The United States is moving aggressively toward value‐based payment. The Department of Health and Human Services recently announced a goal to link 85% of Medicare's fee‐for‐service payments to quality or value by 2016.[1] Despite the inherent logic of paying providers for their results, evidence of the effectiveness of value‐based payment has been mixed and underwhelming. Recent reviews of pay‐for‐performancereflecting the emerging understanding of the complexities of designing successful programshave painted a more negative picture of their overall effectiveness.[2, 3] One study of over 6 million patients found that the Medicare Premier Hospital Quality Incentive Demonstration had no effect on long‐term patient outcomes including 30‐day mortality.[4] At the same time, research suggests that lower performing providers tend to have a disproportionate number of poor patients, many of whom are racial and ethnic minorities. Value‐based payment risks the dual failure of not improving health outcomes while exacerbating health inequities.

We have seen this movie before. In 2001, No Child Left Behind was enacted to improve quality and reduce inequities in K12 education in the United States. Much like healthcare, education suffers from uneven quality and wide socioeconomic disparities.[5] No Child Left Behind attempted to address these problems with new accountability measures. Based on the results from standardized tests, No Child Left Behind rewarded the highest performing schools with more funding while penalizing poor performing schools with reduced funding, and in some cases, forcing failing schools to cede control to outside operators.

In the aftermath of its implementation, however, it became clear that these incentives had not worked as intended. No Child Left Behind did not improve reading performance and was associated with improvements in math performance only for younger students.[6] These modest gains came at a high cost; consistent with teaching to the test, No Child Left Behind led to a shifting of instructional time toward math and reading and away from other subjects. It also led to widespread cheating, challenging the validity of observed performance improvements. Before No Child Left Behind was rolled out, the wealthiest school districts in the country spent as much as 10 times more than the poorest districts.[5] By penalizing the lowest performers, these gaps persisted. Schools were not given the support that they needed to improve performance.

The parallels to healthcare are striking (Table 1). Early results from Medicare's Hospital Value‐Based Purchasing and Readmission Reduction Program show that hospitals caring for more disadvantaged patients have been disproportionately penalized.[7] Similar reverse Robin Hood effects have been observed in incentive programs for physician practices.[8] Over time, financial incentive programs may substantially decrease operating revenue for hospitals and physicians caring for low‐income and minority communities. This could perpetuate the already large disparities in quality and health outcomes facing these populations. Although risk‐adjusting for socioeconomic status may alleviate these concerns in the short term, allowing low‐income or minority patients to have poorer health outcomes simply accepts that disparities exist rather than trying to reduce them.

How then is it possible to improve the quality of care at lower performing hospitals without simultaneously designing an incentive system that hurts them? Lessons from the education policy are again instructive. Every 3 years the Organization for Economic Cooperation and Development ranks countries by the performance of their 15‐year olds on a standardized test called the Program for International Student Assessment.[9] For the past 2 sets of rankings, Shanghai, China has topped the list. Like many attempts to generate international rankings, this one has its flaws, and Shanghai's top position has not been without controversy. For one, China is not ranked at the country‐level like other nations; yet, due to the city's status as a wealthy business and financial center, Shanghai certainly cannot be considered representative of the Chinese education system. Nevertheless, the story of how Shanghai reformed its education system and achieved its high position has important implications.

Prior to implementing reforms, Shanghai's rural outer districts struggled with less funding, high teacher turnover rates, and low test scores compared to wealthier urban districts. To reduce education disparities within the city's schools, the government of Shanghai enacted a number of policies aimed at bringing lower performers up to the same level as schools with the highest degree of student achievement.[10] The government gives schools a grade of A, B, C, or D based on the quality of their infrastructure and student performance. It then uses several programs to facilitate the exchange of staff and ideas among schools at different levels. One program pairs high‐performing districts with low‐performing districts to share education development plans, curricula, teaching materials, and best practices. Another strategycalled commissioned administrationinvolves temporary contracts between schools to exchange both administrators and experienced teachers. In addition to these approaches, the government sets a minimum level of spending for schools and transfers public funds to indigent districts to provide them with assistance to reach this level.

The notion that the very best can help the weak requires a sense of solidarity. This solidarity may falter in environments in which hospitals and physicians are in cutthroat competition. Though there will always be some tension between competition and collaboration, in most markets, competition between hospitals does not rule out collaboration. Policies can either relieve or reinforce the natural tension between competition and collaboration. This suggests that adopting reforms with the same intent as the Shanghai system is still possible in healthcare, especially through physician and other provider networks. The healthcare workforce has a rich history of cross‐organizational collaboration through mentorships, the publication of research, and participation in continuing medical education courses. The Centers for Medicare and Medicaid Services' Hospital Engagement Networks, a program in which leading organizations have helped to disseminate interventions to reduce hospital acquired conditions, are an example of this approach. Quality collaborativesgroups of providers who collaborate across institutions to identify problems and best practices for improvementhave similarly shown great promise.[11] Similar approaches have been used by the Institute for Healthcare Improvement in many of their quality improvement initiatives.

Such collaboration‐based programs could be harnessed and tied to financial incentives for quality improvement. For instance, top‐performing hospitals could be incentivized to participate in a venue where they share their best practices with the lower performers in their field. Low performers, in turn, could be provided with financial assistance to implement the appropriate changes. Over time, financial assistance could be made contingent on quality improvements. By providing physicians and other providers with examples of what success looks like and assisting them with garnering the resources to reach this level, improvement would not only be incentivized, it might also become more tangible.

Although some hospitals and physicians may welcome changes to incentive systems, implementation of collaboration‐based programs would not be possible without a facilitator that is willing to underwrite program costs, provide financial incentivizes to providers, and develop a platform for collaboration. Large insurers are the most likely group to have the financial resources and widespread network to develop such programs, but that does not mean that they would be willing to experiment with this approach. This may especially be the case if cost savings and measurable improvements in quality are not immediate. Even though the results of collaboration‐based efforts have been promising, the implementation of these programs has been limited, and adoption in different contexts may not yield the same results. Collaboration‐based programs that have already shown success can serve as models, but they may need significant adaptations to meet the needs of providers in a given area.

Despite its promise, collaboration‐based strategies alone will not be enough to improve certain aspects of quality and value. Although providing physicians with knowledge on how to reduce unnecessary care, for example, could help limit overutilization, it is not sufficient to overcome the incentives of fee‐for‐service payment. In this case, broader payment reform and population‐based accountability can be paired with programs to encourage collaboration. For instance, the Blue Cross and Blue Shield of Massachusetts' Alternative Contract has used a combination of technical assistance, shared savings, and large quality bonuses to improve quality and reduce medical spending growth.[12] Collaboration‐based strategies should be seen as a complement to these broad, thoughtful reforms and a substitute for narrow incentives that encourage myopia and destructive competition.

Evidence from education and healthcare shows that penalizing the worst and rewarding the best will not shift the bell curve of performance. Such approaches are more likely to entrench and expand disparities. Instead, policy should encourage and incentivize collaboration to expand best practices that improve patient outcomes. Lessons from education provide both cautionary tales and novel solutions that might improve healthcare.

Disclosure: Nothing to report.

The United States is moving aggressively toward value‐based payment. The Department of Health and Human Services recently announced a goal to link 85% of Medicare's fee‐for‐service payments to quality or value by 2016.[1] Despite the inherent logic of paying providers for their results, evidence of the effectiveness of value‐based payment has been mixed and underwhelming. Recent reviews of pay‐for‐performancereflecting the emerging understanding of the complexities of designing successful programshave painted a more negative picture of their overall effectiveness.[2, 3] One study of over 6 million patients found that the Medicare Premier Hospital Quality Incentive Demonstration had no effect on long‐term patient outcomes including 30‐day mortality.[4] At the same time, research suggests that lower performing providers tend to have a disproportionate number of poor patients, many of whom are racial and ethnic minorities. Value‐based payment risks the dual failure of not improving health outcomes while exacerbating health inequities.

We have seen this movie before. In 2001, No Child Left Behind was enacted to improve quality and reduce inequities in K12 education in the United States. Much like healthcare, education suffers from uneven quality and wide socioeconomic disparities.[5] No Child Left Behind attempted to address these problems with new accountability measures. Based on the results from standardized tests, No Child Left Behind rewarded the highest performing schools with more funding while penalizing poor performing schools with reduced funding, and in some cases, forcing failing schools to cede control to outside operators.

In the aftermath of its implementation, however, it became clear that these incentives had not worked as intended. No Child Left Behind did not improve reading performance and was associated with improvements in math performance only for younger students.[6] These modest gains came at a high cost; consistent with teaching to the test, No Child Left Behind led to a shifting of instructional time toward math and reading and away from other subjects. It also led to widespread cheating, challenging the validity of observed performance improvements. Before No Child Left Behind was rolled out, the wealthiest school districts in the country spent as much as 10 times more than the poorest districts.[5] By penalizing the lowest performers, these gaps persisted. Schools were not given the support that they needed to improve performance.

The parallels to healthcare are striking (Table 1). Early results from Medicare's Hospital Value‐Based Purchasing and Readmission Reduction Program show that hospitals caring for more disadvantaged patients have been disproportionately penalized.[7] Similar reverse Robin Hood effects have been observed in incentive programs for physician practices.[8] Over time, financial incentive programs may substantially decrease operating revenue for hospitals and physicians caring for low‐income and minority communities. This could perpetuate the already large disparities in quality and health outcomes facing these populations. Although risk‐adjusting for socioeconomic status may alleviate these concerns in the short term, allowing low‐income or minority patients to have poorer health outcomes simply accepts that disparities exist rather than trying to reduce them.

How then is it possible to improve the quality of care at lower performing hospitals without simultaneously designing an incentive system that hurts them? Lessons from the education policy are again instructive. Every 3 years the Organization for Economic Cooperation and Development ranks countries by the performance of their 15‐year olds on a standardized test called the Program for International Student Assessment.[9] For the past 2 sets of rankings, Shanghai, China has topped the list. Like many attempts to generate international rankings, this one has its flaws, and Shanghai's top position has not been without controversy. For one, China is not ranked at the country‐level like other nations; yet, due to the city's status as a wealthy business and financial center, Shanghai certainly cannot be considered representative of the Chinese education system. Nevertheless, the story of how Shanghai reformed its education system and achieved its high position has important implications.

Prior to implementing reforms, Shanghai's rural outer districts struggled with less funding, high teacher turnover rates, and low test scores compared to wealthier urban districts. To reduce education disparities within the city's schools, the government of Shanghai enacted a number of policies aimed at bringing lower performers up to the same level as schools with the highest degree of student achievement.[10] The government gives schools a grade of A, B, C, or D based on the quality of their infrastructure and student performance. It then uses several programs to facilitate the exchange of staff and ideas among schools at different levels. One program pairs high‐performing districts with low‐performing districts to share education development plans, curricula, teaching materials, and best practices. Another strategycalled commissioned administrationinvolves temporary contracts between schools to exchange both administrators and experienced teachers. In addition to these approaches, the government sets a minimum level of spending for schools and transfers public funds to indigent districts to provide them with assistance to reach this level.

The notion that the very best can help the weak requires a sense of solidarity. This solidarity may falter in environments in which hospitals and physicians are in cutthroat competition. Though there will always be some tension between competition and collaboration, in most markets, competition between hospitals does not rule out collaboration. Policies can either relieve or reinforce the natural tension between competition and collaboration. This suggests that adopting reforms with the same intent as the Shanghai system is still possible in healthcare, especially through physician and other provider networks. The healthcare workforce has a rich history of cross‐organizational collaboration through mentorships, the publication of research, and participation in continuing medical education courses. The Centers for Medicare and Medicaid Services' Hospital Engagement Networks, a program in which leading organizations have helped to disseminate interventions to reduce hospital acquired conditions, are an example of this approach. Quality collaborativesgroups of providers who collaborate across institutions to identify problems and best practices for improvementhave similarly shown great promise.[11] Similar approaches have been used by the Institute for Healthcare Improvement in many of their quality improvement initiatives.

Such collaboration‐based programs could be harnessed and tied to financial incentives for quality improvement. For instance, top‐performing hospitals could be incentivized to participate in a venue where they share their best practices with the lower performers in their field. Low performers, in turn, could be provided with financial assistance to implement the appropriate changes. Over time, financial assistance could be made contingent on quality improvements. By providing physicians and other providers with examples of what success looks like and assisting them with garnering the resources to reach this level, improvement would not only be incentivized, it might also become more tangible.

Although some hospitals and physicians may welcome changes to incentive systems, implementation of collaboration‐based programs would not be possible without a facilitator that is willing to underwrite program costs, provide financial incentivizes to providers, and develop a platform for collaboration. Large insurers are the most likely group to have the financial resources and widespread network to develop such programs, but that does not mean that they would be willing to experiment with this approach. This may especially be the case if cost savings and measurable improvements in quality are not immediate. Even though the results of collaboration‐based efforts have been promising, the implementation of these programs has been limited, and adoption in different contexts may not yield the same results. Collaboration‐based programs that have already shown success can serve as models, but they may need significant adaptations to meet the needs of providers in a given area.

Despite its promise, collaboration‐based strategies alone will not be enough to improve certain aspects of quality and value. Although providing physicians with knowledge on how to reduce unnecessary care, for example, could help limit overutilization, it is not sufficient to overcome the incentives of fee‐for‐service payment. In this case, broader payment reform and population‐based accountability can be paired with programs to encourage collaboration. For instance, the Blue Cross and Blue Shield of Massachusetts' Alternative Contract has used a combination of technical assistance, shared savings, and large quality bonuses to improve quality and reduce medical spending growth.[12] Collaboration‐based strategies should be seen as a complement to these broad, thoughtful reforms and a substitute for narrow incentives that encourage myopia and destructive competition.

Evidence from education and healthcare shows that penalizing the worst and rewarding the best will not shift the bell curve of performance. Such approaches are more likely to entrench and expand disparities. Instead, policy should encourage and incentivize collaboration to expand best practices that improve patient outcomes. Lessons from education provide both cautionary tales and novel solutions that might improve healthcare.

Disclosure: Nothing to report.

The United States is moving aggressively toward value‐based payment. The Department of Health and Human Services recently announced a goal to link 85% of Medicare's fee‐for‐service payments to quality or value by 2016.[1] Despite the inherent logic of paying providers for their results, evidence of the effectiveness of value‐based payment has been mixed and underwhelming. Recent reviews of pay‐for‐performancereflecting the emerging understanding of the complexities of designing successful programshave painted a more negative picture of their overall effectiveness.[2, 3] One study of over 6 million patients found that the Medicare Premier Hospital Quality Incentive Demonstration had no effect on long‐term patient outcomes including 30‐day mortality.[4] At the same time, research suggests that lower performing providers tend to have a disproportionate number of poor patients, many of whom are racial and ethnic minorities. Value‐based payment risks the dual failure of not improving health outcomes while exacerbating health inequities.

We have seen this movie before. In 2001, No Child Left Behind was enacted to improve quality and reduce inequities in K12 education in the United States. Much like healthcare, education suffers from uneven quality and wide socioeconomic disparities.[5] No Child Left Behind attempted to address these problems with new accountability measures. Based on the results from standardized tests, No Child Left Behind rewarded the highest performing schools with more funding while penalizing poor performing schools with reduced funding, and in some cases, forcing failing schools to cede control to outside operators.

In the aftermath of its implementation, however, it became clear that these incentives had not worked as intended. No Child Left Behind did not improve reading performance and was associated with improvements in math performance only for younger students.[6] These modest gains came at a high cost; consistent with teaching to the test, No Child Left Behind led to a shifting of instructional time toward math and reading and away from other subjects. It also led to widespread cheating, challenging the validity of observed performance improvements. Before No Child Left Behind was rolled out, the wealthiest school districts in the country spent as much as 10 times more than the poorest districts.[5] By penalizing the lowest performers, these gaps persisted. Schools were not given the support that they needed to improve performance.

The parallels to healthcare are striking (Table 1). Early results from Medicare's Hospital Value‐Based Purchasing and Readmission Reduction Program show that hospitals caring for more disadvantaged patients have been disproportionately penalized.[7] Similar reverse Robin Hood effects have been observed in incentive programs for physician practices.[8] Over time, financial incentive programs may substantially decrease operating revenue for hospitals and physicians caring for low‐income and minority communities. This could perpetuate the already large disparities in quality and health outcomes facing these populations. Although risk‐adjusting for socioeconomic status may alleviate these concerns in the short term, allowing low‐income or minority patients to have poorer health outcomes simply accepts that disparities exist rather than trying to reduce them.

How then is it possible to improve the quality of care at lower performing hospitals without simultaneously designing an incentive system that hurts them? Lessons from the education policy are again instructive. Every 3 years the Organization for Economic Cooperation and Development ranks countries by the performance of their 15‐year olds on a standardized test called the Program for International Student Assessment.[9] For the past 2 sets of rankings, Shanghai, China has topped the list. Like many attempts to generate international rankings, this one has its flaws, and Shanghai's top position has not been without controversy. For one, China is not ranked at the country‐level like other nations; yet, due to the city's status as a wealthy business and financial center, Shanghai certainly cannot be considered representative of the Chinese education system. Nevertheless, the story of how Shanghai reformed its education system and achieved its high position has important implications.

Prior to implementing reforms, Shanghai's rural outer districts struggled with less funding, high teacher turnover rates, and low test scores compared to wealthier urban districts. To reduce education disparities within the city's schools, the government of Shanghai enacted a number of policies aimed at bringing lower performers up to the same level as schools with the highest degree of student achievement.[10] The government gives schools a grade of A, B, C, or D based on the quality of their infrastructure and student performance. It then uses several programs to facilitate the exchange of staff and ideas among schools at different levels. One program pairs high‐performing districts with low‐performing districts to share education development plans, curricula, teaching materials, and best practices. Another strategycalled commissioned administrationinvolves temporary contracts between schools to exchange both administrators and experienced teachers. In addition to these approaches, the government sets a minimum level of spending for schools and transfers public funds to indigent districts to provide them with assistance to reach this level.

The notion that the very best can help the weak requires a sense of solidarity. This solidarity may falter in environments in which hospitals and physicians are in cutthroat competition. Though there will always be some tension between competition and collaboration, in most markets, competition between hospitals does not rule out collaboration. Policies can either relieve or reinforce the natural tension between competition and collaboration. This suggests that adopting reforms with the same intent as the Shanghai system is still possible in healthcare, especially through physician and other provider networks. The healthcare workforce has a rich history of cross‐organizational collaboration through mentorships, the publication of research, and participation in continuing medical education courses. The Centers for Medicare and Medicaid Services' Hospital Engagement Networks, a program in which leading organizations have helped to disseminate interventions to reduce hospital acquired conditions, are an example of this approach. Quality collaborativesgroups of providers who collaborate across institutions to identify problems and best practices for improvementhave similarly shown great promise.[11] Similar approaches have been used by the Institute for Healthcare Improvement in many of their quality improvement initiatives.

Such collaboration‐based programs could be harnessed and tied to financial incentives for quality improvement. For instance, top‐performing hospitals could be incentivized to participate in a venue where they share their best practices with the lower performers in their field. Low performers, in turn, could be provided with financial assistance to implement the appropriate changes. Over time, financial assistance could be made contingent on quality improvements. By providing physicians and other providers with examples of what success looks like and assisting them with garnering the resources to reach this level, improvement would not only be incentivized, it might also become more tangible.

Although some hospitals and physicians may welcome changes to incentive systems, implementation of collaboration‐based programs would not be possible without a facilitator that is willing to underwrite program costs, provide financial incentivizes to providers, and develop a platform for collaboration. Large insurers are the most likely group to have the financial resources and widespread network to develop such programs, but that does not mean that they would be willing to experiment with this approach. This may especially be the case if cost savings and measurable improvements in quality are not immediate. Even though the results of collaboration‐based efforts have been promising, the implementation of these programs has been limited, and adoption in different contexts may not yield the same results. Collaboration‐based programs that have already shown success can serve as models, but they may need significant adaptations to meet the needs of providers in a given area.

Despite its promise, collaboration‐based strategies alone will not be enough to improve certain aspects of quality and value. Although providing physicians with knowledge on how to reduce unnecessary care, for example, could help limit overutilization, it is not sufficient to overcome the incentives of fee‐for‐service payment. In this case, broader payment reform and population‐based accountability can be paired with programs to encourage collaboration. For instance, the Blue Cross and Blue Shield of Massachusetts' Alternative Contract has used a combination of technical assistance, shared savings, and large quality bonuses to improve quality and reduce medical spending growth.[12] Collaboration‐based strategies should be seen as a complement to these broad, thoughtful reforms and a substitute for narrow incentives that encourage myopia and destructive competition.

Evidence from education and healthcare shows that penalizing the worst and rewarding the best will not shift the bell curve of performance. Such approaches are more likely to entrench and expand disparities. Instead, policy should encourage and incentivize collaboration to expand best practices that improve patient outcomes. Lessons from education provide both cautionary tales and novel solutions that might improve healthcare.

Disclosure: Nothing to report.

We believe that patients, families, and other stakeholders can provide meaningful contributions throughout the research process. Involvement of a diverse group of stakeholders is also encouraged by the Patient Centered Outcomes Research Institute (PCORI), which emphasizes research focused on patient‐ and family‐centered outcomes.[1] Patient and family engagement in healthcare, however, has generally focused on children and adults with chronic conditions.[1, 2] Engagement of families of children with serious acute illnesses is infrequent, and no studies have documented the feasibility or acceptability of different methods of family engagement.[3] Furthermore, stakeholders, such as nurses, may participate in study execution but rarely receive opportunities to inform the research process. In this Perspective, we describe our experiences with family engagement using a novel approach of serial, focused, short‐term engagement of stakeholders.

PRESTUDY WORK

In 2012, our institution introduced a nurse‐led transitional home‐visit program, an approach associated with reduced healthcare utilization in adults.[4] Patients hospitalized for acute illness received a 1‐time transitional home visit 24 to 72 hours after hospital discharge. We formed a multidisciplinary team, consisting of physicians, nurse scientists, home healthcare (HHC) nursing staff, patient families, and research staff to design a mixed‐methods study of the transitional home visit, which was funded by PCORI in 2014. This study, the Hospital‐to‐Home Outcomes (H2O) study, has 3 aims: (1) identify barriers to successful transitions home and outcomes of such transitions that are meaningful to families, (2) optimize the transitional home visits to address family‐identified barriers and outcomes, and (3) determine the efficacy of transitional home visits through a randomized control trial.

Two parents joined the study team during study development. Both had children hospitalized for acute illnesses, received a transitional home visit, and participated in a pilot focus group to provide insight into barriers families encounter during care transitions. These parents made valuable contributions, including recommending strategies for patient enrollment and retention. They also committed to participating in regularly scheduled study meetings and ad hoc discussions. However, feedback from the pilot focus group also highlighted a potential research engagement challenge; specifically, once the acute illness resolved, many families were primarily focused on the return to their normal routine and may not be easily engaged in research.

Based on family input, we included several mechanisms to engage caregivers of children with acute illness in the study design of H2O. Each design element allowed families and other stakeholders to contribute via short‐term focused approaches (eg, focus groups, phone surveys). These short‐term interactions drove iterative changes in study processes and approaches, including how to measure outcomes important to families. Rather than a small group of stakeholders making a series of recommendations over a long period of time, we had dozens of individual stakeholders make a few recommendations apiece that were quickly implemented and subsequently tested via feedback from the next few stakeholders (Figure 1).

Figure 1

PATIENT AND STAKEHOLDER ENGAGEMENT IN THE H2O STUDY

Having the short‐term, focused engagement strategy built into the study proved beneficial, when the 2 parents who were part of the initial design team and had planned to participate longitudinally were no longer able to participate. Over time, their circumstances changed. One parent moved out of the area to pursue a professional opportunity, and the second parent became increasingly difficult to reach and unable to join planned study meetings, a situation anticipated by the pilot focus group participants. These 2 instances illustrate challenges with long‐term engagement of families in research when the potential primary driver of their engagement, their child's acute illness, has resolved.

Short‐Term Focused Engagement Via Phone Calls With Parents/Caregivers

To continuously improve study processes and the transitional home visit during the second aim of H2O, we relied on short‐term focused engagement from 2 stakeholder groups, families and field nurses. We completed 107 phone calls with families who received a transitional home visit during the visit optimization period. These calls, completed 3 to 7 days after the visit, assessed parental perceptions of the effect of recent visit modifications through a standardized survey documented in an electronic database. These data were utilized in plan‐do‐study‐act cycles,[5] every 1 to 2 weeks, to determine if additional modifications to the visits were necessary. A cycle ended when the calls no longer provided new information. The questions asked on the calls also changed over time as different interventions were tested.

As an example, in aim 1, families highlighted the lack of clarity of discharge instructions, particularly regarding when and why to return for medical care. Thus, we developed condition‐specific red flag reminder cards to be shared at transitional home visits to help families remember and recognize concerning signs and symptoms and understand when additional evaluation may be warranted (Figure 2). Families in postvisit calls endorsed the concept of red flags, but sometimes preferred electronic rather than paper versions of the red flag cards to facilitate sharing with family members. Thus, we tested and refined texting the red flag information to families. Subsequent calls strongly supported this practice, so we will continue to use it during the third aim, the randomized trial of the transitional home visit.

Figure 2

The remaining calls (N=72) were completed 14 days after the visit to mirror the time frame for follow‐up calls in the planned randomized trial. These calls allowed us to test measurement of family‐identified outcomes and determine their usability in the trial. We used family feedback to shorten the survey and reorder questions. We also used feedback from these calls to develop an optimal call‐back strategy to maximize family contacts.

ONGOING H2O WORK AND CONCLUSION

The third aim, with ongoing patient enrollment, involves a randomized trial to determine the efficacy of the revised transitional home visit compared with standard of care as measured by subsequent healthcare utilization and outcomes suggested in aim 1 and refined during aim 2, such as parental coping, stress, and confidence in care. We have engaged 1 parent to provide longitudinal feedback during regularly scheduled meetings.

We believe that our short‐term, focused engagement strategies have allowed integration of the invaluable perspective of families and other stakeholders into our research questions, intervention design, outcome measurement, and study execution. Our approach combined short‐term engagement from many stakeholders, blending qualitative techniques with rapid‐cycle implementation methods to quickly react to stakeholder input. Given the challenge of sustaining longitudinal engagement of families in research focused on acute care questions, and the tendency for many families interested in such engagement to be well versed in the care system due to chronic conditions, we propose this short‐term focused approach to include the unique viewpoints of families and patients whose care experience is confined to an acute period. Similarly, we propose that such an approach can efficiently include and rapidly react to input from other hard‐to‐engage key stakeholders such as field nurses.

We believe that patients, families, and other stakeholders can provide meaningful contributions throughout the research process. Involvement of a diverse group of stakeholders is also encouraged by the Patient Centered Outcomes Research Institute (PCORI), which emphasizes research focused on patient‐ and family‐centered outcomes.[1] Patient and family engagement in healthcare, however, has generally focused on children and adults with chronic conditions.[1, 2] Engagement of families of children with serious acute illnesses is infrequent, and no studies have documented the feasibility or acceptability of different methods of family engagement.[3] Furthermore, stakeholders, such as nurses, may participate in study execution but rarely receive opportunities to inform the research process. In this Perspective, we describe our experiences with family engagement using a novel approach of serial, focused, short‐term engagement of stakeholders.

PRESTUDY WORK

In 2012, our institution introduced a nurse‐led transitional home‐visit program, an approach associated with reduced healthcare utilization in adults.[4] Patients hospitalized for acute illness received a 1‐time transitional home visit 24 to 72 hours after hospital discharge. We formed a multidisciplinary team, consisting of physicians, nurse scientists, home healthcare (HHC) nursing staff, patient families, and research staff to design a mixed‐methods study of the transitional home visit, which was funded by PCORI in 2014. This study, the Hospital‐to‐Home Outcomes (H2O) study, has 3 aims: (1) identify barriers to successful transitions home and outcomes of such transitions that are meaningful to families, (2) optimize the transitional home visits to address family‐identified barriers and outcomes, and (3) determine the efficacy of transitional home visits through a randomized control trial.

Two parents joined the study team during study development. Both had children hospitalized for acute illnesses, received a transitional home visit, and participated in a pilot focus group to provide insight into barriers families encounter during care transitions. These parents made valuable contributions, including recommending strategies for patient enrollment and retention. They also committed to participating in regularly scheduled study meetings and ad hoc discussions. However, feedback from the pilot focus group also highlighted a potential research engagement challenge; specifically, once the acute illness resolved, many families were primarily focused on the return to their normal routine and may not be easily engaged in research.

Based on family input, we included several mechanisms to engage caregivers of children with acute illness in the study design of H2O. Each design element allowed families and other stakeholders to contribute via short‐term focused approaches (eg, focus groups, phone surveys). These short‐term interactions drove iterative changes in study processes and approaches, including how to measure outcomes important to families. Rather than a small group of stakeholders making a series of recommendations over a long period of time, we had dozens of individual stakeholders make a few recommendations apiece that were quickly implemented and subsequently tested via feedback from the next few stakeholders (Figure 1).

Figure 1

PATIENT AND STAKEHOLDER ENGAGEMENT IN THE H2O STUDY

Having the short‐term, focused engagement strategy built into the study proved beneficial, when the 2 parents who were part of the initial design team and had planned to participate longitudinally were no longer able to participate. Over time, their circumstances changed. One parent moved out of the area to pursue a professional opportunity, and the second parent became increasingly difficult to reach and unable to join planned study meetings, a situation anticipated by the pilot focus group participants. These 2 instances illustrate challenges with long‐term engagement of families in research when the potential primary driver of their engagement, their child's acute illness, has resolved.

Short‐Term Focused Engagement Via Phone Calls With Parents/Caregivers

To continuously improve study processes and the transitional home visit during the second aim of H2O, we relied on short‐term focused engagement from 2 stakeholder groups, families and field nurses. We completed 107 phone calls with families who received a transitional home visit during the visit optimization period. These calls, completed 3 to 7 days after the visit, assessed parental perceptions of the effect of recent visit modifications through a standardized survey documented in an electronic database. These data were utilized in plan‐do‐study‐act cycles,[5] every 1 to 2 weeks, to determine if additional modifications to the visits were necessary. A cycle ended when the calls no longer provided new information. The questions asked on the calls also changed over time as different interventions were tested.

As an example, in aim 1, families highlighted the lack of clarity of discharge instructions, particularly regarding when and why to return for medical care. Thus, we developed condition‐specific red flag reminder cards to be shared at transitional home visits to help families remember and recognize concerning signs and symptoms and understand when additional evaluation may be warranted (Figure 2). Families in postvisit calls endorsed the concept of red flags, but sometimes preferred electronic rather than paper versions of the red flag cards to facilitate sharing with family members. Thus, we tested and refined texting the red flag information to families. Subsequent calls strongly supported this practice, so we will continue to use it during the third aim, the randomized trial of the transitional home visit.

Figure 2

The remaining calls (N=72) were completed 14 days after the visit to mirror the time frame for follow‐up calls in the planned randomized trial. These calls allowed us to test measurement of family‐identified outcomes and determine their usability in the trial. We used family feedback to shorten the survey and reorder questions. We also used feedback from these calls to develop an optimal call‐back strategy to maximize family contacts.

ONGOING H2O WORK AND CONCLUSION

The third aim, with ongoing patient enrollment, involves a randomized trial to determine the efficacy of the revised transitional home visit compared with standard of care as measured by subsequent healthcare utilization and outcomes suggested in aim 1 and refined during aim 2, such as parental coping, stress, and confidence in care. We have engaged 1 parent to provide longitudinal feedback during regularly scheduled meetings.

We believe that our short‐term, focused engagement strategies have allowed integration of the invaluable perspective of families and other stakeholders into our research questions, intervention design, outcome measurement, and study execution. Our approach combined short‐term engagement from many stakeholders, blending qualitative techniques with rapid‐cycle implementation methods to quickly react to stakeholder input. Given the challenge of sustaining longitudinal engagement of families in research focused on acute care questions, and the tendency for many families interested in such engagement to be well versed in the care system due to chronic conditions, we propose this short‐term focused approach to include the unique viewpoints of families and patients whose care experience is confined to an acute period. Similarly, we propose that such an approach can efficiently include and rapidly react to input from other hard‐to‐engage key stakeholders such as field nurses.

We believe that patients, families, and other stakeholders can provide meaningful contributions throughout the research process. Involvement of a diverse group of stakeholders is also encouraged by the Patient Centered Outcomes Research Institute (PCORI), which emphasizes research focused on patient‐ and family‐centered outcomes.[1] Patient and family engagement in healthcare, however, has generally focused on children and adults with chronic conditions.[1, 2] Engagement of families of children with serious acute illnesses is infrequent, and no studies have documented the feasibility or acceptability of different methods of family engagement.[3] Furthermore, stakeholders, such as nurses, may participate in study execution but rarely receive opportunities to inform the research process. In this Perspective, we describe our experiences with family engagement using a novel approach of serial, focused, short‐term engagement of stakeholders.

PRESTUDY WORK

In 2012, our institution introduced a nurse‐led transitional home‐visit program, an approach associated with reduced healthcare utilization in adults.[4] Patients hospitalized for acute illness received a 1‐time transitional home visit 24 to 72 hours after hospital discharge. We formed a multidisciplinary team, consisting of physicians, nurse scientists, home healthcare (HHC) nursing staff, patient families, and research staff to design a mixed‐methods study of the transitional home visit, which was funded by PCORI in 2014. This study, the Hospital‐to‐Home Outcomes (H2O) study, has 3 aims: (1) identify barriers to successful transitions home and outcomes of such transitions that are meaningful to families, (2) optimize the transitional home visits to address family‐identified barriers and outcomes, and (3) determine the efficacy of transitional home visits through a randomized control trial.

Two parents joined the study team during study development. Both had children hospitalized for acute illnesses, received a transitional home visit, and participated in a pilot focus group to provide insight into barriers families encounter during care transitions. These parents made valuable contributions, including recommending strategies for patient enrollment and retention. They also committed to participating in regularly scheduled study meetings and ad hoc discussions. However, feedback from the pilot focus group also highlighted a potential research engagement challenge; specifically, once the acute illness resolved, many families were primarily focused on the return to their normal routine and may not be easily engaged in research.

Based on family input, we included several mechanisms to engage caregivers of children with acute illness in the study design of H2O. Each design element allowed families and other stakeholders to contribute via short‐term focused approaches (eg, focus groups, phone surveys). These short‐term interactions drove iterative changes in study processes and approaches, including how to measure outcomes important to families. Rather than a small group of stakeholders making a series of recommendations over a long period of time, we had dozens of individual stakeholders make a few recommendations apiece that were quickly implemented and subsequently tested via feedback from the next few stakeholders (Figure 1).

Figure 1

PATIENT AND STAKEHOLDER ENGAGEMENT IN THE H2O STUDY

Having the short‐term, focused engagement strategy built into the study proved beneficial, when the 2 parents who were part of the initial design team and had planned to participate longitudinally were no longer able to participate. Over time, their circumstances changed. One parent moved out of the area to pursue a professional opportunity, and the second parent became increasingly difficult to reach and unable to join planned study meetings, a situation anticipated by the pilot focus group participants. These 2 instances illustrate challenges with long‐term engagement of families in research when the potential primary driver of their engagement, their child's acute illness, has resolved.

Short‐Term Focused Engagement Via Phone Calls With Parents/Caregivers

To continuously improve study processes and the transitional home visit during the second aim of H2O, we relied on short‐term focused engagement from 2 stakeholder groups, families and field nurses. We completed 107 phone calls with families who received a transitional home visit during the visit optimization period. These calls, completed 3 to 7 days after the visit, assessed parental perceptions of the effect of recent visit modifications through a standardized survey documented in an electronic database. These data were utilized in plan‐do‐study‐act cycles,[5] every 1 to 2 weeks, to determine if additional modifications to the visits were necessary. A cycle ended when the calls no longer provided new information. The questions asked on the calls also changed over time as different interventions were tested.

As an example, in aim 1, families highlighted the lack of clarity of discharge instructions, particularly regarding when and why to return for medical care. Thus, we developed condition‐specific red flag reminder cards to be shared at transitional home visits to help families remember and recognize concerning signs and symptoms and understand when additional evaluation may be warranted (Figure 2). Families in postvisit calls endorsed the concept of red flags, but sometimes preferred electronic rather than paper versions of the red flag cards to facilitate sharing with family members. Thus, we tested and refined texting the red flag information to families. Subsequent calls strongly supported this practice, so we will continue to use it during the third aim, the randomized trial of the transitional home visit.

Figure 2

The remaining calls (N=72) were completed 14 days after the visit to mirror the time frame for follow‐up calls in the planned randomized trial. These calls allowed us to test measurement of family‐identified outcomes and determine their usability in the trial. We used family feedback to shorten the survey and reorder questions. We also used feedback from these calls to develop an optimal call‐back strategy to maximize family contacts.

ONGOING H2O WORK AND CONCLUSION

The third aim, with ongoing patient enrollment, involves a randomized trial to determine the efficacy of the revised transitional home visit compared with standard of care as measured by subsequent healthcare utilization and outcomes suggested in aim 1 and refined during aim 2, such as parental coping, stress, and confidence in care. We have engaged 1 parent to provide longitudinal feedback during regularly scheduled meetings.

We believe that our short‐term, focused engagement strategies have allowed integration of the invaluable perspective of families and other stakeholders into our research questions, intervention design, outcome measurement, and study execution. Our approach combined short‐term engagement from many stakeholders, blending qualitative techniques with rapid‐cycle implementation methods to quickly react to stakeholder input. Given the challenge of sustaining longitudinal engagement of families in research focused on acute care questions, and the tendency for many families interested in such engagement to be well versed in the care system due to chronic conditions, we propose this short‐term focused approach to include the unique viewpoints of families and patients whose care experience is confined to an acute period. Similarly, we propose that such an approach can efficiently include and rapidly react to input from other hard‐to‐engage key stakeholders such as field nurses.

Hospitalists have a professional obligation to provide the highest quality care for patients and increasingly, hospitalists lead programs to improve quality, value, and patient experience.[1, 2, 3]

The federal government introduced the hospital Value‐Based Purchasing (VBP) program in 2012, initially with 1% of Medicare hospital payments tied to quality indicators. This percentage will continue to grow and the VBP program has expanded to include metrics related to quality, safety, cost‐effectiveness, and patient satisfaction.[4] Hospitals now face significant financial penalties if they do not achieve these benchmarks; thus, remaining up‐to‐date with the literature and the most promising interventions in these arenas is vital for hospitalists.

The goal of this update is to summarize and critique recently published research that has the greatest potential to impact clinical practice in quality, value, and patient experience in hospital medicine. We reviewed articles published between January 2014 and February 2015. To identify articles, we hand‐searched leading journals, continuing medical education collaborative journal reviews (including New England Journal of Medicine Journal Watch and the American College of Physicians Journal Club), the Agency for Healthcare Research and Quality's Patient Safety network, and PubMed. We evaluated articles based on their scientific rigor (peer review, study methodology, site number, and sample size) and applicability to hospital medicine. In this review, we summarize 9 articles that were felt by the authors to have the highest potential for impact on the clinical practice of hospital medicine, as directly related to quality, value, or patient experience. We present each topic with a current quality question that the accompanying article(s) will help address. We summarize each article and its findings and note cautions and implications for practice. The selected articles cover aspects related to patient safety, readmissions, patient satisfaction, and resource utilization, with each of these topics related to specific metrics included in VBP. We presented this update at the 2015 Society of Hospital Medicine national meeting.

IS THERE ANYTHING WE CAN DO TO MAKE HANDOFFS SAFER?

Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):18031812.

WHAT ARE THE COMMON FEATURES OF INTERVENTIONS THAT HAVE SUCCESSFULLY REDUCED READMISSIONS?

Leppin AL, Glonfriddo MR, Kessler M, et al. Preventing 30‐day hospital readmissions: a systematic review and meta‐analysis of randomized trials. JAMA Intern Med. 2014;174(7):10951107.

DOES PATIENT ACTIVATION CORRELATE WITH DECREASED RESOURCE USE OR READMISSIONS?

Mitchell SE, Gardiner PM, Sadikova E, et al. Patient activation and 30‐day post discharge hospital utilization. J Gen Intern Med. 2014;29(2):349355.

IS THERE A RELATIONSHIP BETWEEN PATIENT SATISFACTION AND UNDERSTANDING OF THE PLAN OF CARE?

Kebede S, Shihab HM, Berger ZD, et al. Patients' understanding of their hospitalizations and association with satisfaction. JAMA Intern Med. 2014;174(10):16981700.

WHAT ARE UNIVERSAL STRATEGIES TO IMPROVE SATISFACTION AND PATIENT OUTCOMES?

Detsky AS, Krumholz HM. Reducing the trauma of hospitalization. JAMA. 2014;311(21):21692170.

DO HOSPITALISTS OVERTEST, AND IF SO, WHY?

Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100108.

DO UNREALISTIC PATIENT EXPECTATIONS ABOUT INTERVENTIONS INFLUENCE DECISION MAKING AND CONTRIBUTE TO OVERUSE?

Hoffmann TC, Del Mar C. Patient expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274286.

HOW BIG OF A PROBLEM IS ANTIBIOTIC OVERUSE IN HOSPITALS AND CAN WE DO BETTER?

Fridkin S, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep. 2014;63(9):194200.

Hospitalists have a professional obligation to provide the highest quality care for patients and increasingly, hospitalists lead programs to improve quality, value, and patient experience.[1, 2, 3]

The federal government introduced the hospital Value‐Based Purchasing (VBP) program in 2012, initially with 1% of Medicare hospital payments tied to quality indicators. This percentage will continue to grow and the VBP program has expanded to include metrics related to quality, safety, cost‐effectiveness, and patient satisfaction.[4] Hospitals now face significant financial penalties if they do not achieve these benchmarks; thus, remaining up‐to‐date with the literature and the most promising interventions in these arenas is vital for hospitalists.

The goal of this update is to summarize and critique recently published research that has the greatest potential to impact clinical practice in quality, value, and patient experience in hospital medicine. We reviewed articles published between January 2014 and February 2015. To identify articles, we hand‐searched leading journals, continuing medical education collaborative journal reviews (including New England Journal of Medicine Journal Watch and the American College of Physicians Journal Club), the Agency for Healthcare Research and Quality's Patient Safety network, and PubMed. We evaluated articles based on their scientific rigor (peer review, study methodology, site number, and sample size) and applicability to hospital medicine. In this review, we summarize 9 articles that were felt by the authors to have the highest potential for impact on the clinical practice of hospital medicine, as directly related to quality, value, or patient experience. We present each topic with a current quality question that the accompanying article(s) will help address. We summarize each article and its findings and note cautions and implications for practice. The selected articles cover aspects related to patient safety, readmissions, patient satisfaction, and resource utilization, with each of these topics related to specific metrics included in VBP. We presented this update at the 2015 Society of Hospital Medicine national meeting.

IS THERE ANYTHING WE CAN DO TO MAKE HANDOFFS SAFER?

Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):18031812.

WHAT ARE THE COMMON FEATURES OF INTERVENTIONS THAT HAVE SUCCESSFULLY REDUCED READMISSIONS?

Leppin AL, Glonfriddo MR, Kessler M, et al. Preventing 30‐day hospital readmissions: a systematic review and meta‐analysis of randomized trials. JAMA Intern Med. 2014;174(7):10951107.

DOES PATIENT ACTIVATION CORRELATE WITH DECREASED RESOURCE USE OR READMISSIONS?

Mitchell SE, Gardiner PM, Sadikova E, et al. Patient activation and 30‐day post discharge hospital utilization. J Gen Intern Med. 2014;29(2):349355.

IS THERE A RELATIONSHIP BETWEEN PATIENT SATISFACTION AND UNDERSTANDING OF THE PLAN OF CARE?

Kebede S, Shihab HM, Berger ZD, et al. Patients' understanding of their hospitalizations and association with satisfaction. JAMA Intern Med. 2014;174(10):16981700.

WHAT ARE UNIVERSAL STRATEGIES TO IMPROVE SATISFACTION AND PATIENT OUTCOMES?

Detsky AS, Krumholz HM. Reducing the trauma of hospitalization. JAMA. 2014;311(21):21692170.

DO HOSPITALISTS OVERTEST, AND IF SO, WHY?

Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100108.

DO UNREALISTIC PATIENT EXPECTATIONS ABOUT INTERVENTIONS INFLUENCE DECISION MAKING AND CONTRIBUTE TO OVERUSE?

Hoffmann TC, Del Mar C. Patient expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274286.

HOW BIG OF A PROBLEM IS ANTIBIOTIC OVERUSE IN HOSPITALS AND CAN WE DO BETTER?

Fridkin S, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep. 2014;63(9):194200.

Hospitalists have a professional obligation to provide the highest quality care for patients and increasingly, hospitalists lead programs to improve quality, value, and patient experience.[1, 2, 3]

The federal government introduced the hospital Value‐Based Purchasing (VBP) program in 2012, initially with 1% of Medicare hospital payments tied to quality indicators. This percentage will continue to grow and the VBP program has expanded to include metrics related to quality, safety, cost‐effectiveness, and patient satisfaction.[4] Hospitals now face significant financial penalties if they do not achieve these benchmarks; thus, remaining up‐to‐date with the literature and the most promising interventions in these arenas is vital for hospitalists.

The goal of this update is to summarize and critique recently published research that has the greatest potential to impact clinical practice in quality, value, and patient experience in hospital medicine. We reviewed articles published between January 2014 and February 2015. To identify articles, we hand‐searched leading journals, continuing medical education collaborative journal reviews (including New England Journal of Medicine Journal Watch and the American College of Physicians Journal Club), the Agency for Healthcare Research and Quality's Patient Safety network, and PubMed. We evaluated articles based on their scientific rigor (peer review, study methodology, site number, and sample size) and applicability to hospital medicine. In this review, we summarize 9 articles that were felt by the authors to have the highest potential for impact on the clinical practice of hospital medicine, as directly related to quality, value, or patient experience. We present each topic with a current quality question that the accompanying article(s) will help address. We summarize each article and its findings and note cautions and implications for practice. The selected articles cover aspects related to patient safety, readmissions, patient satisfaction, and resource utilization, with each of these topics related to specific metrics included in VBP. We presented this update at the 2015 Society of Hospital Medicine national meeting.

IS THERE ANYTHING WE CAN DO TO MAKE HANDOFFS SAFER?

Starmer AJ, Spector ND, Srivastava R, et al. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014;371(19):18031812.

WHAT ARE THE COMMON FEATURES OF INTERVENTIONS THAT HAVE SUCCESSFULLY REDUCED READMISSIONS?

Leppin AL, Glonfriddo MR, Kessler M, et al. Preventing 30‐day hospital readmissions: a systematic review and meta‐analysis of randomized trials. JAMA Intern Med. 2014;174(7):10951107.

DOES PATIENT ACTIVATION CORRELATE WITH DECREASED RESOURCE USE OR READMISSIONS?

Mitchell SE, Gardiner PM, Sadikova E, et al. Patient activation and 30‐day post discharge hospital utilization. J Gen Intern Med. 2014;29(2):349355.

IS THERE A RELATIONSHIP BETWEEN PATIENT SATISFACTION AND UNDERSTANDING OF THE PLAN OF CARE?

Kebede S, Shihab HM, Berger ZD, et al. Patients' understanding of their hospitalizations and association with satisfaction. JAMA Intern Med. 2014;174(10):16981700.

WHAT ARE UNIVERSAL STRATEGIES TO IMPROVE SATISFACTION AND PATIENT OUTCOMES?

Detsky AS, Krumholz HM. Reducing the trauma of hospitalization. JAMA. 2014;311(21):21692170.

DO HOSPITALISTS OVERTEST, AND IF SO, WHY?

Kachalia A, Berg A, Fagerlin A, et al. Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists. Ann Intern Med. 2015;162(2):100108.

DO UNREALISTIC PATIENT EXPECTATIONS ABOUT INTERVENTIONS INFLUENCE DECISION MAKING AND CONTRIBUTE TO OVERUSE?

Hoffmann TC, Del Mar C. Patient expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med. 2015;175(2):274286.

HOW BIG OF A PROBLEM IS ANTIBIOTIC OVERUSE IN HOSPITALS AND CAN WE DO BETTER?

Fridkin S, Baggs J, Fagan R, et al. Vital signs: improving antibiotic use among hospitalized patients. MMWR Morb Mortal Wkly Rep. 2014;63(9):194200.

Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.

To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.

INNOVATION

SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.

SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.

In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.

Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.

PRELIMINARY FINDINGS

The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).

Figure 1

To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.

SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.

Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.

CONCLUSION

SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.

Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.

It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.

Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.

To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.

INNOVATION

SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.

SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.

In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.

Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.

PRELIMINARY FINDINGS

The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).

Figure 1

To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.

SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.

Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.

CONCLUSION

SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.

Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.

It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.

Today's medical students will enter practice over the next decade and inherit the escalating costs of the US healthcare system. Approximately 30% of healthcare costs, or $750 billion dollars annually, are spent on unnecessary tests or procedures.[1] High healthcare costs combined with calls to eliminate waste, improve patient safety, and increase quality[2] are driving our healthcare system to evolve from a fee‐based system to a value‐based system. Additionally, many patients are being harmed by overtesting and the stress associated with rising healthcare bills. Financial risk has increasingly shifted to patients in the form of higher deductibles and reduced caps, and medical indebtedness is the number 1 risk for bankruptcy.[3, 4] False positive results of low‐yield diagnostic tests lead to additional testing, anxiety, excess radiation exposure, and unnecessary invasive procedures.[5] To minimize harm to patients, evidence must guide physicians in their ordering behavior. In addition, any care plan a physician develops should be individualized to incorporate patients' values and preferences. Unfortunately, medical students, who are at an impressionable stage in their careers, frequently observe overtesting and unnecessary treatment behaviors in their clinical encounters.[6] Instead, our medical students and trainees must be prepared to deliver patient care that is evidence based, patient centered, and cost conscious. They must become effective stewards of limited healthcare resources.

To help prepare our students for this evolving healthcare paradigm, we created a new tool called SOAP‐V (Subjective‐Objective‐Assessment‐PlanValue), designed to embed discussion of healthcare value into medical student oral presentations and note writing. Students are encouraged to use this tool at the point of care to bring up value concepts with physicians and residents as part of medical decision making. In so doing, we propose that medical students can serve as change agents to shift physician practice at our academic medical centers to focus on healthcare value. This article describes the SOAP‐V tool, contains links to educational materials to help hospitalists and other clinician educators to implement this tool, and provides preliminary findings and reflections.

INNOVATION

SOAP‐V was conceived at the Millennium Conference on Teaching High‐Value Care, which was sponsored by the Beth Israel Deaconess Medical Center Shapiro Institute for Education and Research, the Association of American Medical Colleges, and the American College of Physicians. Educators from several medical schools decided to form a group to specifically consider ways to train medical students and residents in the concept of high‐value care (HVC), which is framed as improving patient outcomes while decreasing patient cost and harm.[7] Our group recognized several challenges in teaching HVC. First, physician practice habits are influenced by the way they are trained,[8] yet faculty who teach those future physicians frequently have not themselves been taught, nor do they consistently practice HVC.[9] Second, we needed to teach students the requisite HVC knowledge, attitudes, and skills, and therefore wanted to provide opportunities to not only learn, but practice, HVC, preferably in authentic patient experiences to optimize their learning.[10, 11] Third, we recognized that adding another teaching task to the already oversubscribed day of an attending might understandably be met with resistance. We envisioned a tool that could be used with minimal or no faculty training, could be attached to authentic patient experiences, and based on LEAN‐Six Sigma principles,[12] would be embedded in the normal workflow. Furthermore, we considered social networking principles, such as those described by Christakis and Fowler that describe how an individual's behavior impacts behaviors of those surrounding them,[13] and hoped to empower medical students to serve as change agents. Medical students could initiate discussions of value concepts at the point of care in a way that challenges a heavily entrenched test‐ordering culture and encourages other members of the team to balance potential benefit with harms and cost. Following the conference, the group held bimonthly phone conferences and subsequently developed the SOAP‐V tool, created teaching materials, and planned a research project on SOAP‐V.

SOAP‐V modifies the traditional SOAP (Subjective‐Objective‐Assessment‐Plan) oral presentation or medical note, to include value (V). It serves as a cognitive forcing function designed to create a pause and promote discussions of HVC during patient delivery. It prompts the student to ask 3 value questions: (1) Before choosing an intervention, have I considered whether the result would change management? (2) Have I incorporated the patient's goals and values, and considered the potential harm of the intervention compared to alternatives? (3) What is the known and potential cost of the intervention, both immediate and downstream? The student gathers information during the patient interview and brings back the information to the team during rounds where management decisions are made.

In the summer of 2014, we launched an institutional review boardapproved, multi‐institutional study to implement SOAP‐V at Penn State College of Medicine, Harvard Medical School, and Case Western Reserve University School of Medicine for third‐year medical students during their internal medicine clerkships. Students in the intervention arm participated in an interactive workshop on SOAP‐V. Authors S.F., S.G., and C.D.P., who serve as clerkship directors in internal medicine, provided student training for each cohort of intervention students at the beginning of each rotation on general medicine inpatient wards. The workshop began with trigger videos that demonstrate pressures encountered by a student on rounds that might lead to overuse.[14] Following a discussion on overuse and methods to avoid overuse, the students were introduced to the SOAP‐V framework, watched a video of a student modeling a SOAP‐V presentation on rounds,[15] and engaged in a SOAP‐V role play. They received a SOAP‐V pocket card as well as a Web link to Healthcare Bluebook[16] to research costs. An outline of the session and associated materials can be found in an online attachment.[17] The students then used the SOAP‐V tool during inpatient rounds. We advised supervising faculty that students might present using a SOAP‐V format, and provided them with a SOAP‐V card, but we did not provide faculty development on SOAP‐V. Students participating in the control arm did not receive training specific to SOAP‐V.

Students in intervention and control arms at each school were surveyed on their attitudes toward HVC at the beginning of the clerkship year and then again at the completion of the medicine clerkship via a 19‐item questionnaire soliciting perceptions and self‐reported practices in HVC. Intervention arm students received biweekly e‐mail links that allowed them to anonymously document their use of SOAP‐V, as well as an end‐of‐clerkship open‐ended question about the usefulness of SOAP‐V. We analyzed questionnaire results using McNemar's test for paired data.

PRELIMINARY FINDINGS

The preintervention attitudinal survey (n = 226) demonstrated that although 90% of medical students agreed on the importance of considering costs of treatments, only 50% felt comfortable bringing up cost considerations with their team, and 50% considered costs to the healthcare system in clinical decisions. An interim analysis of the available data at 6 months (response rate approximately 50% across sites) showed that students in the intervention arm reported increased agreement with the phrases, I have the power to address the economic healthcare crisis (pre‐37%, post‐65%, P = 0.046); I would be comfortable initiating a discussion about unnecessary tests or treatments with my team, (pre‐46%, post‐85%, P = 0.027); and In my clinical decisions, I consider the potential costs to the healthcare system (pre‐41%, post‐60%, P = 0.023) compared to control arm students, who showed no significant differences pre‐ versus postrotation in these 3 domains (Figure 1).

Figure 1

To date, biweekly surveys and direct observation of rounds have verified student use of SOAP‐V. Student comments have included: Allowed me the ability to raise important issues with the team while feeling like I was helping my patients and the healthcare system. A great principle that I used almost daily. Great to implement this at such a young stage in my med career. Broadened my perspective on the role of a physician.

SOAP‐V has inspired some of our medical students to consider value in healthcare more closely. In a notable example, a SOAP‐Vtrained student admitted a young man with lymphadenopathy, pulmonary infiltrates, and weight loss who underwent an extensive and costly workup including liver biopsy, bronchoscopy, and multiple computed tomography and positron emission tomography scans and was eventually diagnosed with sarcoidosis. The SOAP‐Vtrained student reviewed the patient's workup, estimated that the team spent more than $6000 to make the diagnosis, and recommended a more cost‐effective approach.

Common barriers experienced by the pilot sites included time constraints limiting discussion of value, variability in perceived receptivity depending on team leadership, and student confidence in initiating this dialogue. Solutions included underscoring the notion that value discussions can be brief, may be appropriately initiated by any member of the team, and may have an effect on choice of management and/or patient preference issues that can make medical care more efficient and effective. Resident and faculty physicians were made aware of the intervention, and encouraged to support students in using the SOAP‐V tool.

CONCLUSION

SOAP‐V was successfully implemented within the inpatient internal medicine clerkship at 3 academic institutions. Our preliminary results demonstrate that students can use this framework to apply considerations of high‐value, cost‐conscious care in their medical decision making and to promote discussion of these concepts during rounds with their inpatient teams. Students in the intervention arm report greater comfort discussing unnecessary tests and treatments with their team and a greater likelihood to consider potential costs to the healthcare system. Additionally, these students commented that the SOAP‐V framework broadened their perspective on their role as a physician in curbing costs, and that they felt more empowered to address the economic healthcare crisis. The next phase of our project will involve conducting end‐of‐year surveys to evaluate whether SOAP‐V has a persistent impact on the frequency and quality of value discussions on rounds, as well as students' attitudes about cost consciousness. We will also gauge whether resident and faculty attitudes about HVC have changed as a result of the intervention.

Our SOAP‐V student training was provided in a 1‐hour session. We believe that the ease of training and the simplicity of the SOAP‐V framework permit SOAP‐V to be easily transferred for use by residents, medical students in other clerkships, and other healthcare learners. Additional research is needed to demonstrate this expanded use and prove sustainability. An additional important question is whether use of SOAP‐V by students and residents results in reductions in unnecessary costs. Future educational efforts will include embedding the SOAP‐V tool in other clerkships and promoting the SOAP‐V tool within corresponding residencies in both hospital and outpatient clinic settings and analyzing potential reductions in wasteful spending.

It is generally conceived that medical students learn the information they are taught, and are impacted by the culture in which they reside; multiple studies bear this out.[18, 19] However, students may also be change agents. Our students will inherit the healthcare systems of the future. We must empower them to change the status quo. There can be tremendous utility in employing such a bottom up approach to process improvement. What a student discusses today may spark the resident (or faculty) to consider in their own workflow tomorrow. In this way, we envision that the SOAP‐V is a tool by which ideas concerning HVC can be generated and shared at the point of care. It is our hope that this straightforward intervention is one that may slowly change the culture and perhaps eventually the practice patterns of our academic medical centers.