Medicolegal Issues

Quality Will Be Job One


One of the potential benefits of hospital medicine is the tangible opportunity to change healthcare in a meaningful way. Although much of the initial ballyhoo for hospital medicine has been around service-related issues, that is about to change.

Hospitalists have been willing to take on the inpatient responsibilities for primarily outpatient-based internists, family practitioners, and pediatricians. We have been available to admit and manage the patients who present to emergency rooms with acute illnesses and who have no physician of record. We have actively worked with surgeons and subspecialists to co-manage their patient’s medical problems.

In addition, because hospitalists are much more readily available to acutely ill inpatients, because we have more expertise with these medical problems, and because practice generally makes for better performance, hospitalists have been expected to provide more effective and more efficient care.

We are moving into an era of measurement of defined patient outcomes and expectations from insurance companies, Medicare, the business community, and—yes—even our patients. That era will require us to step up and deliver higher quality healthcare.

But that is just the front end of what is creating the enormous energy behind the hospital medicine movement. We are moving into an era of measurement of defined patient outcomes and expectations from insurance companies, Medicare, the business community, and—yes—even our patients. That era will require us to step up and deliver higher quality healthcare.

This is the driver to the pay-for-performance movement and a shift from just rewarding physicians and hospitals for doing the procedure or “visiting” the patient and moving to where those who can demonstrate expertise and performance are rewarded financially and by reputation.

Hospitalists and SHM take this very seriously and are creating alliances and programs to help hospitalists become leaders in the quality and performance arenas.

Walking through the approach that SHM is taking in improving glycemic control in hospitalized patients (see below) will serve as a template for other activities SHM has planned in heart failure, VTE, hospitalized infections, and other illnesses hospitalists see and treat every day.

In a practical way, hospitals and health professionals finally came into the performance era with the first publication of the individual hospital performance results to performance measures developed by JCAHO and co-promoted with CMS in their Hospital Compare Web site. This was promulgated widely, especially at

Because Hospital Compare was picked up by The New York Times, the Los Angeles Times, and many local papers, hospitals were soon trying to explain why their performance in heart failure, pneumonia, and heart attack looked like a failing grade. Now that the public is involved, hospitals are scrambling to quickly improve their performance rather than attacking the data.

Looking to the future, SHM is working with JCAHO to develop performance standards for glycemic control for inpatients as a way to assess how our hospitals and physicians are doing in managing diabetes. SHM is also allying with many other key stakeholders to form a steering committee for this project. These standards will take almost three years to develop, test, and implement. So the first reporting of how every hospital is doing in diabetes is most likely a 2008 or 2009 event.

Expecting that many hospitals will improve their performance in diabetic care during 2008 and 2009, SHM is now developing the tools and the training to allow hospitalists to be ready with practical solutions.

In October 2005 SHM convened a Working Group on Inpatient Glycemic Control in Chicago. This meeting under the leadership of Greg Maynard, MD, associate clinical professor of medicine, chief of the division of hospital medicine, University of California at San Diego, brought together nationally recognized diabetologists and endocrinologists with hospitalist leaders, as well as experts in the field of nursing, case management, pharmacy, risk management, and nutrition. The end result is an understanding of what constitutes an ideal management of inpatient diabetes and what role hospitalists can play.

This work group now is analyzing what resources currently exist and what gaps need to be filled. Next SHM will develop an implementation plan to get this information out to our nation’s hospitalists.

SHM has some experience in developing quality improvement tools, as you can see in our Resource Rooms on the SHM Web site. For a current working example, take a look at the DVT Quality Improvement Resource Room at

But SHM plans a more aggressive approach with proposed training sessions at the SHM Annual Meeting quality pre-course and taking these tools and approaches out to our hospitalists at local meetings throughout the country. SHM is also looking into creating a network of quality mentors that will work with individual hospitalists groups as they put SHM quality improvement tools into the workflow at their hospitals. SHM will also develop strategies for baseline measurement, ongoing data collection, involvement of team members, and procurement of local resources. SHM hopes to support research to further develop best practices and approaches.

The game plan goes something like this: SHM will develop the resources hospitalists need to improve management of inpatient diabetes in 2006. In 2007 and 2008 SHM will roll out this strategy to as many hospitalists as we can train. By 2008 JCAHO and CMS will have deployed their Performance Measures in Diabetes. When the first scores show the same deficiencies as we have seen this year in MI and heart failure, our nation’s hospitalists will be well armed to provide practical tangible solutions to improve quality.

And the beauty of this approach is that SHM is working on similar strategies right now for heart failure, DVT, pneumonia, and other key clinical conditions.

Those who pay for and receive care in our hospitals are looking at our current performance and demanding improvements. For the first time hospitals and those with resources are ready to make measurable quality a high priority. The presence of hospitalists in more than 2,000 hospitals (and more in the near future) ideally positions hospitalists to be a key change agent. The tools SHM is developing will give hospitalists the strategies and the expertise to make this happen.

This is a watershed moment in American healthcare. There is a palpable swing in the priorities of our patients. Hospitalists can help the healthcare team find real solutions. SHM has the vision and the plan to provide you with as much help as you need. Together we will do great things. TH

Dr. Wellikson has been CEO of SHM since 2000.

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