline among PCPs. We found factors significantly associated with satisfaction to include both physician (age and specialty) and job factors (work demand, work control, colleague support, ability to maintain patient relationships, practice setting, income satisfaction, and incentive types). Based on limited data, the association with race/ethnicity and part‐time work requires more research, and factors that do not appear to have an independent effect on satisfaction include physician gender, patient‐payer mix, and patient characteristics.

As the fastest growing specialty in the history of American medicine, hospital medicine should focus on career satisfaction as a top priority in shaping the future of the more than 20,000 hospitalists now practicing. Although the term hospitalist was coined less than 15 years ago114 the demand for hospitalists is expected to grow to as many as 50,000 by 2020.115 In this time of rapid growth, in order to mold a sustainable specialty, we must all recognize the factors that contribute to satisfaction and strive to maintain good job‐person fit. For individual hospitalists, all of these mediators of satisfaction should be considered when contemplating employment. To ensure a mutual fit, each physician must reflect on how their goals and values coincide with those of the program they are considering. For hospital medicine program leaders, areas of program‐specific dissatisfaction must be continually sought and addressed.

In this review, the variables with the strongest associations with satisfaction that are most pertinent to hospitalists are work demand, control, income/emncentives, and collegial relationships. These variables coincide with the 4 pillars of career satisfaction identified in the Society of Hospital Medicine Career Satisfaction Task Force.116 Perceived work stress/pressure and objective workload can easily (and serially) be measured, and the latter can be compared to national benchmarks to ensure appropriate workload expectations.116 Reducing work pressure/stress may involve assessing and matching variations in workload with manpower, reducing nonclinical tasks by utilizing administrative assistants or physician extenders, or having an emergency plan for unexpected absences. Autonomy and control can be assessed by the job‐fit questionnaire to identify programwide and physician‐specific areas of potential discontent.116 Increasing autonomy/control may involve pursuing leadership within hospital projects or committees, creatively scheduling flexibility, and seeking support from hospital administration. Income expectations should also be couched within national benchmarks, and incentive programs should reflect work quality rather than quantity. Collegial support can be enhanced by instituting a mentoring program, journal club, regular social function, or configuration of offices spaces to allow proximity. Although the conclusions of this review are limited by the lack of hospitalists included in the studies and our inability to perform a meta‐analysis, we believe extrapolation of this information to hospitalist physicians is valid and appropriate. That said, future studies specifically addressing hospitalist satisfaction are needed to ensure this.

Conclusions

In summary, physician satisfaction is not a static parameter, but a dynamic entity mediated by both physician‐related and job‐related factors, the majority of which are modifiable. Thus hospitalists and hospital medicine program leaders can be optimistic that uncovering the presence of dissatisfaction through surveys, and addressing the issues triggering it, should enhance physician satisfaction. With improved awareness of mitigating factors of dissatisfaction and commitments to improvement, there is reason for hope. It is unreasonable to believe that dissatisfaction is intrinsic to any medical profession. It is reasonable to believe that physician satisfaction, with all of its desirable implications, can be attained through continual research and prioritization.

The burden of dissatisfaction among medical professionals concerns both physicians and policy makers, especially given the potential ramifications on the work force.1, 2 Abundant research documents a strong relationship between low levels of physician satisfaction and burnout,37 intention to leave,6, 815 and job turnover.13, 1618 Moreover, low physician satisfaction is associated with self‐reported psychiatric symptoms1921 and poorer perceived mental health.22 Not surprisingly, dissatisfied physicians are less likely to recommend to medical students that they pursue their specialty.23

Importantly, physician satisfaction appears to benefit patients. Several studies show a positive relationship between higher physician satisfaction and patient satisfaction and outcomes.2426 Patients cared for by satisfied physicians declare more trust and confidence in their physicians, have better continuity, higher ratings of their care,26, 27 lower no‐show rates,25 and enhanced adherence to their medical care.28 There is also some evidence that higher job satisfaction is associated with lower likelihood of patient errors and suboptimal patient care.29

Physician satisfaction can be influenced by factors intrinsic to the individual physician (age, gender, race, and specialty) and extrinsic to the physician (work environment, practice setting, patient characteristics, and income).22, 30 In this way, satisfaction is not a static property in any physician or physician group, but reflects a dynamic interplay among the expectations and environments within which they work. Although each physician, physician group, and specialty has distinct factors that affect satisfaction, none are immune to potential dissatisfaction.

Given the documented impact of physician satisfaction on multiple aspects of healthcare delivery, we undertook a systematic review of the existing literature to achieve a greater understanding of the current state of U.S. physician satisfaction. In addition, we sought to identify the major survey tools used to measure satisfaction and the characteristics intrinsic and extrinsic to the physician that are associated with satisfaction. We conclude by suggesting needed additional research.

Materials and Methods

We performed a literature search of MEDLINE (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed) for articles from 1970 through 2007 to identify studies that provide a quantitative assessment of U.S. physician satisfaction and/or the factors associated with satisfaction. With assistance from a medical librarian with expertise in search coordination, we chose the following Medical Subject Heading (MeSH) phrases: (physicians OR physician's role OR physician's, women) AND (job satisfaction OR career satisfaction OR burnout). The search was further limited to humans and abstracts with no language restriction. The reviewers also searched reference lists to identify other relevant studies not in the search, as well as available online abstracts from the national meetings of the Society of Hospital Medicine (20022005) and the Society of General Internal Medicine (20052007). All of the abstracts were reviewed by 2 independent reviewers (D.S. and S.M.) for inclusion into the study. Study inclusion was limited to articles that reported physician satisfaction (career, professional, work, practice, job satisfaction, or overall satisfaction) or factors associated with physician satisfaction. Disagreements were resolved by consensus. After exclusions, 97 articles were included for review (Figure 1). Each study was listed by physician type sampled, whether the information was derived from a previously conducted (larger) sample, the sample size and response rate, the satisfaction measurement/subale, and satisfaction results (Appendix 1). Thirty‐seven studies that utilized multivariate analyses to report factors independently associated with satisfaction are listed in Appendix 2, along with the direction and strength of association. Confounders controlled for in these studies are listed in Appendix 3. Studies that extracted data from 1 of the 4 nationally representative studies (Community Tracking Studies [CTS], Physician Worklife Study [PWS], Women Physician Health Study [WPHS], and Robert Wood Johnson Studies [RWJS]) were considered of higher quality and generalizability than the small cross‐sectional studies. Due to the heterogeneity in physician type sampled and multiple satisfaction measurements used, a meta‐analysis of the literature was not performed, and a qualitative analysis is reported.

Figure 1

Results

Of the 97 studies, 69 were cross‐sectional (distributed to purposive and often convenience samples of physicians) with sampling sizes ranging from 39 to 6441 and response rates ranging from 31% to 97% (Appendix 1). The other 28 were from larger nationally representative studies (Table 1), including the CTS (n = 92, 45, 71, 74, 91, 102, 104106), RWJS (n = 81, 18, 3334, 39, 40, 60, 61), PWS (n = 711, 22, 23, 55, 83, 92, 99), and WPHS (n = 444, 4951). Fourteen articles reported information from longitudinal (n = 2)18, 86 or repeated cross‐sectional studies (n = 12)1, 2, 39, 73, 76, 79, 85, 91, 96, 97, 102, 110 to help determine satisfaction trends. The survey instruments from the 4 national physician surveys are outlined in Table 1. The types of satisfaction reported are outlined in Figure 2.

Figure 2

Major Characteristics Associated with Physician Satisfaction

Both factors intrinsic to the physician and characteristics of the job influence physician satisfaction (Figure 3). Intrinsic physician factors are typically not changeable when developing strategies to improve satisfaction. However, they do significantly affect what physicians consider important when choosing a job, and influence how physicians respond to changes in the job. Job characteristics, or extrinsic factors, are generally considered more modifiable when developing institutional strategies to improve satisfaction. Although the intrinsic factors are seemingly unmodifiable, one must take them into account when assessing satisfaction in order to determine the independent effects that the more modifiable extrinsic factors have on satisfaction. The next section describes the variables associated with satisfaction, from the 37 studies that utilized multivariate analyses (Appendix 2) to control for other factors (Appendix 3).

Figure 3

Physician Factors

Job Factors

Other Physician Factors

Board certification may be modestly positively associated with satisfaction, and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.9, 45, 74, 98, 104, 106 Other physician characteristics, such as personal matters (marital status, home stress, mental health, personal satisfaction), work matters (amount of charity care they provide and history of work harassment), and personality (reform mindedness and tolerance for uncertainty) require further research.50, 56, 88, 98, 104

Discussion

Our review of satisfaction trends for U.S. physicians revealed relative stability except for a slight decline among PCPs. We found factors significantly associated with satisfaction to include both physician (age and specialty) and job factors (work demand, work control, colleague support, ability to maintain patient relationships, practice setting, income satisfaction, and incentive types). Based on limited data, the association with race/ethnicity and part‐time work requires more research, and factors that do not appear to have an independent effect on satisfaction include physician gender, patient‐payer mix, and patient characteristics.

As the fastest growing specialty in the history of American medicine, hospital medicine should focus on career satisfaction as a top priority in shaping the future of the more than 20,000 hospitalists now practicing. Although the term hospitalist was coined less than 15 years ago114 the demand for hospitalists is expected to grow to as many as 50,000 by 2020.115 In this time of rapid growth, in order to mold a sustainable specialty, we must all recognize the factors that contribute to satisfaction and strive to maintain good job‐person fit. For individual hospitalists, all of these mediators of satisfaction should be considered when contemplating employment. To ensure a mutual fit, each physician must reflect on how their goals and values coincide with those of the program they are considering. For hospital medicine program leaders, areas of program‐specific dissatisfaction must be continually sought and addressed.

In this review, the variables with the strongest associations with satisfaction that are most pertinent to hospitalists are work demand, control, income/emncentives, and collegial relationships. These variables coincide with the 4 pillars of career satisfaction identified in the Society of Hospital Medicine Career Satisfaction Task Force.116 Perceived work stress/pressure and objective workload can easily (and serially) be measured, and the latter can be compared to national benchmarks to ensure appropriate workload expectations.116 Reducing work pressure/stress may involve assessing and matching variations in workload with manpower, reducing nonclinical tasks by utilizing administrative assistants or physician extenders, or having an emergency plan for unexpected absences. Autonomy and control can be assessed by the job‐fit questionnaire to identify programwide and physician‐specific areas of potential discontent.116 Increasing autonomy/control may involve pursuing leadership within hospital projects or committees, creatively scheduling flexibility, and seeking support from hospital administration. Income expectations should also be couched within national benchmarks, and incentive programs should reflect work quality rather than quantity. Collegial support can be enhanced by instituting a mentoring program, journal club, regular social function, or configuration of offices spaces to allow proximity. Although the conclusions of this review are limited by the lack of hospitalists included in the studies and our inability to perform a meta‐analysis, we believe extrapolation of this information to hospitalist physicians is valid and appropriate. That said, future studies specifically addressing hospitalist satisfaction are needed to ensure this.

Conclusions

In summary, physician satisfaction is not a static parameter, but a dynamic entity mediated by both physician‐related and job‐related factors, the majority of which are modifiable. Thus hospitalists and hospital medicine program leaders can be optimistic that uncovering the presence of dissatisfaction through surveys, and addressing the issues triggering it, should enhance physician satisfaction. With improved awareness of mitigating factors of dissatisfaction and commitments to improvement, there is reason for hope. It is unreasonable to believe that dissatisfaction is intrinsic to any medical profession. It is reasonable to believe that physician satisfaction, with all of its desirable implications, can be attained through continual research and prioritization.

The burden of dissatisfaction among medical professionals concerns both physicians and policy makers, especially given the potential ramifications on the work force.1, 2 Abundant research documents a strong relationship between low levels of physician satisfaction and burnout,37 intention to leave,6, 815 and job turnover.13, 1618 Moreover, low physician satisfaction is associated with self‐reported psychiatric symptoms1921 and poorer perceived mental health.22 Not surprisingly, dissatisfied physicians are less likely to recommend to medical students that they pursue their specialty.23

Importantly, physician satisfaction appears to benefit patients. Several studies show a positive relationship between higher physician satisfaction and patient satisfaction and outcomes.2426 Patients cared for by satisfied physicians declare more trust and confidence in their physicians, have better continuity, higher ratings of their care,26, 27 lower no‐show rates,25 and enhanced adherence to their medical care.28 There is also some evidence that higher job satisfaction is associated with lower likelihood of patient errors and suboptimal patient care.29

Physician satisfaction can be influenced by factors intrinsic to the individual physician (age, gender, race, and specialty) and extrinsic to the physician (work environment, practice setting, patient characteristics, and income).22, 30 In this way, satisfaction is not a static property in any physician or physician group, but reflects a dynamic interplay among the expectations and environments within which they work. Although each physician, physician group, and specialty has distinct factors that affect satisfaction, none are immune to potential dissatisfaction.

Given the documented impact of physician satisfaction on multiple aspects of healthcare delivery, we undertook a systematic review of the existing literature to achieve a greater understanding of the current state of U.S. physician satisfaction. In addition, we sought to identify the major survey tools used to measure satisfaction and the characteristics intrinsic and extrinsic to the physician that are associated with satisfaction. We conclude by suggesting needed additional research.

Materials and Methods

We performed a literature search of MEDLINE (http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed) for articles from 1970 through 2007 to identify studies that provide a quantitative assessment of U.S. physician satisfaction and/or the factors associated with satisfaction. With assistance from a medical librarian with expertise in search coordination, we chose the following Medical Subject Heading (MeSH) phrases: (physicians OR physician's role OR physician's, women) AND (job satisfaction OR career satisfaction OR burnout). The search was further limited to humans and abstracts with no language restriction. The reviewers also searched reference lists to identify other relevant studies not in the search, as well as available online abstracts from the national meetings of the Society of Hospital Medicine (20022005) and the Society of General Internal Medicine (20052007). All of the abstracts were reviewed by 2 independent reviewers (D.S. and S.M.) for inclusion into the study. Study inclusion was limited to articles that reported physician satisfaction (career, professional, work, practice, job satisfaction, or overall satisfaction) or factors associated with physician satisfaction. Disagreements were resolved by consensus. After exclusions, 97 articles were included for review (Figure 1). Each study was listed by physician type sampled, whether the information was derived from a previously conducted (larger) sample, the sample size and response rate, the satisfaction measurement/subale, and satisfaction results (Appendix 1). Thirty‐seven studies that utilized multivariate analyses to report factors independently associated with satisfaction are listed in Appendix 2, along with the direction and strength of association. Confounders controlled for in these studies are listed in Appendix 3. Studies that extracted data from 1 of the 4 nationally representative studies (Community Tracking Studies [CTS], Physician Worklife Study [PWS], Women Physician Health Study [WPHS], and Robert Wood Johnson Studies [RWJS]) were considered of higher quality and generalizability than the small cross‐sectional studies. Due to the heterogeneity in physician type sampled and multiple satisfaction measurements used, a meta‐analysis of the literature was not performed, and a qualitative analysis is reported.

Figure 1

Results

Of the 97 studies, 69 were cross‐sectional (distributed to purposive and often convenience samples of physicians) with sampling sizes ranging from 39 to 6441 and response rates ranging from 31% to 97% (Appendix 1). The other 28 were from larger nationally representative studies (Table 1), including the CTS (n = 92, 45, 71, 74, 91, 102, 104106), RWJS (n = 81, 18, 3334, 39, 40, 60, 61), PWS (n = 711, 22, 23, 55, 83, 92, 99), and WPHS (n = 444, 4951). Fourteen articles reported information from longitudinal (n = 2)18, 86 or repeated cross‐sectional studies (n = 12)1, 2, 39, 73, 76, 79, 85, 91, 96, 97, 102, 110 to help determine satisfaction trends. The survey instruments from the 4 national physician surveys are outlined in Table 1. The types of satisfaction reported are outlined in Figure 2.

Figure 2

Major Characteristics Associated with Physician Satisfaction

Both factors intrinsic to the physician and characteristics of the job influence physician satisfaction (Figure 3). Intrinsic physician factors are typically not changeable when developing strategies to improve satisfaction. However, they do significantly affect what physicians consider important when choosing a job, and influence how physicians respond to changes in the job. Job characteristics, or extrinsic factors, are generally considered more modifiable when developing institutional strategies to improve satisfaction. Although the intrinsic factors are seemingly unmodifiable, one must take them into account when assessing satisfaction in order to determine the independent effects that the more modifiable extrinsic factors have on satisfaction. The next section describes the variables associated with satisfaction, from the 37 studies that utilized multivariate analyses (Appendix 2) to control for other factors (Appendix 3).

Figure 3

Physician Factors

Job Factors

Other Physician Factors

Board certification may be modestly positively associated with satisfaction, and being a foreign medical graduate may be modestly negatively associated with satisfaction, although this is limited to few studies.9, 45, 74, 98, 104, 106 Other physician characteristics, such as personal matters (marital status, home stress, mental health, personal satisfaction), work matters (amount of charity care they provide and history of work harassment), and personality (reform mindedness and tolerance for uncertainty) require further research.50, 56, 88, 98, 104

Discussion

Our review of satisfaction trends for U.S. physicians revealed relative stability except for a slight decline among PCPs. We found factors significantly associated with satisfaction to include both physician (age and specialty) and job factors (work demand, work control, colleague support, ability to maintain patient relationships, practice setting, income satisfaction, and incentive types). Based on limited data, the association with race/ethnicity and part‐time work requires more research, and factors that do not appear to have an independent effect on satisfaction include physician gender, patient‐payer mix, and patient characteristics.

As the fastest growing specialty in the history of American medicine, hospital medicine should focus on career satisfaction as a top priority in shaping the future of the more than 20,000 hospitalists now practicing. Although the term hospitalist was coined less than 15 years ago114 the demand for hospitalists is expected to grow to as many as 50,000 by 2020.115 In this time of rapid growth, in order to mold a sustainable specialty, we must all recognize the factors that contribute to satisfaction and strive to maintain good job‐person fit. For individual hospitalists, all of these mediators of satisfaction should be considered when contemplating employment. To ensure a mutual fit, each physician must reflect on how their goals and values coincide with those of the program they are considering. For hospital medicine program leaders, areas of program‐specific dissatisfaction must be continually sought and addressed.

In this review, the variables with the strongest associations with satisfaction that are most pertinent to hospitalists are work demand, control, income/emncentives, and collegial relationships. These variables coincide with the 4 pillars of career satisfaction identified in the Society of Hospital Medicine Career Satisfaction Task Force.116 Perceived work stress/pressure and objective workload can easily (and serially) be measured, and the latter can be compared to national benchmarks to ensure appropriate workload expectations.116 Reducing work pressure/stress may involve assessing and matching variations in workload with manpower, reducing nonclinical tasks by utilizing administrative assistants or physician extenders, or having an emergency plan for unexpected absences. Autonomy and control can be assessed by the job‐fit questionnaire to identify programwide and physician‐specific areas of potential discontent.116 Increasing autonomy/control may involve pursuing leadership within hospital projects or committees, creatively scheduling flexibility, and seeking support from hospital administration. Income expectations should also be couched within national benchmarks, and incentive programs should reflect work quality rather than quantity. Collegial support can be enhanced by instituting a mentoring program, journal club, regular social function, or configuration of offices spaces to allow proximity. Although the conclusions of this review are limited by the lack of hospitalists included in the studies and our inability to perform a meta‐analysis, we believe extrapolation of this information to hospitalist physicians is valid and appropriate. That said, future studies specifically addressing hospitalist satisfaction are needed to ensure this.

Conclusions

In summary, physician satisfaction is not a static parameter, but a dynamic entity mediated by both physician‐related and job‐related factors, the majority of which are modifiable. Thus hospitalists and hospital medicine program leaders can be optimistic that uncovering the presence of dissatisfaction through surveys, and addressing the issues triggering it, should enhance physician satisfaction. With improved awareness of mitigating factors of dissatisfaction and commitments to improvement, there is reason for hope. It is unreasonable to believe that dissatisfaction is intrinsic to any medical profession. It is reasonable to believe that physician satisfaction, with all of its desirable implications, can be attained through continual research and prioritization.

Midlevel providers (physician assistants and nurse practitioners) have long been employed by academic medical centers, predominantly on surgical services, or on medical subspecialty services, where they have typically had a limited scope of practice, focused in a narrowly defined area or set of procedures.17 In contrast, there are relatively few reports of experiences deploying midlevel providers to replace house staff on inpatient general medicine services in academic centers,810 and few studies of the effect of midlevel providers on quality and efficiency of care in the academic setting. Despite this, reductions in house officer duty hours as mandated by the Accreditation Council on Graduate Medical Education (ACGME)11 have resulted in academic centers increasingly using midlevel providers to decrease house staff workload on inpatient services.12, 13 In general, midlevel practitioners on general medicine services have been deployed to: (1) care for a population of patients separate from and in parallel with house staff; this population may be narrowly defined (eg, patients with chest pain) or not; (2) assist with the management of patients cared for by house staff by performing certain tasks (eg, scheduling appointments, discharging patients). Even as midlevel providers become more prevalent on academic general medicine services, the best model of care incorporating them into clinical care remains unclear, and few studies have rigorously examined the care provided on services that use them.

We developed an inpatient general medicine service within a large academic medical center staffed by physician assistants and hospitalists to help our residency program meet ACGME duty hour requirements. We hypothesized that by creating a service that is geographically localized and supervised by full‐time hospitalists, by instituting multidisciplinary rounds, and by investing in the professional development of highly‐skilled physician assistants, we could provide care for medically complex, acutely ill general medicine inpatients with similar quality and efficiency as compared to house staff teams. We report our experience during the first year of implementing the service, and compare quality and efficiency of care on this service with that of our traditional house staff services. We also evaluate the effects of this service on patient satisfaction and self‐reported house staff workload.

PATIENTS AND METHODS

RESULTS

Patient Satisfaction

Patients were similarly satisfied with their care on the PACE service and on the house staff services. In specific areas and globally, percentages of patients satisfied with their physicians and with the discharge process were not different, as measured by the Press‐Ganey survey (Press‐Ganey Associates, South Bend, IN; Figures 1 and 2). The survey distinguishes between attendings and residents, but not physician assistants; therefore, Figure 1 only includes responses to the attending questions. Given the sampling procedure of the Press‐Ganey survey, exact response rates cannot be calculated, but Press‐Ganey reports a response rate of about 40% for the English survey and about 20% for the Spanish survey.

Figure 1

Figure 2

DISCUSSION

As academic centers struggle with developing a workforce to provide patient care no longer provided by residents, questions about the ideal structure of nonhouse staff inpatient services abound. Although solutions to this problem will be determined to some extent by local factors such as institutional culture and resources, some lessons learned in developing such services will be more widely applicable. We found that by implementing a geographically localized, physician assistant‐staffed hospitalist service, we were able to provide care of similar quality and efficiency to that of traditional house staff services, despite inexperienced hospitalists staffing the service and a medical residency program commonly recognized as one of the best in the country. Adjusted total costs were slightly lower on the PACE service, but this difference was small and of borderline statistical significance. Likewise, no significant differences were seen in any of several quality measures or in patient satisfaction.

Our findings add to the available evidence supporting the use of physician assistants on academic general medicine services, and are germane to academic centers facing reductions in house staff availability and seeking alternative models of care for inpatients. Several specific characteristics of the PACE service and the implications of these should be considered:

• 1

  The service accepted all patients, regardless of diagnosis, acuity, or complexity of illness. This was unlike many previously described nonhouse staff services which were more limited in scope, and allowed more flexibility with patient flow. However, in the end, patients on the PACE service did have a modestly lower case mix index and Charlson score, suggesting that, despite a lack of triage guidelines, there was some bias in the triage of admissions, possibly due to a perception that physician assistants should take care of lower complexity patients. If it is desirable to have a similar distribution of higher complexity patients across house staff and nonhouse staff services, extra efforts may be necessary to overcome this perception.

• 2

  The service was geographically regionalized. Geographic regionalization offered many important advantages, especially with regards to communication among staff, nursing, and consultants, and allowed for multidisciplinary rounds. However, it is possible that the modest, but not statistically significant, trend toward an increased LOS seen on the PACE service might be a reflection of geographic admitting (less incentive to discharge since discharging a patient means taking a new admission).

• 3

  The education and professional development of the physician assistants was a priority. Physician assistants had considerable autonomy and responsibility, and rather than being assigned only lower level administrative tasks, performed all aspects of patient care. They also received regular teaching from the hospitalists, attended house staff teaching conferences, and developed nonclinical roles in education and quality improvement. The higher standards expected of the physician assistants were quite possibly a factor in the quality of care delivered, and almost certainly contributed to physician assistant satisfaction and retention.

Our findings contrast with those of Myers et al.,9 who found that a nonteaching service staffed by hospitalists and nurse practitioners had a significantly lower median LOS and hospital charges compared to similar patients on resident‐based services. However, unlike ours, their service cared for a select patient population, and only accepted patients with chest pain at low risk for acute coronary syndrome. Van Rhee et al.10 found that physician assistants on a general medicine service used fewer resources for patients with pneumonia, stroke, and congestive heart failure than resident physicians, and did not exceed the resources used by residents in other diagnoses. The authors did not find a difference in LOS, but did find a significantly higher mortality among patients with pneumonia cared for by physician assistants.

Several limitations should be noted. First, the study was a retrospective analysis of administrative data rather than a randomized trial, and although we employed a standard approach to adjust for a wide range of patient characteristics including severity of illness, there may have been undetected differences in the patient populations studied that may have confounded our results. Second, resident moonlighters admitted patients to the PACE service and, at other times, to the house staff services, and this may have diluted any differences between the groups. However, when we limited our analysis to the subgroup of patients admitted during the day, similar results were obtained, with the exception that the PACE service had a lower rate of 14‐day readmissions, an unexpected finding deserving of further study. Third, the study was conducted in a single academic institution and our findings may not be generalizable to others with different needs and resources; indeed, the costs associated with implementing such a service may be prohibitive for some institutions. Fourth, because of simultaneous changes that were taking place in our residency program, we are unable to accurately assess the impact of the PACE service on resident duty hours. However, resident duty hours did not increase over this time period on the general medicine service, and implementation of the service allowed for redistribution of house staff to other services and positions. Fifth, patient satisfaction data were obtained from responses to the mailed Press‐Ganey survey, to which there is a relatively low response rate. Also, we did not survey providers regarding their satisfaction with the service during the study period. Sixth, the study had limited power to detect clinically important differences in mortality and ICU transfers. Finally, this study is unable to compare this particular model of incorporating midlevel providers into general medical services with other models, only with traditional house staff services.

Future research should focus on determining the most effective and efficient ways to incorporate midlevel providers on academic general medicine services. One important question from the standpoint of house staff training is whether such services should be separate but equal, or should house staff gain experience during residency working with midlevel providers, since they are likely to encounter them in the future whether they stay in academics or not. Different models of care will likely have large implications for the quality and efficiency of patient care, house staff education and satisfaction, and physician assistant job satisfaction and turnover.

In summary, our study demonstrates that a geographically regionalized, multidisciplinary service staffed by hospitalists and physician assistants can be a safe alternative to house staff‐based services for the care of general medicine inpatients in an academic medical center.

Midlevel providers (physician assistants and nurse practitioners) have long been employed by academic medical centers, predominantly on surgical services, or on medical subspecialty services, where they have typically had a limited scope of practice, focused in a narrowly defined area or set of procedures.17 In contrast, there are relatively few reports of experiences deploying midlevel providers to replace house staff on inpatient general medicine services in academic centers,810 and few studies of the effect of midlevel providers on quality and efficiency of care in the academic setting. Despite this, reductions in house officer duty hours as mandated by the Accreditation Council on Graduate Medical Education (ACGME)11 have resulted in academic centers increasingly using midlevel providers to decrease house staff workload on inpatient services.12, 13 In general, midlevel practitioners on general medicine services have been deployed to: (1) care for a population of patients separate from and in parallel with house staff; this population may be narrowly defined (eg, patients with chest pain) or not; (2) assist with the management of patients cared for by house staff by performing certain tasks (eg, scheduling appointments, discharging patients). Even as midlevel providers become more prevalent on academic general medicine services, the best model of care incorporating them into clinical care remains unclear, and few studies have rigorously examined the care provided on services that use them.

We developed an inpatient general medicine service within a large academic medical center staffed by physician assistants and hospitalists to help our residency program meet ACGME duty hour requirements. We hypothesized that by creating a service that is geographically localized and supervised by full‐time hospitalists, by instituting multidisciplinary rounds, and by investing in the professional development of highly‐skilled physician assistants, we could provide care for medically complex, acutely ill general medicine inpatients with similar quality and efficiency as compared to house staff teams. We report our experience during the first year of implementing the service, and compare quality and efficiency of care on this service with that of our traditional house staff services. We also evaluate the effects of this service on patient satisfaction and self‐reported house staff workload.

PATIENTS AND METHODS

RESULTS

Patient Satisfaction

Patients were similarly satisfied with their care on the PACE service and on the house staff services. In specific areas and globally, percentages of patients satisfied with their physicians and with the discharge process were not different, as measured by the Press‐Ganey survey (Press‐Ganey Associates, South Bend, IN; Figures 1 and 2). The survey distinguishes between attendings and residents, but not physician assistants; therefore, Figure 1 only includes responses to the attending questions. Given the sampling procedure of the Press‐Ganey survey, exact response rates cannot be calculated, but Press‐Ganey reports a response rate of about 40% for the English survey and about 20% for the Spanish survey.

Figure 1

Figure 2

DISCUSSION

As academic centers struggle with developing a workforce to provide patient care no longer provided by residents, questions about the ideal structure of nonhouse staff inpatient services abound. Although solutions to this problem will be determined to some extent by local factors such as institutional culture and resources, some lessons learned in developing such services will be more widely applicable. We found that by implementing a geographically localized, physician assistant‐staffed hospitalist service, we were able to provide care of similar quality and efficiency to that of traditional house staff services, despite inexperienced hospitalists staffing the service and a medical residency program commonly recognized as one of the best in the country. Adjusted total costs were slightly lower on the PACE service, but this difference was small and of borderline statistical significance. Likewise, no significant differences were seen in any of several quality measures or in patient satisfaction.

Our findings add to the available evidence supporting the use of physician assistants on academic general medicine services, and are germane to academic centers facing reductions in house staff availability and seeking alternative models of care for inpatients. Several specific characteristics of the PACE service and the implications of these should be considered:

• 1

  The service accepted all patients, regardless of diagnosis, acuity, or complexity of illness. This was unlike many previously described nonhouse staff services which were more limited in scope, and allowed more flexibility with patient flow. However, in the end, patients on the PACE service did have a modestly lower case mix index and Charlson score, suggesting that, despite a lack of triage guidelines, there was some bias in the triage of admissions, possibly due to a perception that physician assistants should take care of lower complexity patients. If it is desirable to have a similar distribution of higher complexity patients across house staff and nonhouse staff services, extra efforts may be necessary to overcome this perception.

• 2

  The service was geographically regionalized. Geographic regionalization offered many important advantages, especially with regards to communication among staff, nursing, and consultants, and allowed for multidisciplinary rounds. However, it is possible that the modest, but not statistically significant, trend toward an increased LOS seen on the PACE service might be a reflection of geographic admitting (less incentive to discharge since discharging a patient means taking a new admission).

• 3

  The education and professional development of the physician assistants was a priority. Physician assistants had considerable autonomy and responsibility, and rather than being assigned only lower level administrative tasks, performed all aspects of patient care. They also received regular teaching from the hospitalists, attended house staff teaching conferences, and developed nonclinical roles in education and quality improvement. The higher standards expected of the physician assistants were quite possibly a factor in the quality of care delivered, and almost certainly contributed to physician assistant satisfaction and retention.

Our findings contrast with those of Myers et al.,9 who found that a nonteaching service staffed by hospitalists and nurse practitioners had a significantly lower median LOS and hospital charges compared to similar patients on resident‐based services. However, unlike ours, their service cared for a select patient population, and only accepted patients with chest pain at low risk for acute coronary syndrome. Van Rhee et al.10 found that physician assistants on a general medicine service used fewer resources for patients with pneumonia, stroke, and congestive heart failure than resident physicians, and did not exceed the resources used by residents in other diagnoses. The authors did not find a difference in LOS, but did find a significantly higher mortality among patients with pneumonia cared for by physician assistants.

Several limitations should be noted. First, the study was a retrospective analysis of administrative data rather than a randomized trial, and although we employed a standard approach to adjust for a wide range of patient characteristics including severity of illness, there may have been undetected differences in the patient populations studied that may have confounded our results. Second, resident moonlighters admitted patients to the PACE service and, at other times, to the house staff services, and this may have diluted any differences between the groups. However, when we limited our analysis to the subgroup of patients admitted during the day, similar results were obtained, with the exception that the PACE service had a lower rate of 14‐day readmissions, an unexpected finding deserving of further study. Third, the study was conducted in a single academic institution and our findings may not be generalizable to others with different needs and resources; indeed, the costs associated with implementing such a service may be prohibitive for some institutions. Fourth, because of simultaneous changes that were taking place in our residency program, we are unable to accurately assess the impact of the PACE service on resident duty hours. However, resident duty hours did not increase over this time period on the general medicine service, and implementation of the service allowed for redistribution of house staff to other services and positions. Fifth, patient satisfaction data were obtained from responses to the mailed Press‐Ganey survey, to which there is a relatively low response rate. Also, we did not survey providers regarding their satisfaction with the service during the study period. Sixth, the study had limited power to detect clinically important differences in mortality and ICU transfers. Finally, this study is unable to compare this particular model of incorporating midlevel providers into general medical services with other models, only with traditional house staff services.

Future research should focus on determining the most effective and efficient ways to incorporate midlevel providers on academic general medicine services. One important question from the standpoint of house staff training is whether such services should be separate but equal, or should house staff gain experience during residency working with midlevel providers, since they are likely to encounter them in the future whether they stay in academics or not. Different models of care will likely have large implications for the quality and efficiency of patient care, house staff education and satisfaction, and physician assistant job satisfaction and turnover.

In summary, our study demonstrates that a geographically regionalized, multidisciplinary service staffed by hospitalists and physician assistants can be a safe alternative to house staff‐based services for the care of general medicine inpatients in an academic medical center.

Midlevel providers (physician assistants and nurse practitioners) have long been employed by academic medical centers, predominantly on surgical services, or on medical subspecialty services, where they have typically had a limited scope of practice, focused in a narrowly defined area or set of procedures.17 In contrast, there are relatively few reports of experiences deploying midlevel providers to replace house staff on inpatient general medicine services in academic centers,810 and few studies of the effect of midlevel providers on quality and efficiency of care in the academic setting. Despite this, reductions in house officer duty hours as mandated by the Accreditation Council on Graduate Medical Education (ACGME)11 have resulted in academic centers increasingly using midlevel providers to decrease house staff workload on inpatient services.12, 13 In general, midlevel practitioners on general medicine services have been deployed to: (1) care for a population of patients separate from and in parallel with house staff; this population may be narrowly defined (eg, patients with chest pain) or not; (2) assist with the management of patients cared for by house staff by performing certain tasks (eg, scheduling appointments, discharging patients). Even as midlevel providers become more prevalent on academic general medicine services, the best model of care incorporating them into clinical care remains unclear, and few studies have rigorously examined the care provided on services that use them.

We developed an inpatient general medicine service within a large academic medical center staffed by physician assistants and hospitalists to help our residency program meet ACGME duty hour requirements. We hypothesized that by creating a service that is geographically localized and supervised by full‐time hospitalists, by instituting multidisciplinary rounds, and by investing in the professional development of highly‐skilled physician assistants, we could provide care for medically complex, acutely ill general medicine inpatients with similar quality and efficiency as compared to house staff teams. We report our experience during the first year of implementing the service, and compare quality and efficiency of care on this service with that of our traditional house staff services. We also evaluate the effects of this service on patient satisfaction and self‐reported house staff workload.

PATIENTS AND METHODS

RESULTS

Patient Satisfaction

Patients were similarly satisfied with their care on the PACE service and on the house staff services. In specific areas and globally, percentages of patients satisfied with their physicians and with the discharge process were not different, as measured by the Press‐Ganey survey (Press‐Ganey Associates, South Bend, IN; Figures 1 and 2). The survey distinguishes between attendings and residents, but not physician assistants; therefore, Figure 1 only includes responses to the attending questions. Given the sampling procedure of the Press‐Ganey survey, exact response rates cannot be calculated, but Press‐Ganey reports a response rate of about 40% for the English survey and about 20% for the Spanish survey.

Figure 1

Figure 2

DISCUSSION

As academic centers struggle with developing a workforce to provide patient care no longer provided by residents, questions about the ideal structure of nonhouse staff inpatient services abound. Although solutions to this problem will be determined to some extent by local factors such as institutional culture and resources, some lessons learned in developing such services will be more widely applicable. We found that by implementing a geographically localized, physician assistant‐staffed hospitalist service, we were able to provide care of similar quality and efficiency to that of traditional house staff services, despite inexperienced hospitalists staffing the service and a medical residency program commonly recognized as one of the best in the country. Adjusted total costs were slightly lower on the PACE service, but this difference was small and of borderline statistical significance. Likewise, no significant differences were seen in any of several quality measures or in patient satisfaction.

Our findings add to the available evidence supporting the use of physician assistants on academic general medicine services, and are germane to academic centers facing reductions in house staff availability and seeking alternative models of care for inpatients. Several specific characteristics of the PACE service and the implications of these should be considered:

• 1

  The service accepted all patients, regardless of diagnosis, acuity, or complexity of illness. This was unlike many previously described nonhouse staff services which were more limited in scope, and allowed more flexibility with patient flow. However, in the end, patients on the PACE service did have a modestly lower case mix index and Charlson score, suggesting that, despite a lack of triage guidelines, there was some bias in the triage of admissions, possibly due to a perception that physician assistants should take care of lower complexity patients. If it is desirable to have a similar distribution of higher complexity patients across house staff and nonhouse staff services, extra efforts may be necessary to overcome this perception.

• 2

  The service was geographically regionalized. Geographic regionalization offered many important advantages, especially with regards to communication among staff, nursing, and consultants, and allowed for multidisciplinary rounds. However, it is possible that the modest, but not statistically significant, trend toward an increased LOS seen on the PACE service might be a reflection of geographic admitting (less incentive to discharge since discharging a patient means taking a new admission).

• 3

  The education and professional development of the physician assistants was a priority. Physician assistants had considerable autonomy and responsibility, and rather than being assigned only lower level administrative tasks, performed all aspects of patient care. They also received regular teaching from the hospitalists, attended house staff teaching conferences, and developed nonclinical roles in education and quality improvement. The higher standards expected of the physician assistants were quite possibly a factor in the quality of care delivered, and almost certainly contributed to physician assistant satisfaction and retention.

Our findings contrast with those of Myers et al.,9 who found that a nonteaching service staffed by hospitalists and nurse practitioners had a significantly lower median LOS and hospital charges compared to similar patients on resident‐based services. However, unlike ours, their service cared for a select patient population, and only accepted patients with chest pain at low risk for acute coronary syndrome. Van Rhee et al.10 found that physician assistants on a general medicine service used fewer resources for patients with pneumonia, stroke, and congestive heart failure than resident physicians, and did not exceed the resources used by residents in other diagnoses. The authors did not find a difference in LOS, but did find a significantly higher mortality among patients with pneumonia cared for by physician assistants.

Several limitations should be noted. First, the study was a retrospective analysis of administrative data rather than a randomized trial, and although we employed a standard approach to adjust for a wide range of patient characteristics including severity of illness, there may have been undetected differences in the patient populations studied that may have confounded our results. Second, resident moonlighters admitted patients to the PACE service and, at other times, to the house staff services, and this may have diluted any differences between the groups. However, when we limited our analysis to the subgroup of patients admitted during the day, similar results were obtained, with the exception that the PACE service had a lower rate of 14‐day readmissions, an unexpected finding deserving of further study. Third, the study was conducted in a single academic institution and our findings may not be generalizable to others with different needs and resources; indeed, the costs associated with implementing such a service may be prohibitive for some institutions. Fourth, because of simultaneous changes that were taking place in our residency program, we are unable to accurately assess the impact of the PACE service on resident duty hours. However, resident duty hours did not increase over this time period on the general medicine service, and implementation of the service allowed for redistribution of house staff to other services and positions. Fifth, patient satisfaction data were obtained from responses to the mailed Press‐Ganey survey, to which there is a relatively low response rate. Also, we did not survey providers regarding their satisfaction with the service during the study period. Sixth, the study had limited power to detect clinically important differences in mortality and ICU transfers. Finally, this study is unable to compare this particular model of incorporating midlevel providers into general medical services with other models, only with traditional house staff services.

Future research should focus on determining the most effective and efficient ways to incorporate midlevel providers on academic general medicine services. One important question from the standpoint of house staff training is whether such services should be separate but equal, or should house staff gain experience during residency working with midlevel providers, since they are likely to encounter them in the future whether they stay in academics or not. Different models of care will likely have large implications for the quality and efficiency of patient care, house staff education and satisfaction, and physician assistant job satisfaction and turnover.

In summary, our study demonstrates that a geographically regionalized, multidisciplinary service staffed by hospitalists and physician assistants can be a safe alternative to house staff‐based services for the care of general medicine inpatients in an academic medical center.

The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.

The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.

The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.

METHODS

Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.

Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.

The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.

The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.

Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.

RESULTS

The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).

Figure 1

Figure 2

DISCUSSION

A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.

Figure 3

Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.

Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?

The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.

The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.

The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.

We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.

The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.

Figure 4

As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.

As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.

Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.

CONCLUSIONS

The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.

The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.

Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.

The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.

The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.

The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.

METHODS

Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.

Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.

The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.

The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.

Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.

RESULTS

The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).

Figure 1

Figure 2

DISCUSSION

A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.

Figure 3

Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.

Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?

The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.

The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.

The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.

We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.

The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.

Figure 4

As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.

As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.

Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.

CONCLUSIONS

The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.

The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.

Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.

The goal of this article is to explain how the first in a series of online resource rooms provides trainees and hospitalists with quality improvement tools that can be applied locally to improve inpatient care.1 During the emergence and explosive growth of hospital medicine, the SHM recognized the need to revise training relating to inpatient care and hospital process design to meet the evolving expectation of hospitalists that their performance will be measured, to actively set quality parameters, and to lead multidisciplinary teams to improve hospital performance.2 Armed with the appropriate skill set, hospitalists would be uniquely situated to lead and manage improvements in processes in the hospitals in which they work.

The content of the first Society of Hospital Medicine (SHM) Quality Improvement Resource Room (QI RR) supports hospitalists leading a multidisciplinary team dedicated to improving inpatient outcomes by preventing hospital‐acquired venous thromboembolism (VTE), a common cause of morbidity and mortality in hospitalized patients.3 The SHM developed this educational resource in the context of numerous reports on the incidence of medical errors in US hospitals and calls for action to improve the quality of health care.'47 Hospital report cards on quality measures are now public record, and hospitals will require uniformity in practice among physicians. Hospitalists are increasingly expected to lead initiatives that will implement national standards in key practices such as VTE prophylaxis2.

The QI RRs of the SHM are a collection of electronic tools accessible through the SHM Web site. They are designed to enhance the readiness of hospitalists and members of the multidisciplinary inpatient team to redesign care at the institutional level. Although all performance improvement is ultimately occurs locally, many QI methods and tools transcend hospital geography and disease topic. Leveraging a Web‐based platform, the SHM QI RRs present hospitalists with a general approach to QI, enriched by customizable workbooks that can be downloaded to best meet user needs. This resource is an innovation in practice‐based learning, quality improvement, and systems‐based practice.

METHODS

Development of the first QI RR followed a series of steps described in Curriculum Development for Medical Education8 (for process and timeline, see Table 1). Inadequate VTE prophylaxis was identified as an ongoing widespread problem of health care underutilization despite randomized clinical trials supporting the efficacy of prophylaxis.9, 10 Mirroring the AHRQ's assessment of underutilization of VTE prophylaxis as the single most important safety priority,6 the first QI RR focused on VTE, with plans to cover additional clinical conditions over time. As experts in the care of inpatients, hospitalists should be able to take custody of predictable complications of serious illness, identify and lower barriers to prevention, critically review prophylaxis options, utilize hospital‐specific data, and devise strategies to bridge the gap between knowledge and practice. Already leaders of multidisciplinary care teams, hospitalists are primed to lead multidisciplinary improvement teams as well.

Available data on the demographics of hospitalists and feedback from the SHM membership, leadership, and committees indicated that most learners would have minimal previous exposure to QI concepts and only a few years of management experience. Any previous quality improvement initiatives would tend to have been isolated, experimental, or smaller in scale. The resource rooms are designed to facilitate quality improvement learning among hospitalists that is practice‐based and immediately relevant to patient care. Measurable improvement in particular care processes or outcomes should correlate with actual learning.

The educational strategy of the SHM was predicated on ensuring that a quality and patient safety curriculum would retain clinical applicability in the hospital setting. This approach, grounded in adult learning principles and common to medical education, teaches general principles by framing the learning experience as problem centered.11 Several domains were identified as universally important to any quality improvement effort: raising awareness of a local performance gap, applying the best current evidence to practice, tapping the experience of others leading QI efforts, and using measurements derived from rapid‐cycle tests of change. Such a template delineates the components of successful QI planning, implementation, and evaluation and provides users with a familiar RR format applicable to improving any care process, not just VTE.

The Internet was chosen as the mechanism for delivering training on the basis of previous surveys of the SHM membership in which members expressed a preference for electronic and Web‐based forms of educational content delivery. Drawing from the example of other organizations teaching quality improvement, including the Institute for Healthcare Improvement and Intermountain Health Care, the SHM valued the ubiquity of a Web‐based educational resource. To facilitate on‐the‐job training, the first SHM QI RR provides a comprehensive tool kit to guide hospitalists through the process of advocating, developing, implementing, and evaluating a QI initiative for VTE.

Prior to launching the resource room, formative input was collected from SHM leaders, a panel of education and QI experts, and attendees of the society's annual meetings. Such input followed each significant step in the development of the RR curricula. For example, visitors at a kiosk at the 2005 SHM annual meeting completed surveys as they navigated through the VTE QI RR. This focused feedback shaped prelaunch development. The ultimate performance evaluation and feedback for the QI RR curricula will be gauged by user reports of measurable improvement in specific hospital process or outcomes measures. The VTE QI RR was launched in August 2005 and promoted at the SHM Web site.

RESULTS

The content and layout of the VTE QI RR are depicted in Figure 1. The self‐directed learner may navigate through the entire resource room or just select areas for study. Those likely to visit only a single area are individuals looking for guidance to support discrete roles on the improvement team: champion, clinical leader, facilitator of the QI process, or educator of staff or patient audiences (see Figure 2).

Figure 1

Figure 2

DISCUSSION

A case example, shown in Figure 3, demonstrates how content accessible through the SHM VTE QI RR may be used to catalyze a local quality improvement effort.

Figure 3

Hospitals will be measured on rates of VTE prophylaxis on medical and surgical services. Failure to standardize prophylaxis among different physician groups may adversely affect overall performance, with implications for both patient care and accreditation. The lack of a agreed‐on gold standard of what constitutes appropriate prophylaxis for a given patient does not absolve an institution of the duty to implement its own standards. The challenge of achieving local consensus on appropriate prophylaxis should not outweigh the urgency to address preventable in‐hospital deaths. In caring for increasing numbers of general medical and surgical patients, hospitalists are likely to be asked to develop and implement a protocol for VTE prophylaxis that can be used hospitalwide. In many instances hospitalists will accept this charge in the aftermath of previous hospital failures in which admission order sets or VTE assessment protocols were launched but never widely implemented. As the National Quality Forum or JCAHO regulations for uniformity among hospitals shift VTE prophylaxis from being voluntary to compulsory, hospitalists will need to develop improvement strategies that have greater reliability.

Hospitalists with no formal training in either vascular medicine or quality improvement may not be able to immediately cite the most current data about VTE prophylaxis rates and regimens and may not have the time to enroll in a training course on quality improvement. How would hospitalists determine baseline rates of appropriate VTE prophylaxis? How can medical education be used to build consensus and recruit support from other physicians? What should be the scope of the QI initiative, and what patient population should be targeted for intervention?

The goal of the SHM QI RR is to provide the tools and the framework to help hospitalists develop, implement, and manage a VTE prophylaxis quality improvement initiative. Suggested Steps to Action in the Awareness section depict exactly how a hospital medicine service can use the campaign's materials to raise institutional support for tackling this preventable problem. Hospital quality officers can direct the hospital's public relations department to the Awareness section for DVT Awareness Month materials, including public service announcements in audio, visual, and print formats. The hold music at the hospital can be temporarily replaced, television kiosks can be set up to run video loops, and banners can be printed and hung in central locations, all to get out the message simultaneously to patients and medical staff.

The Evidence section of the VTE QI RR references a key benchmark study, the DVT‐Free Prospective Registry.9 This study reported that at 183 sites in North America and Europe, more than twice as many medical patients as surgical patients failed to receive prophylaxis. The Evidence section includes the 7th American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy and also highlights 3 randomized placebo‐controlled clinical trials (MEDENOX 1999, ARTEMIS 2003, and PREVENT 2004) that have reported significant reduction of risk of VTE (50%‐60%) from pharmacologic prophylaxis in moderate‐risk medical inpatients.1315 Review of the data helps to determine which patient population to study first, which prophylaxis options a hospital could deploy appropriately, and the expected magnitude of the effect. Because the literature has already been narrowed and is kept current, hospitalists can save time in answering a range of questions, from the most commonly agreed‐on factors to stratify risk to which populations require alternative interventions.

The Experience section references the first clinical trial demonstrating improved patient outcomes from a quality improvement initiative aimed at improving utilization of VTE prophylaxis.10 At the large teaching hospital where the electronic alerts were studied, a preexisting wealth of educational information on the hospital Web site, in the form of multiple seminars and lectures on VTE prophylaxis by opinion leaders and international experts, had little impact on practice. For this reason, the investigators implemented a trial of how to change physician behavior by introducing a point‐of‐care intervention, the computer alerts. Clinicians prompted by an electronic alert to consider DVT prophylaxis for at‐risk patients employed nearly double the rate of pharmacologic prophylaxis and reduced the incidence of DVT or pulmonary embolism (PE) by 41%. This study suggests that a change introduced to the clinical workflow can improve evidence‐based VTE prophylaxis and also can reduce the incidence of VTE in acutely ill hospitalized patients.

We believe that if hospitalists use the current evidence and experience assembled in the VTE QI RR, they could develop and lead a systematic approach to improving utilization of VTE prophylaxis. Although there is no gold standard method for integrating VTE risk assessment into clinical workflow, the VTE QI RR presents key lessons both from the literature and real world experiences. The crucial take‐home message is that hospitalists can facilitate implementation of VTE risk assessments if they stress simplicity (ie, the sick, old, surgery benefit), link the risk assessment to a menu of evidence‐based prophylaxis options, and require assessment of VTE risk as part of a regular routine (on admission and at regular intervals). Although many hospitals do not yet have computerized entry of physician orders, the simple 4‐point VTE risk assessment described by Kucher et al might be applied to other hospitals.10 The 4‐point system would identify the patients at highest risk, a reasonable starting point for a QI initiative. Whatever the modelCPOE alerts of very high‐risk patients, CPOE‐forced VTE risk assessments, nursing assessments, or paper‐based order setsregular VTE risk assessment can be incorporated into the daily routine of hospital care.

The QI workbook sequences the steps of a multidisciplinary improvement team and prompts users to set specific goals, collect practical metrics, and conduct plan‐do‐study‐act (PDSA) cycles of learning and action (Figure 4). Hospitalists and other team members can use the information in the workbook to estimate the prevalence of use of the appropriate VTE prophylaxis and the incidence of hospital‐acquired VTE at their medical centers, develop a suitable VTE risk assessment model, and plan interventions. Starting with all patients admitted to one nurse on one unit, then expanding to an entire nursing unit, an improvement team could implement rapid PDSA cycles to iron out the wrinkles of a risk assessment protocol. After demonstrating a measurable benefit for the patients at highest risk, the team would then be expected to capture more patients at risk for VTE by modifying the risk assessment protocol to identify moderate‐risk patients (hospitalized patients with one risk factor), as in the MEDENOX, ARTEMIS, and PREVENT clinical trials. Within the first several months, the QI intervention could be expanded to more nursing units. An improvement report profiling a clinically important increase in the rate of appropriate VTE prophylaxis would advocate for additional local resources and projects.

Figure 4

As questions arise in assembling an improvement team, setting useful aims and metrics, choosing interventions, implementing and studying change, or collecting performance data, hospitalists can review answers to questions already posted and post their own questions in the Ask the Expert area. For example, one user asked whether there was a standard risk assessment tool for identifying patients at high risk of VTE. Another asked about the use of unfractionated heparin as a low‐cost alternative to low‐molecular‐weight heparin. Both these questions were answered within 24 hours by the content editor of the VTE QI RR and, for one question, also by 2 pharmacists and an international expert in VTE.

As other hospitalists begin de novo efforts of their own, success stories and strategies posted in the online forums of the VTE QI RR will be an evolving resource for basic know‐how and innovation.

Suggestions from a community of resource room users will be solicited, evaluated, and incorporated into the QI RR in order to improve its educational value and utility. The curricula could also be adapted or refined by others with an interest in systems‐based care or practice‐based learning, such as directors of residency training programs.

CONCLUSIONS

The QI RRs bring QI theory and practice to the hospitalist, when and wherever it is wanted, minimizing time away from patient care. The workbook links theory to practice and can be used to launch, sustain, and document a local VTE‐specific QI initiative. A range of experience is accommodated. Content is provided in a way that enables the user to immediately apply and adapt it to a local contextusers can access and download the subset of tools that best meet their needs. For practicing hospitalists, this QI resource offers an opportunity to bridge the training gap in systems‐based hospital care and should increase the quality and quantity of and support for opportunities to lead successful QI projects.

The Accreditation Council of Graduate Medical Education (ACGME) now requires education in health care systems, a requirement not previously mandated for traditional medical residency programs.17 Because the resource rooms should increase the number of hospitalists competently leading local efforts that achieve measurable gains in hospital outcomes, a wider potential constituency also includes residency program directors, internal medicine residents, physician assistants and nurse‐practitioners, nurses, hospital quality officers, and hospital medicine practice leaders.

Further research is needed to determine the clinical impact of the VTE QI workbook on outcomes for hospitalized patients. The effectiveness of such an educational method should be evaluated, at least in part, by documenting changes in clinically important process and outcome measures, in this case those specific to hospital‐acquired VTE. Investigation also will need to generate an impact assessment to see if the curricula are effective in meeting the strategic educational goals of the Society of Hospital Medicine. Further investigation will examine whether this resource can help residency training programs achieve ACGME goals for practice‐based learning and systems‐based care.