New CDC research published in the June issue of Infection Control and Hospital Epidemiology estimates that as many as 200,000 central-line-associated bloodstream infections (CLABSIs) in ICUs nationally have been prevented since 1990.³ The report indicates much of the success is due to U.S. hospitals adopting successful prevention strategies, namely the dissemination of guideline-supported central-line insertion and maintenance best practices, infection-control treatment bundles, and widespread availability of alcohol-based hand rubs.

Between 462,000 and 636,000 CLABSIs occurred in non-neonatal ICU patients from 1990-2010, CDC estimates, about 104,000 to 198,000 less CLABSIs than would have occurred if rates had remained the same as they were in 1990.

“These findings suggest that technical innovations and dissemination of evidence-based CLABSI prevention practices have likely been effective on a national scale,” Matthew Wise, PhD, lead author of the study, said in a statement.

At the same time, a CLABSI-reduction intervention in a hospital in Hawaii found that while the costs of care were much higher for patients who developed a CLABSI, reimbursement and the hospital’s margin also were higher (margin of $54,906 vs. $6,506).⁴ The authors conclude that current reimbursement practices offer a perverse incentive for hospitals to have more line infections, “while an optimal reimbursement system would reward them for prevention rather than treating illness.”

Lead author Eugene Hsu, MD, MBA, of Johns Hopkins University School of Medicine said in an email that the study demonstrates how a quality initiative led by providers and funded by a major commercial insurer can save both lives and money. “Hospitalists, like all healthcare providers, must be aware of the distorted financial incentives that may affect how they provide care to patients,” Dr. Hsu said.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

New CDC research published in the June issue of Infection Control and Hospital Epidemiology estimates that as many as 200,000 central-line-associated bloodstream infections (CLABSIs) in ICUs nationally have been prevented since 1990.³ The report indicates much of the success is due to U.S. hospitals adopting successful prevention strategies, namely the dissemination of guideline-supported central-line insertion and maintenance best practices, infection-control treatment bundles, and widespread availability of alcohol-based hand rubs.

Between 462,000 and 636,000 CLABSIs occurred in non-neonatal ICU patients from 1990-2010, CDC estimates, about 104,000 to 198,000 less CLABSIs than would have occurred if rates had remained the same as they were in 1990.

“These findings suggest that technical innovations and dissemination of evidence-based CLABSI prevention practices have likely been effective on a national scale,” Matthew Wise, PhD, lead author of the study, said in a statement.

At the same time, a CLABSI-reduction intervention in a hospital in Hawaii found that while the costs of care were much higher for patients who developed a CLABSI, reimbursement and the hospital’s margin also were higher (margin of $54,906 vs. $6,506).⁴ The authors conclude that current reimbursement practices offer a perverse incentive for hospitals to have more line infections, “while an optimal reimbursement system would reward them for prevention rather than treating illness.”

Lead author Eugene Hsu, MD, MBA, of Johns Hopkins University School of Medicine said in an email that the study demonstrates how a quality initiative led by providers and funded by a major commercial insurer can save both lives and money. “Hospitalists, like all healthcare providers, must be aware of the distorted financial incentives that may affect how they provide care to patients,” Dr. Hsu said.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

New CDC research published in the June issue of Infection Control and Hospital Epidemiology estimates that as many as 200,000 central-line-associated bloodstream infections (CLABSIs) in ICUs nationally have been prevented since 1990.³ The report indicates much of the success is due to U.S. hospitals adopting successful prevention strategies, namely the dissemination of guideline-supported central-line insertion and maintenance best practices, infection-control treatment bundles, and widespread availability of alcohol-based hand rubs.

Between 462,000 and 636,000 CLABSIs occurred in non-neonatal ICU patients from 1990-2010, CDC estimates, about 104,000 to 198,000 less CLABSIs than would have occurred if rates had remained the same as they were in 1990.

“These findings suggest that technical innovations and dissemination of evidence-based CLABSI prevention practices have likely been effective on a national scale,” Matthew Wise, PhD, lead author of the study, said in a statement.

At the same time, a CLABSI-reduction intervention in a hospital in Hawaii found that while the costs of care were much higher for patients who developed a CLABSI, reimbursement and the hospital’s margin also were higher (margin of $54,906 vs. $6,506).⁴ The authors conclude that current reimbursement practices offer a perverse incentive for hospitals to have more line infections, “while an optimal reimbursement system would reward them for prevention rather than treating illness.”

Lead author Eugene Hsu, MD, MBA, of Johns Hopkins University School of Medicine said in an email that the study demonstrates how a quality initiative led by providers and funded by a major commercial insurer can save both lives and money. “Hospitalists, like all healthcare providers, must be aware of the distorted financial incentives that may affect how they provide care to patients,” Dr. Hsu said.

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

One in 20 hospitalized patients picks up an infection in the hospital, and a recent article by the Associated Press describes the emergence of new technologies to fight antibiotic-resistant superbugs: “They sweep. They swab. They sterilize. And still the germs persist.”¹

Hospitals across the country are testing new approaches to stop the spread of superbugs, which are tied to an estimated 100,000 deaths per year, according to the CDC. New approaches include robotlike machines that emit ultraviolet light or hydrogen-peroxide vapors, germ-resistant copper bed rails and call buttons, antimicrobial linens and wall paint, and hydrogel post-surgical dressings infused with silver ions that have antimicrobial properties.

Research firm Frost & Sullivan estimates that the market for bug-killing products and technologies will grow to $80 million from $30 million in the next three years. And yet evidence of positive outcomes from them continues to be debated.

“In short, escalating antimicrobial-resistance issues have us facing the prospect of untreatable bacterial pathogens, particularly involving gram-negative organisms,” James Pile, MD, FACP, SFHM, a hospital medicine and infectious diseases physician at Cleveland Clinic, wrote in an email. “In fact, many of our hospitals already deal with a limited number of infections caused by bacteria we have no clearly effective antibiotics against; the issue is only going to get worse.”

As an example, the CDC recently issued a warning about carbapenum-resistant Enterobacteriaceae (CRE), which has a 40% mortality rate and last year was reported in 4.6% of U.S. hospitals.² CDC recommends that hospitals use more of the existing prevention measures against CRE, including active-case detection and segregation of patients and the staff who care for them. Dr. Pile says health facilities need to do a better job of preventing infections involving multi-drug-resistant pathogens, but in the meantime, “proven technologies such as proper hand hygiene and antimicrobial stewardship are more important than ever.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

One in 20 hospitalized patients picks up an infection in the hospital, and a recent article by the Associated Press describes the emergence of new technologies to fight antibiotic-resistant superbugs: “They sweep. They swab. They sterilize. And still the germs persist.”¹

Hospitals across the country are testing new approaches to stop the spread of superbugs, which are tied to an estimated 100,000 deaths per year, according to the CDC. New approaches include robotlike machines that emit ultraviolet light or hydrogen-peroxide vapors, germ-resistant copper bed rails and call buttons, antimicrobial linens and wall paint, and hydrogel post-surgical dressings infused with silver ions that have antimicrobial properties.

Research firm Frost & Sullivan estimates that the market for bug-killing products and technologies will grow to $80 million from $30 million in the next three years. And yet evidence of positive outcomes from them continues to be debated.

“In short, escalating antimicrobial-resistance issues have us facing the prospect of untreatable bacterial pathogens, particularly involving gram-negative organisms,” James Pile, MD, FACP, SFHM, a hospital medicine and infectious diseases physician at Cleveland Clinic, wrote in an email. “In fact, many of our hospitals already deal with a limited number of infections caused by bacteria we have no clearly effective antibiotics against; the issue is only going to get worse.”

As an example, the CDC recently issued a warning about carbapenum-resistant Enterobacteriaceae (CRE), which has a 40% mortality rate and last year was reported in 4.6% of U.S. hospitals.² CDC recommends that hospitals use more of the existing prevention measures against CRE, including active-case detection and segregation of patients and the staff who care for them. Dr. Pile says health facilities need to do a better job of preventing infections involving multi-drug-resistant pathogens, but in the meantime, “proven technologies such as proper hand hygiene and antimicrobial stewardship are more important than ever.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

One in 20 hospitalized patients picks up an infection in the hospital, and a recent article by the Associated Press describes the emergence of new technologies to fight antibiotic-resistant superbugs: “They sweep. They swab. They sterilize. And still the germs persist.”¹

Hospitals across the country are testing new approaches to stop the spread of superbugs, which are tied to an estimated 100,000 deaths per year, according to the CDC. New approaches include robotlike machines that emit ultraviolet light or hydrogen-peroxide vapors, germ-resistant copper bed rails and call buttons, antimicrobial linens and wall paint, and hydrogel post-surgical dressings infused with silver ions that have antimicrobial properties.

Research firm Frost & Sullivan estimates that the market for bug-killing products and technologies will grow to $80 million from $30 million in the next three years. And yet evidence of positive outcomes from them continues to be debated.

“In short, escalating antimicrobial-resistance issues have us facing the prospect of untreatable bacterial pathogens, particularly involving gram-negative organisms,” James Pile, MD, FACP, SFHM, a hospital medicine and infectious diseases physician at Cleveland Clinic, wrote in an email. “In fact, many of our hospitals already deal with a limited number of infections caused by bacteria we have no clearly effective antibiotics against; the issue is only going to get worse.”

As an example, the CDC recently issued a warning about carbapenum-resistant Enterobacteriaceae (CRE), which has a 40% mortality rate and last year was reported in 4.6% of U.S. hospitals.² CDC recommends that hospitals use more of the existing prevention measures against CRE, including active-case detection and segregation of patients and the staff who care for them. Dr. Pile says health facilities need to do a better job of preventing infections involving multi-drug-resistant pathogens, but in the meantime, “proven technologies such as proper hand hygiene and antimicrobial stewardship are more important than ever.”

Larry Beresford is a freelance writer in Oakland, Calif.

References

1. Stobbe, M. Germ-zapping “robots”: Hospitals combat superbugs. Associated Press website. Available at: http://bigstory.ap.org/article/hospitals-see-surge-superbug-fighting-products. Accessed June 7, 2013.
2. Centers for Disease Control and Prevention. Vital Signs: Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control and Prevention website. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6209a3.htm?s_cid=mm6209a3_w. Accessed June 7, 2013.
3. Wise ME, Scott RD, Baggs JM, et al. National estimates of central line-associated bloodstream infections in critical care patients. Infect Control Hosp Epidemiol, 2013;34(6):547-554.
4. Hsu E, Lin D, Evans SJ, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual, 2013 May 7 [Epub ahead of print].
5. Association of American Medical Colleges. Medical school enrollment on pace to reach 30 percent increase by 2017. Association of American Medical Colleges website. Available at: https://www.aamc.org/newsroom/newsreleases/ 335244/050213.html. Accessed June 7, 2013.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Job One during your first months as a working hospitalist is to acclimate to your hospital and HM group’s procedures. Increasingly, hospitalist teams include nurse practitioners (NPs) and physician assistants (PAs); for some new hospitalists, this will require another level of learning on the job. The 2012 State of Hospital Medicine report (www.hospitalmedicine.org/survey) noted that approximately half of HM groups serving adults and children utilized NPs and/or PAs. Although the report also acknowledged that identifying trends is difficult, the converging factors of aging U.S. demographics and the growing physician shortage indicate that NPs and PAs will become more prevalent in hospital medicine.

Physicians who have not worked alongside NPs or PAs often are unsure of how to approach the working relationship, says Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations at Hospitalists of Northern Michigan and a member of SHM’s Nurse Practitioner/Physician Assistant (NP/PA) Committee.

Roles and Scope of Practice

NPs and PAs perform myriad clinical and management responsibilities as hospitalists:

• Coordination of admissions and discharge planning;
• Patient histories, physical examinations, and diagnostic and therapeutic procedures (placing central lines, doing lumbar punctures, etc.);
• Medication orders; and
• Hospital committee work to improve processes of care.

Licensing requirements, physician oversight requirements, and scope of practice vary state to state and hospital to hospital. “If you’ve seen one hospital medicine group, you’ve seen one hospital medicine group”— coined by Mitchell Wilson, MD, SFHM, CMO at Atlanta-based Eagle Hospital Physicians—also applies to the way in which HM groups structure their use of NPs and PAs, says Tracy E. Cardin, ACNP-BC, of the University of Chicago Hospital and chair of the NP/PA Committee. SHM’s website offers information about the scope of practice and best ways to incorporate NPs and PAs into hospitalist practice.

Cardin

To hospitalists who express anxiety about an NP or PA overstepping bounds and putting the physician’s license at risk, Kalupa reminds them that she, too, has a license that is at risk. When roles are clearly delineated for tasks that NPs and PAs will perform, jeopardizing a license will not be an issue.

Literature supports equivalent outcomes in both primary care and inpatient settings when PAs and NPs are implemented to handle responsibilities within their scope of practice.^1,2 Using a PA or NP to handle uncomplicated pneumonia cases, to conduct a stress test, or assemble data for patient rounding, for example, can have a physician multiplier effect, says committee member David A. Friar, MD, SFHM, also a member of the NP/PA Committee. Dr. Friar, based in Traverse City, Mich., works daily with nurse practitioners and physician assistants as part of HNM.

“I think of the healthcare team as a toolbox with which we need to provide care for our patients,” he says. “A screwdriver is not half of a hammer, but it can be the best tool for a certain job. In addition, physicians are often seen as Swiss army knives—that we can do anything. We can make photocopies, but it doesn’t make sense for us to do that. So for cases of simple pneumonia or urinary tract infections, or for following people waiting for discharge, management by an NP or PA makes a lot of sense from an economic standpoint.”

Dr. Friar

Position Parity

Hospital leadership should set the tone for building a strong multidisciplinary team, Cardin says. Individual physicians can make a difference with the right approach to the working relationship. “If you are going to have successful collaborations with NPs and PAs,” she says, “you have to treat them like a doctor.” This does not mean that the pay structure will be the same, but in areas such as continuing medical education and group socializing, every member of the team should be treated as an equal. That approach makes sense to Dr. Friar, who makes it a point to call every person on the HM team a hospitalist.

He and Kalupa also point out that NPs and PAs can successfully fill team leadership roles. “Physicians need to be willing to accept that the personality traits that made them great clinicians are often not those that one would desire in a team leader,” Dr. Friar says. Using a football analogy, he notes that an important part of being a good team member is to play to other members’ strengths and protect them from their weaknesses. “You don’t have the linebacker run the ball, or the quarterback kick the field goal attempt; you use people’s strengths where they will be most effective for the care of your patients.”

When Conflicts Arise

Successful working relationships between physicians and NP/PAs hinge on clear expectations and the willingness to have difficult conversations, Cardin says. She has practiced as a hospitalist for seven years and prior to that worked in the acute-care setting. As a result, she says, she is quite comfortable seeing patients independently.

Hospitalists new to the group or those who have not worked with NPs before may bristle at that idea, she notes. If a problem arises, such as a perceived encroachment on one’s scope of practice, be willing to address it openly. All relationships are constantly evolving, and it’s important not to overreact.

It’s “just like driving a car,” she says. “If you overcorrect when a wheel comes off the road, you will wreck the car. Sometimes all that’s needed is a small adjustment to manage the problem.”

Gretchen Henkel is a freelance writer in California.

What’s in a Name?

Dr. Kalupa

When Jeanette Kalupa, DNP, ACNP-BC, SFHM, vice president of clinical operations for Hospitalists of Northern Michigan, first joined SHM’s Nurse Practitioner/Physician Assistant Committee in 2003, it was called the “NP/PA Task Force.” The name was changed to the Nonphysician Provider (NPP) Committee to accommodate other allied professionals, such as pharmacists and case managers. She and her NP colleagues object to the NPP moniker “because it designates us as what we are not.”

The term “midlevel provider,” another common designation, is also problematic, she says, because it heightens awareness of a hierarchy. Just this past year, the committee name was changed to NP/PA Committee. “We’ve evolved over time,” Kalupa says. “I think rather than labeling someone as a ‘midlevel provider,’ it’s better to just call them what they are.”

—Gretchen Henkel

References

1. Iglesias B, Ramos F, Serrano B, et al. A randomized controlled trial of nurses vs. doctors in the resolution of acute disease of low complexity in primary care. J Adv Nurs. 2013 March 21. doi: 10.1111/jan.12120 [Epub ahead of print].
2. Hoffman LA, Tasota FJ, Zullo TG, et al. Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit. Am J Crit Care. 2005;14(2):121-130; quiz 131-132.

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

Dr. Conway

Hospitalist leaders are taking a proactive approach to the latest wrinkle of the specialty’s rock-and-a-hard-place dilemma when it comes to how clinicians code for their services. The oft-lamented issue is the Centers for Medicare & Medicaid Services’ (CMS) dearth of CPT codes designated for day-to-day hospitalist services.

But the latest twist to the story is what happens in skilled-nursing facilities (SNFs). Hospitalists increasingly are taking lead roles in SNFs, yet they must use the same care codes as nursing-home providers despite the higher acuity and longer length of stay found in SNFs compared to nursing homes. Additionally, Medicare recognizes SNFs and nursing homes as primary care for reimbursement via accountable-care organizations (ACOs).

Kerry Weiner, MD, a member of SHM’s Public Policy Committee, says SHM and others, including the American Medical Directors Association, are pushing CMS to reclassify SNF care as inpatient service, similar to acute rehabilitation facilities, inpatient psychiatric care, and long-term acute-care facilities. Dr. Weiner suggests rank-and-file practitioners do the same.

“We think attributing providers to be primary care versus specialty care versus acute care only on the basis of E&M codes will not really capture the nuances of primary-care practice in the country right now,” says Dr. Weiner, chief medical officer at North Hollywood, Calif.-based IPC: The Hospitalist Company. “This is an example of how just using E&M codes does not really capture the style of practice and the type of patient you’re seeing.”

The arguments for reclassification include:

• Hospitalists and other physicians practicing in SNFs need to spend most of their time there to provide optimal care, but it is difficult to financially justify maintaining that presence without an adequate patient census.
• Generating that census while practicing in one ACO is difficult because most facilities service multiple ACOs, and PCP exclusivity rules tied to many ACO contracts are a hurdle for physicians working with one just ACO (working with multiple ACOs requires multiple tax identification numbers and can be “operationally and politically difficult,” Dr. Wiener says).
• All told, ACO setup creates a fiscal hurdle for providers working in SNFs and does not recognize the clinical burden that separates the types of care provided in SNFs and nursing homes. Were care in SNFs reclassified as inpatient care, the exclusivity rule would not apply, and therefore, hospitalists in those facilities could more easily attain a patient census that justifies their continued presence. Dr. Weiner says one solution is to create a set of CPT codes just for SNFs that could be used by specialist physicians, including hospitalists.

“We are proposing a ‘work around’ by using the site of service as a determinator,” he adds.

Issues to Address

Dr. Weiner, SHM officials, and others have met with CMS to discuss the potential reclassification. Dr. Weiner says that as the Physician Quality Reporting System (PQRS) morphs into the Value-Based Payment Modifier (VBPM) program, the issue of ACO exclusivity could become even more prevalent as compensation is tied to performance.

“One of the components of physician value-based purchasing is the cost of care,” Dr. Weiner says. “If you compare a hospitalist’s cost to the pool of primary care, which includes hospitals, SNFs, etc., you’re obviously going to be higher because you have a much sicker population; A lot more things are going on, so there’s a lot higher utilization. So this concept of assigning doctors to a style of practice just based on E&M codes is just inadequate.”

Patrick Conway, MD, MSc, FAAP, SFHM, chief medical officer of CMS and director of CMS’ Center of Clinical Standards and Quality, says the agency is sympathetic to the issue. Via PQRS and VBPM, CMS is working to put in place “a robust set of measures that hospitalists can choose to report on,” he says.

“CMS has sought public comment on allowing hospitalists to align with their hospital’s quality measures for CMS quality programs,” he says. “But without this alignment option or a specialty code, we need to at least have sufficient measures to reflect hospitalists’ actual practice and what’s important to hospital medicine.”

Dr. Conway, a former hospitalist and chair of SHM’s Public Policy Committee, says he welcomes feedback from SHM and its members on suggested changes to CMS policy.

“I would certainly encourage hospital medicine to have discussions with the CMS payment and coding team that makes determinations about specialty status,” he says.

The Future?

Ironically, the potential panacea of HM-specific codes has not been fully embraced because of fears of unintended consequences. For example, in the case of hospitalists practicing in SNFs, the PCP designation is problematic in terms of lower reimbursement rates. Some hospitalists, however, will see a bump in total revenue the next two years because they will be designated PCPs and paid more via the Medicaid-to-Medicare parity regulation included in the Affordable Care Act.

“Hospital medicine will want to think about that as it goes through the process,” Dr. Conway says. “Internally with CMS, if you’re a specialty, we will specifically consider if you’re primary care or not. Whereas, if you’re in the internal-medicine bucket, by definition from the traditional CMS specialty coding perspective, you are primary care. So if you make a point to carve out your own category, then it’ll be a decision every time if you’re primary care or are you a specialty.”

Richard Quinn is a freelance writer in New Jersey.

Call for PQRS Measures

Dr. Conway

CMS’ annual call for Physician Quality Reporting System (PQRS) measures is a rite of summer. And Dr. Conway hopes that when CMS culls through this summer’s batch, hospitalists weighed in often.

“I know that the surgeons, the cardiologists, and others, every year, they say, ‘Here are the 20 new measures we’re thinking about for our specialty,’” he says. “So I just want to make clear that SHM should do the same. Identify the measures out there that are most relevant to you.”

Dr. Conway adds that the process shouldn’t be limited to the society level. Individual practitioners can reach out to CMS and weigh in as well.

Physicians “need to have sufficient measures to cover [their] specialty, and societies can play a key role in developing measures or identifying measures,” Dr. Conway says. “If there’s measures you want in the program, by all means, tell us.”

—Richard Quinn

Leaving a job is never an easy decision, whether it is made voluntarily or not. A physician terminating a relationship with an employer may face emotionally charged conversations, difficult financial considerations, and long-term legal consequences. As you plan your exit strategy, it is critical for you to be aware of these issues and address them proactively with your employer. This can minimize hard feelings and surprises down the road for you, your former employer, and your colleagues.

In today’s competitive climate, a physician might work for several employers during the length of his or her career. With the tighter financial medical market and pressures from managed care mounting, employers are less likely to tolerate a nonproductive employee. Interoffice or personality conflicts may become intolerable for an unhappy or stressed physician. Physician turnover is a more common occurrence, and if not handled properly, it can be disruptive for all parties involved.

The following steps are meant for physicians contemplating leaving their place of employment or who may be asked to leave in the near future.

Step 1: Consider the Employment Agreement

Ideally, physician-separation matters are addressed preemptively when the physician enters the employer-employee relationship and signs an employment agreement. Thus, before contemplating a move, you should always start by reviewing the terms of your current employment agreement. A well-drafted employment agreement should specify the grounds for termination, both for cause (i.e. a specific set of reasons for immediate termination) and without cause (i.e. either party may terminate voluntarily). The agreement should specify the parties’ rights and obligations following a termination. These rights and obligations likely will vary depending on the basis for termination.

Typically, an employer will provide malpractice insurance for its physicians during the term of employment. However, physicians may be responsible for the cost of “tail coverage” upon the termination of employment. This is designed to protect the departing physician’s professional acts after leaving the employ of an employer with claims-made coverage. Because the coverage can be quite costly, a well-drafted employment agreement often will set forth which party is responsible for the procurement and payment of tail coverage. It is prudent for a departing physician to review the employment agreement to identify who has the affirmative obligation to provide the tail coverage, as it can be a costly surprise at termination.

The employment agreement also must be reviewed to determine the proper method to provide notice of termination (such as first-class mail, overnight courier, or hand delivery). Often, employment agreements will include a clause titled “Notice” that outlines the delivery method for proper notice to the employer.

Step 2: Consider a Termination/Separation Agreement

Entering into a termination agreement (sometimes referred to as a separation agreement) between the departing physician and the employer may address and resolve many of the outstanding issues that are not otherwise addressed in the employment agreement. A termination agreement may avoid unnecessary problems down the road and potentially acrimonious and costly litigation.

The termination agreement can fill in the gaps where the employment agreement is silent (or if an employment agreement does not exist). The key elements of a termination agreement often include:

• The effective date of the separation as well as what exactly is ending (e.g. employment, co-ownership, board membership, medical staff privileges);
• Payment and buyout terms;
• The physician’s removal from any management or administrative position (e.g. member of the governing board);
• Deferred compensation payments or severance pay that may need to be calculated and distributed;
• Employer obligations (if any) to provide the departing physician’s fringe benefits and business expenses, including retirement-plan contributions, health insurance, life insurance, medical dues, etc.; and
• Unused vacation days, bonuses, or expenses due.

If previously addressed in the employment agreement, the parties should reaffirm their respective rights and obligations regarding medical records, confidential information, noncompetition and nonsolicitation provisions. Otherwise, the termination agreement should identify the physician’s competitive and solicitation activities post-termination.

A noncompetition provision should include the geographic territory in which and the time period during which the departing physician cannot compete with the former employer. It is important to remember courts will render these provisions as unenforceable and invalid if improperly drafted or overly broad. It is common to see nondisparagement provisions, whereby each party agrees to refrain from making any negative or false statements regarding the other. Nondisclosure provisions are common as well with regards to what may be disclosed to third parties.

The separation agreement also should address the return of company property, including office key, credit card, computer, cell phone, and beeper. Patient records and charts should be completed and returned to the employer. Often, the departing physician will still be allowed reasonable access to patient records post-termination for certain authorized purposes (e.g. defending disciplinary actions, malpractice claims, and billing/payer claims and audits), usually at the physician’s own expense.

The termination agreement may also outline how patients will be notified about the physician’s departure. If a patient wishes to continue treatment with the departing physician, the former employer must be ready to transition the patient.

A well-written termination agreement will provide for mutual releases. However, there are often exclusions from the mutual releases, such as pre-termination date liabilities; medical malpractice claims resulting from the physician’s misconduct; or taxes, interests, and penalties covering the pre-termination date.

Step 3: Severance Pay

Depending on the circumstances surrounding the termination and employment agreements, a physician may be entitled to severance payments beginning on the date of termination and/or for a period of time post-termination. The departing physician should determine whether severance is appropriate and whether he or she is willing to forego severance payments in exchange for other benefits. Depending on the dollar amount and the physician’s career objectives, it may be worthwhile to sacrifice severance payments for a less onerous noncompete provision, for example.

Step 4: Take the High Road

Because you never know when your paths might cross with former coworkers or employers, it is always sensible to remain discreet and level-headed during this trying period. Although it is natural to discuss an impending move with others, a prudent physician will avoid water-cooler gossip.

In the event conflicts arise, limit the public disclosure of these disputes. Neither side wins the public relations battle, and often, both sides lose. This is a circumstance where experienced legal counsel can be invaluable as you navigate these potentially rocky waters. You would be well served to seek legal advice to discuss your intentions before making an actual move.

As always, remember conversations you have with counsel are typically protected by attorney-client privilege. It is always advisable to secure legal counsel to review the terms of an employment agreement, negotiate a fair termination/separation agreement, and serve as an advocate during this challenging career move.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Leaving a job is never an easy decision, whether it is made voluntarily or not. A physician terminating a relationship with an employer may face emotionally charged conversations, difficult financial considerations, and long-term legal consequences. As you plan your exit strategy, it is critical for you to be aware of these issues and address them proactively with your employer. This can minimize hard feelings and surprises down the road for you, your former employer, and your colleagues.

In today’s competitive climate, a physician might work for several employers during the length of his or her career. With the tighter financial medical market and pressures from managed care mounting, employers are less likely to tolerate a nonproductive employee. Interoffice or personality conflicts may become intolerable for an unhappy or stressed physician. Physician turnover is a more common occurrence, and if not handled properly, it can be disruptive for all parties involved.

The following steps are meant for physicians contemplating leaving their place of employment or who may be asked to leave in the near future.

Step 1: Consider the Employment Agreement

Ideally, physician-separation matters are addressed preemptively when the physician enters the employer-employee relationship and signs an employment agreement. Thus, before contemplating a move, you should always start by reviewing the terms of your current employment agreement. A well-drafted employment agreement should specify the grounds for termination, both for cause (i.e. a specific set of reasons for immediate termination) and without cause (i.e. either party may terminate voluntarily). The agreement should specify the parties’ rights and obligations following a termination. These rights and obligations likely will vary depending on the basis for termination.

Typically, an employer will provide malpractice insurance for its physicians during the term of employment. However, physicians may be responsible for the cost of “tail coverage” upon the termination of employment. This is designed to protect the departing physician’s professional acts after leaving the employ of an employer with claims-made coverage. Because the coverage can be quite costly, a well-drafted employment agreement often will set forth which party is responsible for the procurement and payment of tail coverage. It is prudent for a departing physician to review the employment agreement to identify who has the affirmative obligation to provide the tail coverage, as it can be a costly surprise at termination.

The employment agreement also must be reviewed to determine the proper method to provide notice of termination (such as first-class mail, overnight courier, or hand delivery). Often, employment agreements will include a clause titled “Notice” that outlines the delivery method for proper notice to the employer.

Step 2: Consider a Termination/Separation Agreement

Entering into a termination agreement (sometimes referred to as a separation agreement) between the departing physician and the employer may address and resolve many of the outstanding issues that are not otherwise addressed in the employment agreement. A termination agreement may avoid unnecessary problems down the road and potentially acrimonious and costly litigation.

The termination agreement can fill in the gaps where the employment agreement is silent (or if an employment agreement does not exist). The key elements of a termination agreement often include:

• The effective date of the separation as well as what exactly is ending (e.g. employment, co-ownership, board membership, medical staff privileges);
• Payment and buyout terms;
• The physician’s removal from any management or administrative position (e.g. member of the governing board);
• Deferred compensation payments or severance pay that may need to be calculated and distributed;
• Employer obligations (if any) to provide the departing physician’s fringe benefits and business expenses, including retirement-plan contributions, health insurance, life insurance, medical dues, etc.; and
• Unused vacation days, bonuses, or expenses due.

If previously addressed in the employment agreement, the parties should reaffirm their respective rights and obligations regarding medical records, confidential information, noncompetition and nonsolicitation provisions. Otherwise, the termination agreement should identify the physician’s competitive and solicitation activities post-termination.

A noncompetition provision should include the geographic territory in which and the time period during which the departing physician cannot compete with the former employer. It is important to remember courts will render these provisions as unenforceable and invalid if improperly drafted or overly broad. It is common to see nondisparagement provisions, whereby each party agrees to refrain from making any negative or false statements regarding the other. Nondisclosure provisions are common as well with regards to what may be disclosed to third parties.

The separation agreement also should address the return of company property, including office key, credit card, computer, cell phone, and beeper. Patient records and charts should be completed and returned to the employer. Often, the departing physician will still be allowed reasonable access to patient records post-termination for certain authorized purposes (e.g. defending disciplinary actions, malpractice claims, and billing/payer claims and audits), usually at the physician’s own expense.

The termination agreement may also outline how patients will be notified about the physician’s departure. If a patient wishes to continue treatment with the departing physician, the former employer must be ready to transition the patient.

A well-written termination agreement will provide for mutual releases. However, there are often exclusions from the mutual releases, such as pre-termination date liabilities; medical malpractice claims resulting from the physician’s misconduct; or taxes, interests, and penalties covering the pre-termination date.

Step 3: Severance Pay

Depending on the circumstances surrounding the termination and employment agreements, a physician may be entitled to severance payments beginning on the date of termination and/or for a period of time post-termination. The departing physician should determine whether severance is appropriate and whether he or she is willing to forego severance payments in exchange for other benefits. Depending on the dollar amount and the physician’s career objectives, it may be worthwhile to sacrifice severance payments for a less onerous noncompete provision, for example.

Step 4: Take the High Road

Because you never know when your paths might cross with former coworkers or employers, it is always sensible to remain discreet and level-headed during this trying period. Although it is natural to discuss an impending move with others, a prudent physician will avoid water-cooler gossip.

In the event conflicts arise, limit the public disclosure of these disputes. Neither side wins the public relations battle, and often, both sides lose. This is a circumstance where experienced legal counsel can be invaluable as you navigate these potentially rocky waters. You would be well served to seek legal advice to discuss your intentions before making an actual move.

As always, remember conversations you have with counsel are typically protected by attorney-client privilege. It is always advisable to secure legal counsel to review the terms of an employment agreement, negotiate a fair termination/separation agreement, and serve as an advocate during this challenging career move.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Leaving a job is never an easy decision, whether it is made voluntarily or not. A physician terminating a relationship with an employer may face emotionally charged conversations, difficult financial considerations, and long-term legal consequences. As you plan your exit strategy, it is critical for you to be aware of these issues and address them proactively with your employer. This can minimize hard feelings and surprises down the road for you, your former employer, and your colleagues.

In today’s competitive climate, a physician might work for several employers during the length of his or her career. With the tighter financial medical market and pressures from managed care mounting, employers are less likely to tolerate a nonproductive employee. Interoffice or personality conflicts may become intolerable for an unhappy or stressed physician. Physician turnover is a more common occurrence, and if not handled properly, it can be disruptive for all parties involved.

The following steps are meant for physicians contemplating leaving their place of employment or who may be asked to leave in the near future.

Step 1: Consider the Employment Agreement

Ideally, physician-separation matters are addressed preemptively when the physician enters the employer-employee relationship and signs an employment agreement. Thus, before contemplating a move, you should always start by reviewing the terms of your current employment agreement. A well-drafted employment agreement should specify the grounds for termination, both for cause (i.e. a specific set of reasons for immediate termination) and without cause (i.e. either party may terminate voluntarily). The agreement should specify the parties’ rights and obligations following a termination. These rights and obligations likely will vary depending on the basis for termination.

Typically, an employer will provide malpractice insurance for its physicians during the term of employment. However, physicians may be responsible for the cost of “tail coverage” upon the termination of employment. This is designed to protect the departing physician’s professional acts after leaving the employ of an employer with claims-made coverage. Because the coverage can be quite costly, a well-drafted employment agreement often will set forth which party is responsible for the procurement and payment of tail coverage. It is prudent for a departing physician to review the employment agreement to identify who has the affirmative obligation to provide the tail coverage, as it can be a costly surprise at termination.

The employment agreement also must be reviewed to determine the proper method to provide notice of termination (such as first-class mail, overnight courier, or hand delivery). Often, employment agreements will include a clause titled “Notice” that outlines the delivery method for proper notice to the employer.

Step 2: Consider a Termination/Separation Agreement

Entering into a termination agreement (sometimes referred to as a separation agreement) between the departing physician and the employer may address and resolve many of the outstanding issues that are not otherwise addressed in the employment agreement. A termination agreement may avoid unnecessary problems down the road and potentially acrimonious and costly litigation.

The termination agreement can fill in the gaps where the employment agreement is silent (or if an employment agreement does not exist). The key elements of a termination agreement often include:

• The effective date of the separation as well as what exactly is ending (e.g. employment, co-ownership, board membership, medical staff privileges);
• Payment and buyout terms;
• The physician’s removal from any management or administrative position (e.g. member of the governing board);
• Deferred compensation payments or severance pay that may need to be calculated and distributed;
• Employer obligations (if any) to provide the departing physician’s fringe benefits and business expenses, including retirement-plan contributions, health insurance, life insurance, medical dues, etc.; and
• Unused vacation days, bonuses, or expenses due.

If previously addressed in the employment agreement, the parties should reaffirm their respective rights and obligations regarding medical records, confidential information, noncompetition and nonsolicitation provisions. Otherwise, the termination agreement should identify the physician’s competitive and solicitation activities post-termination.

A noncompetition provision should include the geographic territory in which and the time period during which the departing physician cannot compete with the former employer. It is important to remember courts will render these provisions as unenforceable and invalid if improperly drafted or overly broad. It is common to see nondisparagement provisions, whereby each party agrees to refrain from making any negative or false statements regarding the other. Nondisclosure provisions are common as well with regards to what may be disclosed to third parties.

The separation agreement also should address the return of company property, including office key, credit card, computer, cell phone, and beeper. Patient records and charts should be completed and returned to the employer. Often, the departing physician will still be allowed reasonable access to patient records post-termination for certain authorized purposes (e.g. defending disciplinary actions, malpractice claims, and billing/payer claims and audits), usually at the physician’s own expense.

The termination agreement may also outline how patients will be notified about the physician’s departure. If a patient wishes to continue treatment with the departing physician, the former employer must be ready to transition the patient.

A well-written termination agreement will provide for mutual releases. However, there are often exclusions from the mutual releases, such as pre-termination date liabilities; medical malpractice claims resulting from the physician’s misconduct; or taxes, interests, and penalties covering the pre-termination date.

Step 3: Severance Pay

Depending on the circumstances surrounding the termination and employment agreements, a physician may be entitled to severance payments beginning on the date of termination and/or for a period of time post-termination. The departing physician should determine whether severance is appropriate and whether he or she is willing to forego severance payments in exchange for other benefits. Depending on the dollar amount and the physician’s career objectives, it may be worthwhile to sacrifice severance payments for a less onerous noncompete provision, for example.

Step 4: Take the High Road

Because you never know when your paths might cross with former coworkers or employers, it is always sensible to remain discreet and level-headed during this trying period. Although it is natural to discuss an impending move with others, a prudent physician will avoid water-cooler gossip.

In the event conflicts arise, limit the public disclosure of these disputes. Neither side wins the public relations battle, and often, both sides lose. This is a circumstance where experienced legal counsel can be invaluable as you navigate these potentially rocky waters. You would be well served to seek legal advice to discuss your intentions before making an actual move.

As always, remember conversations you have with counsel are typically protected by attorney-client privilege. It is always advisable to secure legal counsel to review the terms of an employment agreement, negotiate a fair termination/separation agreement, and serve as an advocate during this challenging career move.

Steven M. Harris, Esq., is a nationally recognized healthcare attorney and a member of the law firm McDonald Hopkins LLC in Chicago. Write to him at [email protected].

Dr. Tappenden

Health-care reform is on everyone’s mind these days, and SHM, along with numerous other groups, believes some reform goals can be achieved through the stomach.

Data show an effective program of nutritional intervention during a patient’s hospital stay can go a long way toward improving patient outcomes and reducing costs.¹ Hospitalists, however, often have little formal nutrition training. A multidisciplinary approach to patient nutrition that brings together multiple stakeholders—hospitalists, nurses, and dietitians—might effectively address this need with a team tactic, according to Melissa Parkhurst, MD, medical director of the hospital medicine section at the University of Kansas Medical Center in Kansas City.¹

Between 20% and 50% of inpatients suffer from malnutrition.² Many patients, especially the elderly, are malnourished on admission. Many more become malnourished within a few days of their hospital stay due to NPO orders and the effects of disease on metabolism.2 Malnutrition has been associated with worsened discharge status, longer length of stay, higher costs, and greater mortality, as well as increased risk of:²

• Nosocomial infections;
• Falls;
• Pressure ulcers; and
• 30-day readmissions.

Dr. Tappenden

To address malnutrition prevalence and its detrimental effects, SHM and the Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), the American Society of Parenteral and Enteral Nutrition (ASPEN), and Abbott Nutrition have formed the Alliance for Patient Nutrition. Kelly Tappenden, MD, PhD, professor of food science and human nutrition at the University of Illinois at Urbana, says the alliance aims to raise awareness of the impact nutrition can have on patient outcomes (see “Three Steps to Better Nutrition,” below).

The campaign is being initiated with the publication of a consensus paper in several peer-reviewed journals. A baseline survey will be conducted among professionals represented in the alliance to assess their familiarity with the prevalence of malnutrition in a hospital setting. The next step is to foster this change in patient care by providing resources on the alliance’s website (www.malnutrition.com), including malnutrition screening tools, a toolkit to facilitate multidisciplinary collaboration, and continuing medical education (CME) information.

Dr. Parkhurst

As a founding member of the alliance, SHM is communicating this message to its members, encouraging hospitalists to lead the way in transforming hospital culture to recognize the critical role nutrition plays in patient care.

“Nutrition matters,” Dr. Parkhurst says. “You can be winning the battle and losing the war if you are not paying attention to patient nutrition.”

Team Approach

Dr. Quatrara

Beth Quatrara, DNP, RN, director of the nursing research program at the University of Virginia Health System in Charlottesville and nursing spokesperson for the alliance, says several shortcomings can be identified in the nutritional care U.S. hospitals provide from admission through discharge and beyond. For example, the Joint Commission requires that all patients be screened for malnutrition risk within 48 hours of admission. But screening is often as cursory as looking at the patient and deciding that he or she “looks fine.” Diets often are set for patients with no thought to taste, texture, or cultural preferences, or even to such practical matters as ascertaining whether the patient has dentures, Quatrara says. Meal trays are left when patients are out of their rooms for procedures and retrieved by dietary staff before patients return. And except for calorie count orders, accurate records often are not kept of actual food consumption.

The alliance, which is made possible with support from Abbott's nutrition business, recommends that physicians implement a three-step plan to improve patient outcomes. The approach begins with an evaluation of a patient’s nutritional status on admission using a simple, validated screening tool, such as the Malnutrition Screening Tool. When an at-risk status is determined, a more in-depth screening is performed. “When patients at risk for malnutrition can be identified faster, appropriate interventions can be put into place sooner,” Quatrara says.

The second step is nutrition intervention with a personalized nutritional care plan that takes into account the individual’s health conditions, caloric needs, physical limitations, tastes, and preferences. An interdisciplinary team approach can transform hospital nutrition, bringing together hospitalists, nurses, nursing assistants, registered dietitians, and the dietary staff to collaboratively develop a nutrition care plan that will be central to patient’s overall treatment, Dr. Tappenden says.

“There is a science behind nutrition and metabolic care,” Dr. Tappenden says. “Just like any other aspect of patient care, we can’t just throw out a blanket solution.”

But nutritional care cannot stop with developing this plan at the outset. Patients must be rescreened throughout their time at the hospital to measure any changes in nutritional status due to disease progression or treatment success.

For optimal impact, all members of the nutritional care team—nurses, nursing assistants, dietary support staff, and family members—should take responsibility for an essential component of the patient’s care: tracking and reporting consumption to the physician to open a dialogue about balancing an individual’s needs with tastes and preferences.

The hospitalist’s final step is developing a discharge plan that includes nutrition care and education so that patients, families, and caregivers can implement better nutrition at home.

“Nutrition makes sense,” Dr. Tappenden says. “Everything we are working toward in healthcare reform can be achieved by taking more care to make nutrition part of the solution.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. J Hosp Med. 2013;8:52-58.
2. Alliance for Patient Nutrition. Malnutrition Backgrounder.
3. Banks M, Bauer J, Graves N, Ash S. Malnutrition and pressure ulcer risk in adults in Australian health care facilities. Clin Nutr. 2010;26:896-901.
4. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145:148-151.
5. Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119:693-699.
6. Neelemaat F, Lips P, Bosmans J, Thijs A, Seidell JC, van Bokhorst-de van der Schuerer MA. Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. J Am Geriatr Soc. 2012;60:691-699.
7. Brugler L, DiPrinzio MJ, Bernstein L. The five-year evolution of a malnutrition treatment program in a community hospital. J Qual Improv. 1999;25:191-206.
8. Stratton PJ, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4:422-450.
9. Lawson RM, Doshi MK, Barton JR, Cobden I. The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcomes of elderly orthopaedic patients. Clin Nutr. 2003;22:39-46.

Dr. Tappenden

Health-care reform is on everyone’s mind these days, and SHM, along with numerous other groups, believes some reform goals can be achieved through the stomach.

Data show an effective program of nutritional intervention during a patient’s hospital stay can go a long way toward improving patient outcomes and reducing costs.¹ Hospitalists, however, often have little formal nutrition training. A multidisciplinary approach to patient nutrition that brings together multiple stakeholders—hospitalists, nurses, and dietitians—might effectively address this need with a team tactic, according to Melissa Parkhurst, MD, medical director of the hospital medicine section at the University of Kansas Medical Center in Kansas City.¹

Between 20% and 50% of inpatients suffer from malnutrition.² Many patients, especially the elderly, are malnourished on admission. Many more become malnourished within a few days of their hospital stay due to NPO orders and the effects of disease on metabolism.2 Malnutrition has been associated with worsened discharge status, longer length of stay, higher costs, and greater mortality, as well as increased risk of:²

• Nosocomial infections;
• Falls;
• Pressure ulcers; and
• 30-day readmissions.

Dr. Tappenden

To address malnutrition prevalence and its detrimental effects, SHM and the Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), the American Society of Parenteral and Enteral Nutrition (ASPEN), and Abbott Nutrition have formed the Alliance for Patient Nutrition. Kelly Tappenden, MD, PhD, professor of food science and human nutrition at the University of Illinois at Urbana, says the alliance aims to raise awareness of the impact nutrition can have on patient outcomes (see “Three Steps to Better Nutrition,” below).

The campaign is being initiated with the publication of a consensus paper in several peer-reviewed journals. A baseline survey will be conducted among professionals represented in the alliance to assess their familiarity with the prevalence of malnutrition in a hospital setting. The next step is to foster this change in patient care by providing resources on the alliance’s website (www.malnutrition.com), including malnutrition screening tools, a toolkit to facilitate multidisciplinary collaboration, and continuing medical education (CME) information.

Dr. Parkhurst

As a founding member of the alliance, SHM is communicating this message to its members, encouraging hospitalists to lead the way in transforming hospital culture to recognize the critical role nutrition plays in patient care.

“Nutrition matters,” Dr. Parkhurst says. “You can be winning the battle and losing the war if you are not paying attention to patient nutrition.”

Team Approach

Dr. Quatrara

Beth Quatrara, DNP, RN, director of the nursing research program at the University of Virginia Health System in Charlottesville and nursing spokesperson for the alliance, says several shortcomings can be identified in the nutritional care U.S. hospitals provide from admission through discharge and beyond. For example, the Joint Commission requires that all patients be screened for malnutrition risk within 48 hours of admission. But screening is often as cursory as looking at the patient and deciding that he or she “looks fine.” Diets often are set for patients with no thought to taste, texture, or cultural preferences, or even to such practical matters as ascertaining whether the patient has dentures, Quatrara says. Meal trays are left when patients are out of their rooms for procedures and retrieved by dietary staff before patients return. And except for calorie count orders, accurate records often are not kept of actual food consumption.

The alliance, which is made possible with support from Abbott's nutrition business, recommends that physicians implement a three-step plan to improve patient outcomes. The approach begins with an evaluation of a patient’s nutritional status on admission using a simple, validated screening tool, such as the Malnutrition Screening Tool. When an at-risk status is determined, a more in-depth screening is performed. “When patients at risk for malnutrition can be identified faster, appropriate interventions can be put into place sooner,” Quatrara says.

The second step is nutrition intervention with a personalized nutritional care plan that takes into account the individual’s health conditions, caloric needs, physical limitations, tastes, and preferences. An interdisciplinary team approach can transform hospital nutrition, bringing together hospitalists, nurses, nursing assistants, registered dietitians, and the dietary staff to collaboratively develop a nutrition care plan that will be central to patient’s overall treatment, Dr. Tappenden says.

“There is a science behind nutrition and metabolic care,” Dr. Tappenden says. “Just like any other aspect of patient care, we can’t just throw out a blanket solution.”

But nutritional care cannot stop with developing this plan at the outset. Patients must be rescreened throughout their time at the hospital to measure any changes in nutritional status due to disease progression or treatment success.

For optimal impact, all members of the nutritional care team—nurses, nursing assistants, dietary support staff, and family members—should take responsibility for an essential component of the patient’s care: tracking and reporting consumption to the physician to open a dialogue about balancing an individual’s needs with tastes and preferences.

The hospitalist’s final step is developing a discharge plan that includes nutrition care and education so that patients, families, and caregivers can implement better nutrition at home.

“Nutrition makes sense,” Dr. Tappenden says. “Everything we are working toward in healthcare reform can be achieved by taking more care to make nutrition part of the solution.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. J Hosp Med. 2013;8:52-58.
2. Alliance for Patient Nutrition. Malnutrition Backgrounder.
3. Banks M, Bauer J, Graves N, Ash S. Malnutrition and pressure ulcer risk in adults in Australian health care facilities. Clin Nutr. 2010;26:896-901.
4. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145:148-151.
5. Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119:693-699.
6. Neelemaat F, Lips P, Bosmans J, Thijs A, Seidell JC, van Bokhorst-de van der Schuerer MA. Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. J Am Geriatr Soc. 2012;60:691-699.
7. Brugler L, DiPrinzio MJ, Bernstein L. The five-year evolution of a malnutrition treatment program in a community hospital. J Qual Improv. 1999;25:191-206.
8. Stratton PJ, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4:422-450.
9. Lawson RM, Doshi MK, Barton JR, Cobden I. The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcomes of elderly orthopaedic patients. Clin Nutr. 2003;22:39-46.

Dr. Tappenden

Health-care reform is on everyone’s mind these days, and SHM, along with numerous other groups, believes some reform goals can be achieved through the stomach.

Data show an effective program of nutritional intervention during a patient’s hospital stay can go a long way toward improving patient outcomes and reducing costs.¹ Hospitalists, however, often have little formal nutrition training. A multidisciplinary approach to patient nutrition that brings together multiple stakeholders—hospitalists, nurses, and dietitians—might effectively address this need with a team tactic, according to Melissa Parkhurst, MD, medical director of the hospital medicine section at the University of Kansas Medical Center in Kansas City.¹

Between 20% and 50% of inpatients suffer from malnutrition.² Many patients, especially the elderly, are malnourished on admission. Many more become malnourished within a few days of their hospital stay due to NPO orders and the effects of disease on metabolism.2 Malnutrition has been associated with worsened discharge status, longer length of stay, higher costs, and greater mortality, as well as increased risk of:²

• Nosocomial infections;
• Falls;
• Pressure ulcers; and
• 30-day readmissions.

Dr. Tappenden

To address malnutrition prevalence and its detrimental effects, SHM and the Academy of Medical-Surgical Nurses (AMSN), the Academy of Nutrition and Dietetics (AND), the American Society of Parenteral and Enteral Nutrition (ASPEN), and Abbott Nutrition have formed the Alliance for Patient Nutrition. Kelly Tappenden, MD, PhD, professor of food science and human nutrition at the University of Illinois at Urbana, says the alliance aims to raise awareness of the impact nutrition can have on patient outcomes (see “Three Steps to Better Nutrition,” below).

The campaign is being initiated with the publication of a consensus paper in several peer-reviewed journals. A baseline survey will be conducted among professionals represented in the alliance to assess their familiarity with the prevalence of malnutrition in a hospital setting. The next step is to foster this change in patient care by providing resources on the alliance’s website (www.malnutrition.com), including malnutrition screening tools, a toolkit to facilitate multidisciplinary collaboration, and continuing medical education (CME) information.

Dr. Parkhurst

As a founding member of the alliance, SHM is communicating this message to its members, encouraging hospitalists to lead the way in transforming hospital culture to recognize the critical role nutrition plays in patient care.

“Nutrition matters,” Dr. Parkhurst says. “You can be winning the battle and losing the war if you are not paying attention to patient nutrition.”

Team Approach

Dr. Quatrara

Beth Quatrara, DNP, RN, director of the nursing research program at the University of Virginia Health System in Charlottesville and nursing spokesperson for the alliance, says several shortcomings can be identified in the nutritional care U.S. hospitals provide from admission through discharge and beyond. For example, the Joint Commission requires that all patients be screened for malnutrition risk within 48 hours of admission. But screening is often as cursory as looking at the patient and deciding that he or she “looks fine.” Diets often are set for patients with no thought to taste, texture, or cultural preferences, or even to such practical matters as ascertaining whether the patient has dentures, Quatrara says. Meal trays are left when patients are out of their rooms for procedures and retrieved by dietary staff before patients return. And except for calorie count orders, accurate records often are not kept of actual food consumption.

The alliance, which is made possible with support from Abbott's nutrition business, recommends that physicians implement a three-step plan to improve patient outcomes. The approach begins with an evaluation of a patient’s nutritional status on admission using a simple, validated screening tool, such as the Malnutrition Screening Tool. When an at-risk status is determined, a more in-depth screening is performed. “When patients at risk for malnutrition can be identified faster, appropriate interventions can be put into place sooner,” Quatrara says.

The second step is nutrition intervention with a personalized nutritional care plan that takes into account the individual’s health conditions, caloric needs, physical limitations, tastes, and preferences. An interdisciplinary team approach can transform hospital nutrition, bringing together hospitalists, nurses, nursing assistants, registered dietitians, and the dietary staff to collaboratively develop a nutrition care plan that will be central to patient’s overall treatment, Dr. Tappenden says.

“There is a science behind nutrition and metabolic care,” Dr. Tappenden says. “Just like any other aspect of patient care, we can’t just throw out a blanket solution.”

But nutritional care cannot stop with developing this plan at the outset. Patients must be rescreened throughout their time at the hospital to measure any changes in nutritional status due to disease progression or treatment success.

For optimal impact, all members of the nutritional care team—nurses, nursing assistants, dietary support staff, and family members—should take responsibility for an essential component of the patient’s care: tracking and reporting consumption to the physician to open a dialogue about balancing an individual’s needs with tastes and preferences.

The hospitalist’s final step is developing a discharge plan that includes nutrition care and education so that patients, families, and caregivers can implement better nutrition at home.

“Nutrition makes sense,” Dr. Tappenden says. “Everything we are working toward in healthcare reform can be achieved by taking more care to make nutrition part of the solution.”

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. J Hosp Med. 2013;8:52-58.
2. Alliance for Patient Nutrition. Malnutrition Backgrounder.
3. Banks M, Bauer J, Graves N, Ash S. Malnutrition and pressure ulcer risk in adults in Australian health care facilities. Clin Nutr. 2010;26:896-901.
4. Fry DE, Pine M, Jones BL, Meimban RJ. Patient characteristics and the occurrence of never events. Arch Surg. 2010;145:148-151.
5. Gariballa S, Forster S, Walters S, Powers H. A randomized, double-blind, placebo-controlled trial of nutritional supplementation during acute illness. Am J Med. 2006;119:693-699.
6. Neelemaat F, Lips P, Bosmans J, Thijs A, Seidell JC, van Bokhorst-de van der Schuerer MA. Short-term oral nutritional intervention with protein and vitamin D decreases falls in malnourished older adults. J Am Geriatr Soc. 2012;60:691-699.
7. Brugler L, DiPrinzio MJ, Bernstein L. The five-year evolution of a malnutrition treatment program in a community hospital. J Qual Improv. 1999;25:191-206.
8. Stratton PJ, et al. Enteral nutritional support in prevention and treatment of pressure ulcers: a systematic review and meta-analysis. Ageing Res Rev. 2005;4:422-450.
9. Lawson RM, Doshi MK, Barton JR, Cobden I. The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcomes of elderly orthopaedic patients. Clin Nutr. 2003;22:39-46.

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

Empathy: ability to understand and share the feelings of another.

In today’s increasingly hyper-measured healthcare world, we are looking more and more at measures of patient outcomes. The Institute for Healthcare Improvement (IHI) touts the Triple Aim principle as the lens through which we should be approaching our work. The Triple Aim is the three-part goal and simultaneous focus of improving the health of the community and our patients, improving affordability of care, and finally and perhaps most elusively, improving the patient experience. Who wouldn’t want to hit on these admirable goals? How do we do it?

In approaching the health aspect of the Triple Aim, we, as hospitalists, have tried-and-true frameworks of process improvement. Clinical research and peer-reviewed publication advance the knowledge of what medicines and procedures can improve care. Although powerful and generally truthful, this system results in a slow diffusion of practice improvement, not to mention idiosyncratic and nonstandardized care. This has led to a new toolkit of improvement techniques: continuous quality improvement, Lean, and Six Sigma. We learn and adopt these and watch our scores go up at a steady pace.

Improving affordability has its challenges, some huge, like our basic cultural ethos that “more is better.” Yet affordability is still something we can grasp. It is rooted in systems we are all familiar with, from basic personal finance to resource allocation to generally accepted accounting principles. We all can grasp that the current system of pay for widgets is teetering at the edge, just waiting for a shove from CMS to send it to its doom. Once this happens, affordability likely will become something we can start to make serious headway against.

Improving the experience of patients and families is perhaps the toughest of the three and where I would like to focus.

Patients First

First, a question: Are experience scores reflective of the true experience of a patient?

Two weeks after discharge, when patients receive their HCAHPS questionnaire in the mail, do they remember the details of their stay? And who was their doctor anyway? The cardiologist who placed a stent? The on-call doctor? The hospitalist who visited them every morning? If all we focus on is the scores, and we lack faith that the scores represent the true experience of patients, then how can we ever truly create a more satisfying experience for our patients?

I believe that the answer lies with empathy. What’s unique about this part of the Triple Aim is that many of the answers are within us. Gaining empathy with our patients requires us to ask questions of them and also to ask questions of ourselves. It requires us to invoke ancient methods of learning and thinking, like walking in another’s shoes for a day or using the Golden Rule. Experience doesn’t lend itself to being taught by PowerPoint. It must be lived and channeled back and out through our emotional selves as empathy.

Using the wisdom of patients themselves is one way to understand their needs and develop the empathy to motivate us to change how we do things in health care. Many organizations around the country have used some form of patient focus group to help learn from patients. Park Nicollet, a large health system in Minnesota, has incorporated family councils in nearly every clinic and care area. They usually are patients or caregivers from the area, bound together by a common disease or location. They dedicate their time, often meeting monthly, to share their stories, give opinions on care processes, and even to shape the design of a care area. Currently, there are more than 100 patient councils in the system, and the number continues to grow.

Film, when done skillfully, is a powerful tool in helping us gain empathy. The Cleveland Clinic has produced an amazing short film called “Empathy: The Human Connection to Patient Care.” It follows patients, families, and staff through the care system. As the camera focuses on each person, floating text appears near them, explaining their situation, inner thoughts, or fears, all overlaid by an emotional piano score. Tears will flow. Understanding follows.

Jim Merlino, MD, Cleveland Clinic’s chief experience officer, explains, “We need to understand that being on the other side of health care is frightening, and our job, our responsibility as people responsible for other people, is to help ease that fear.” Cleveland Clinic has done a remarkable job in reminding us why we went in to health care.

Morgan Spurlock of “Super Size Me” fame produced a reality series called “30 Days.” In each episode, a participant spent 30 days in the shoes of another. In the “Life in a Wheelchair” episode, Super Bowl-winning football player Ray Crockett lives in a wheelchair for 30 days and explores what it is like going through recovery and the healthcare system. He meets several rehabbing paraplegics and quadriplegics and accompanies them through their daily lives at home and the hospital. Viewers gain empathy directly in seeing these patients struggle to get better and work with the healthcare system. We also gain empathy watching Crockett gain empathy. The combination is powerful.

In Patients’ Shoes

In addition to listening and observation, we can begin to literally walk in the shoes of our patients.

I recently attended IHI’s International Forum in London. The National Health Service (NHS) in England is using a new tool to help providers understand what it is like for geriatric patients who must navigate the healthcare system with diminished senses and capabilities. Providers put on an age-simulation suit (www.age-simulation-suit.com) that mimics the impairments of aging. Special goggles fog the vision and narrow the visual field. Head mobility is reduced so that it becomes difficult to see beyond the field cuts. Earmuffs reduce high-frequency hearing and the ability to understand speech clearly. The overall suit impedes motion and reduces strength. Thick gloves make it difficult to coordinate fine motions. Wearing this suit and trying to go through a hospital or clinic setting instantly makes the wearer gain empathy for our patients’ needs.

Most important, be a patient. SHM immediate past president Shaun Frost, MD, SFHM, whose personal mission during his tenure was to help the society understand patient experience, explained it best to me. “In one episode in the hospital with a family member, I learned more about patient experience than all the reading and self-educating I have been doing for the last year.”

I think any of us who have been a patient in the hospital, or accompanied a loved one, comes out frustrated that the healthcare system is so convoluted and lacking in clarity for patients. Then there is often a sense of renewal, hopefully,followed by evangelism to spread their newfound empathy to others in the system.

In our busy work lives as hospitalists, it isn’t easy turning our daily focus away from efficiency and productivity. Yet we must always remain mindful of that core idea every one of us wrote down as the heart of our personal statements on our applications to medical school. Do you remember writing something like this? “I want to help people and relieve suffering in their time of need.”

Empathy is the start of our work.

Dr. Kealey is medical director of hospital specialties at HealthPartners Medical Group in St. Paul, Minn. He is an SHM board member and SHM president-elect.

The Centers for Medicare & Medicaid Services (CMS) recently released a few Fact Sheets on how they anticipate funding changes on a few of their programs that were implemented (or sustained) under the Affordable Care Act. As a background, CMS pays most acute-care hospitals by prospectively determining payment based on a patient’s diagnosis and the severity of illness within that diagnosis (e.g. “MS-DRG”). These payment amounts are updated annually after evaluating several factors, including the costs associated with the delivery of care.

One of the most major changes described in the Fact Sheet that will affect hospitalists is how CMS will review inpatient stays based on the number of nights in the hospital. CMS has proposed that any patient who stays in the hospital for two or more “midnights” should be appropriate for payment under Medicare Part A. For those who stay in the hospital for only one (or zero) midnights, payment under Medicare Part A will only be appropriate if:

1. There is sufficient documentation at the time of admission that the anticipated length of stay is two or more nights; and.
2. Further documentation that circumstances changed, and the hospital stay ended prematurely because of those changes.

Overall for hospitalists, this should substantially simplify the admitting process, whereby most inpatients being admitted with the anticipation of two or more nights should qualify for an inpatient stay. This also reduces the administrative burden of correcting the “inpatient” versus “observation” designation, which keeps many hospital staffs entirely too busy. This change also should relieve a significant burden from the patients and their families, who if kept in observation for a period of time, may have to pay substantially out of pocket to make up for the difference between the cost of the stay and the reimbursement from CMS for observation status. So this is one of the moves that CMS is making to simplify (and not complicate) an already too-complicated payment system. This should go into effect October 2013 and will be a sigh of much relief from many of us.

A few other anticipated changes that will affect hospitalists include:

Payments for Unfunded Care

Another major change that will go into affect October 2013 is the amount of monies received by hospitals that care for unfunded patients. These payments historically have been made to “Disproportionate Share Hospitals” (DSH), which are hospitals that care for a higher percentage of unfunded patients. Under the Affordable Care Act, only 25% of these payments will be distributed to DSH hospitals; the remaining 75% will be reduced based on the number of uninsured in the U.S., then redistributed to DSH hospitals based on their portion of uninsured care delivered.

Most DSH hospitals should expect a decrease in DSH payments, the amount of which will depend on their share of unfunded patients.

Any reduction in the “bottom line” to the hospital can affect hospitalists, especially those who are directly employed by the hospital.

Hospital-Acquired Conditions

CMS has long had the Hospital-Acquired Condition (HAC) program in effect, which has the ability to reduce the amount of payment for inpatients who acquire a HAC during their hospital stay. Starting in October 2014, CMS will impose additional financial penalties for hospitals with high HAC rates.

Specifically, those hospitals in the highest 25th percentile of HAC rates will be penalized 1% of their overall CMS payments. Another proposed change is that the following be included in the HAC reduction plan (two “domains” of measures):

• Domain No. 1: Six of the AHRQ Patient Safety Indicators (PSIs), including pressure ulcers, foreign bodies left in after surgery, iatrogenic pneumothorax, postoperative physiologic or metabolic derangements, postoperative VTE, and accidental puncture/laceration.
• Domain No. 2: Central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTIs).

The domains will be weighted equally, and an average score will determine the total score. There will be some methodology for risk adjustment, and hospitals will be given a review and comment period to validate their own scores.

Most hospitalists have at least indirect control over many of these HACs,and all need to pay very close attention to their hospital’s rates of these now and in the future.

Readmissions

As we all know, the Hospital Readmission Reduction program went into effect October 2012; it placed 1% of CMS payments at risk. This will increase to 2% of payments as of October 2013. CMS will continue to use AMI, CHF, and pneumonia as the three conditions under which the readmissions are measured but will put in some methodology to account for planned readmissions.

In addition, in October 2014, they plan to add readmission rates for COPD and for hip/knee arthroplasty.

Hospitalists will continue to need to progress their transitions of care programs, at least for these five patients conditions but more likely (and more effectively) for all hospital discharges.

Quality Measures

Currently more than 99% of acute-care hospitals participate in the pay-for-reporting quality program through CMS, the results of which have been displayed on the Hospital Compare website (www.hospitalcompare.hhs.gov) for years. The program started in 2004 with 10 quality metrics and now includes 57 metrics. These include process and outcome measures for AMI, CHF, and pneumonia, as well as process measures for surgical care, HACs, and patient-satisfaction surveys, among others.

This program will continue to expand over time, including hospital-acquired MRSA and Clostridium difficile rates. The few hospitals not participating will have their CMS annual payments reduced by 2%.

EHR Incentives

CMS is evaluating ways to reduce the burden of reporting by aligning EHR incentives with the Inpatient Quality Reporting program.

Summary

After an open commentary period, the Final Rule will be published Aug. 1, and will become effective for discharges on or after Oct. 1. Although CMS will continue to expand the total number of measures that need to be reported, and the penalties for non-reporting or low performance will continue to escalate, CMS is at least attempting to reduce the overall burden of reporting by combining measures and programs over time and using EHRs to facilitate the bulk of reporting over time.

The global message to hospitalists is: Continue to focus on reducing the burden of HACs, enhance throughput, and carefully and thoughtfully transition patients to the next provider after their hospital discharge. All in all, although at times this can feel overwhelming, these changes represent the right direction to move for high-quality and safe patient care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

Reference

1. Centers for Medicare & Medicaid. Fact Sheets: CMS proposals to improve quality of care during hospital inpatient stays. Centers for Medicare & Medicaid website. Available at: www.cms.gov/apps/media/press/factsheet.asp?Counter=4586&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed May 1, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently released a few Fact Sheets on how they anticipate funding changes on a few of their programs that were implemented (or sustained) under the Affordable Care Act. As a background, CMS pays most acute-care hospitals by prospectively determining payment based on a patient’s diagnosis and the severity of illness within that diagnosis (e.g. “MS-DRG”). These payment amounts are updated annually after evaluating several factors, including the costs associated with the delivery of care.

One of the most major changes described in the Fact Sheet that will affect hospitalists is how CMS will review inpatient stays based on the number of nights in the hospital. CMS has proposed that any patient who stays in the hospital for two or more “midnights” should be appropriate for payment under Medicare Part A. For those who stay in the hospital for only one (or zero) midnights, payment under Medicare Part A will only be appropriate if:

1. There is sufficient documentation at the time of admission that the anticipated length of stay is two or more nights; and.
2. Further documentation that circumstances changed, and the hospital stay ended prematurely because of those changes.

Overall for hospitalists, this should substantially simplify the admitting process, whereby most inpatients being admitted with the anticipation of two or more nights should qualify for an inpatient stay. This also reduces the administrative burden of correcting the “inpatient” versus “observation” designation, which keeps many hospital staffs entirely too busy. This change also should relieve a significant burden from the patients and their families, who if kept in observation for a period of time, may have to pay substantially out of pocket to make up for the difference between the cost of the stay and the reimbursement from CMS for observation status. So this is one of the moves that CMS is making to simplify (and not complicate) an already too-complicated payment system. This should go into effect October 2013 and will be a sigh of much relief from many of us.

A few other anticipated changes that will affect hospitalists include:

Payments for Unfunded Care

Another major change that will go into affect October 2013 is the amount of monies received by hospitals that care for unfunded patients. These payments historically have been made to “Disproportionate Share Hospitals” (DSH), which are hospitals that care for a higher percentage of unfunded patients. Under the Affordable Care Act, only 25% of these payments will be distributed to DSH hospitals; the remaining 75% will be reduced based on the number of uninsured in the U.S., then redistributed to DSH hospitals based on their portion of uninsured care delivered.

Most DSH hospitals should expect a decrease in DSH payments, the amount of which will depend on their share of unfunded patients.

Any reduction in the “bottom line” to the hospital can affect hospitalists, especially those who are directly employed by the hospital.

Hospital-Acquired Conditions

CMS has long had the Hospital-Acquired Condition (HAC) program in effect, which has the ability to reduce the amount of payment for inpatients who acquire a HAC during their hospital stay. Starting in October 2014, CMS will impose additional financial penalties for hospitals with high HAC rates.

Specifically, those hospitals in the highest 25th percentile of HAC rates will be penalized 1% of their overall CMS payments. Another proposed change is that the following be included in the HAC reduction plan (two “domains” of measures):

• Domain No. 1: Six of the AHRQ Patient Safety Indicators (PSIs), including pressure ulcers, foreign bodies left in after surgery, iatrogenic pneumothorax, postoperative physiologic or metabolic derangements, postoperative VTE, and accidental puncture/laceration.
• Domain No. 2: Central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTIs).

The domains will be weighted equally, and an average score will determine the total score. There will be some methodology for risk adjustment, and hospitals will be given a review and comment period to validate their own scores.

Most hospitalists have at least indirect control over many of these HACs,and all need to pay very close attention to their hospital’s rates of these now and in the future.

Readmissions

As we all know, the Hospital Readmission Reduction program went into effect October 2012; it placed 1% of CMS payments at risk. This will increase to 2% of payments as of October 2013. CMS will continue to use AMI, CHF, and pneumonia as the three conditions under which the readmissions are measured but will put in some methodology to account for planned readmissions.

In addition, in October 2014, they plan to add readmission rates for COPD and for hip/knee arthroplasty.

Hospitalists will continue to need to progress their transitions of care programs, at least for these five patients conditions but more likely (and more effectively) for all hospital discharges.

Quality Measures

Currently more than 99% of acute-care hospitals participate in the pay-for-reporting quality program through CMS, the results of which have been displayed on the Hospital Compare website (www.hospitalcompare.hhs.gov) for years. The program started in 2004 with 10 quality metrics and now includes 57 metrics. These include process and outcome measures for AMI, CHF, and pneumonia, as well as process measures for surgical care, HACs, and patient-satisfaction surveys, among others.

This program will continue to expand over time, including hospital-acquired MRSA and Clostridium difficile rates. The few hospitals not participating will have their CMS annual payments reduced by 2%.

EHR Incentives

CMS is evaluating ways to reduce the burden of reporting by aligning EHR incentives with the Inpatient Quality Reporting program.

Summary

After an open commentary period, the Final Rule will be published Aug. 1, and will become effective for discharges on or after Oct. 1. Although CMS will continue to expand the total number of measures that need to be reported, and the penalties for non-reporting or low performance will continue to escalate, CMS is at least attempting to reduce the overall burden of reporting by combining measures and programs over time and using EHRs to facilitate the bulk of reporting over time.

The global message to hospitalists is: Continue to focus on reducing the burden of HACs, enhance throughput, and carefully and thoughtfully transition patients to the next provider after their hospital discharge. All in all, although at times this can feel overwhelming, these changes represent the right direction to move for high-quality and safe patient care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

Reference

1. Centers for Medicare & Medicaid. Fact Sheets: CMS proposals to improve quality of care during hospital inpatient stays. Centers for Medicare & Medicaid website. Available at: www.cms.gov/apps/media/press/factsheet.asp?Counter=4586&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed May 1, 2013.

The Centers for Medicare & Medicaid Services (CMS) recently released a few Fact Sheets on how they anticipate funding changes on a few of their programs that were implemented (or sustained) under the Affordable Care Act. As a background, CMS pays most acute-care hospitals by prospectively determining payment based on a patient’s diagnosis and the severity of illness within that diagnosis (e.g. “MS-DRG”). These payment amounts are updated annually after evaluating several factors, including the costs associated with the delivery of care.

One of the most major changes described in the Fact Sheet that will affect hospitalists is how CMS will review inpatient stays based on the number of nights in the hospital. CMS has proposed that any patient who stays in the hospital for two or more “midnights” should be appropriate for payment under Medicare Part A. For those who stay in the hospital for only one (or zero) midnights, payment under Medicare Part A will only be appropriate if:

1. There is sufficient documentation at the time of admission that the anticipated length of stay is two or more nights; and.
2. Further documentation that circumstances changed, and the hospital stay ended prematurely because of those changes.

Overall for hospitalists, this should substantially simplify the admitting process, whereby most inpatients being admitted with the anticipation of two or more nights should qualify for an inpatient stay. This also reduces the administrative burden of correcting the “inpatient” versus “observation” designation, which keeps many hospital staffs entirely too busy. This change also should relieve a significant burden from the patients and their families, who if kept in observation for a period of time, may have to pay substantially out of pocket to make up for the difference between the cost of the stay and the reimbursement from CMS for observation status. So this is one of the moves that CMS is making to simplify (and not complicate) an already too-complicated payment system. This should go into effect October 2013 and will be a sigh of much relief from many of us.

A few other anticipated changes that will affect hospitalists include:

Payments for Unfunded Care

Another major change that will go into affect October 2013 is the amount of monies received by hospitals that care for unfunded patients. These payments historically have been made to “Disproportionate Share Hospitals” (DSH), which are hospitals that care for a higher percentage of unfunded patients. Under the Affordable Care Act, only 25% of these payments will be distributed to DSH hospitals; the remaining 75% will be reduced based on the number of uninsured in the U.S., then redistributed to DSH hospitals based on their portion of uninsured care delivered.

Most DSH hospitals should expect a decrease in DSH payments, the amount of which will depend on their share of unfunded patients.

Any reduction in the “bottom line” to the hospital can affect hospitalists, especially those who are directly employed by the hospital.

Hospital-Acquired Conditions

CMS has long had the Hospital-Acquired Condition (HAC) program in effect, which has the ability to reduce the amount of payment for inpatients who acquire a HAC during their hospital stay. Starting in October 2014, CMS will impose additional financial penalties for hospitals with high HAC rates.

Specifically, those hospitals in the highest 25th percentile of HAC rates will be penalized 1% of their overall CMS payments. Another proposed change is that the following be included in the HAC reduction plan (two “domains” of measures):

• Domain No. 1: Six of the AHRQ Patient Safety Indicators (PSIs), including pressure ulcers, foreign bodies left in after surgery, iatrogenic pneumothorax, postoperative physiologic or metabolic derangements, postoperative VTE, and accidental puncture/laceration.
• Domain No. 2: Central-line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTIs).

The domains will be weighted equally, and an average score will determine the total score. There will be some methodology for risk adjustment, and hospitals will be given a review and comment period to validate their own scores.

Most hospitalists have at least indirect control over many of these HACs,and all need to pay very close attention to their hospital’s rates of these now and in the future.

Readmissions

As we all know, the Hospital Readmission Reduction program went into effect October 2012; it placed 1% of CMS payments at risk. This will increase to 2% of payments as of October 2013. CMS will continue to use AMI, CHF, and pneumonia as the three conditions under which the readmissions are measured but will put in some methodology to account for planned readmissions.

In addition, in October 2014, they plan to add readmission rates for COPD and for hip/knee arthroplasty.

Hospitalists will continue to need to progress their transitions of care programs, at least for these five patients conditions but more likely (and more effectively) for all hospital discharges.

Quality Measures

Currently more than 99% of acute-care hospitals participate in the pay-for-reporting quality program through CMS, the results of which have been displayed on the Hospital Compare website (www.hospitalcompare.hhs.gov) for years. The program started in 2004 with 10 quality metrics and now includes 57 metrics. These include process and outcome measures for AMI, CHF, and pneumonia, as well as process measures for surgical care, HACs, and patient-satisfaction surveys, among others.

This program will continue to expand over time, including hospital-acquired MRSA and Clostridium difficile rates. The few hospitals not participating will have their CMS annual payments reduced by 2%.

EHR Incentives

CMS is evaluating ways to reduce the burden of reporting by aligning EHR incentives with the Inpatient Quality Reporting program.

Summary

After an open commentary period, the Final Rule will be published Aug. 1, and will become effective for discharges on or after Oct. 1. Although CMS will continue to expand the total number of measures that need to be reported, and the penalties for non-reporting or low performance will continue to escalate, CMS is at least attempting to reduce the overall burden of reporting by combining measures and programs over time and using EHRs to facilitate the bulk of reporting over time.

The global message to hospitalists is: Continue to focus on reducing the burden of HACs, enhance throughput, and carefully and thoughtfully transition patients to the next provider after their hospital discharge. All in all, although at times this can feel overwhelming, these changes represent the right direction to move for high-quality and safe patient care.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at [email protected].

Reference

1. Centers for Medicare & Medicaid. Fact Sheets: CMS proposals to improve quality of care during hospital inpatient stays. Centers for Medicare & Medicaid website. Available at: www.cms.gov/apps/media/press/factsheet.asp?Counter=4586&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date. Accessed May 1, 2013.

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Funeral-home representatives sometimes make multiple trips to a hospital or doctor’s office to get a death certificate signed, often waiting in the lobby for hours. I first realized this in the 1980s when starting post-residency practice as a hospitalist. I began asking these guys (they are nearly always men, in my experience) how much time they typically invest getting each certificate signed. They told of walking halfway across a golf course to catch the doctor on the 13th hole or making the 90-minute drive (each way) to a doctor’s office, sometimes finding the doctor had just left, only to repeat the process several times before getting the signature.

When the Clinton administration made electronic signatures via the Internet valid, I thought about starting a business charging funeral homes something like $200 for getting the doctor to sign it electronically within 48 hours. I would use about half of the $200 to provide an incentive for the doctor to sign quickly (sign within 48 hours, and you’ll get a $100 gift card!), then use the rest to fund the company. Since funeral homes probably spend much more than $200 per certificate paying their staff to drive around getting signatures on paper, I thought they would jump at this idea.

I never pursued it, but that doesn’t stop me from loudly proclaiming to friends and family that it was a “can’t-miss” blockbuster Internet business idea. Of course, I never tested that theory, but it makes for fun chest-thumping at parties.

A number of states, including Florida, Texas, and others, now have in place online completion of death certificates. Indiana has required use of its online death certificate since 2011; there is no option to use paper. I suspect nearly every state will do the same before long. But that alone won’t ensure timely completion. Doctors and others who complete the certificates need to ensure they respond quickly, something they often fail to do.

It Really Matters

Lack of a death certificate can hold up burial or cremation, and things like life-insurance payouts and estate settlement are delayed. For a grieving family, these things only add to their pain.

I’m aware of a tragic case from a few years ago in which a certificate was passed around to a number of doctors, each of whom thought with some justification that someone else should sign it. It sat in two different mailboxes for many days while the intended recipients were vacationing. All of this delayed the burial, and the poor family had to send updates to loved ones saying, “We don’t know when Dad’s funeral will be.” About three weeks later, the certificate was completed and the funeral held. What a terribly sad story!

Some states have laws governing how quickly certificates must be signed. A thought-provoking 2004 Medical Staff Update from Stanford University says that California requires a signature within 15 hours of death, though I wonder how often this is enforced.

Improving Turnaround Time

There are several things hospitalists could consider to improve timely completion of death certificates:

• Ensure doctors liberally complete them for one another. Don’t let one doctor’s absence delay, even for a day, getting it completed and signed. This means the “covering” doctor has access to the discharge (death) summary in the medical record.
• When several doctors in different specialties are caring for a patient at the time of death, nearly any of them could reasonably sign the certificate. It might be appropriate to adopt a policy that whichever doctor (e.g. hospitalist, intensivist, or oncologist) who had contact with the patient and is presented with the certificate should go ahead and sign it rather than passing it along to one of the other specialties, regardless of which served as attending.
• Consider creating a central access point at your hospital for receipt of death certificates. Ideally, a funeral-home representative can deliver it to one person at the hospital who will do the leg work of getting a doctor to sign it quickly. Delays are likely if the funeral-home representative has to “shop it around” to different departments and physician offices. A hospital staffer should be able to navigate this quickly.
• Pressure EMR vendors to include some sort of death-certificate functionality in the future. I don’t know if some have it already, but it seems like it shouldn’t be too difficult for an EMR to spit out a prefilled certificate in much the same way e-prescribing works. It could even be delivered electronically to the funeral home.
• For hospitalists with 24-hour, on-site presence, it could be reasonable to have an on-duty hospitalist complete the certificate at the time of death rather than waiting for the funeral home to initiate the process. This was standard when I was a resident, and it may be a practical approach in many settings.
• Consider copying one hospital I worked with previously: They created a hospitalist salary bonus for timely completion. I assure you this policy was very effective.

Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].

Dr. Hospitalist

I am a third-year internal-medicine resident and currently looking for a nocturnist opportunity. I have no experience in negotiating a job or salary. When I interview for a job, should I negotiate for salary? How do I know that the salary is correct and what others in the same group are getting? Thanks for the help.

–Santhosh Mannem, New York City

Dr. Hospitalist responds:

Salary discussions are always intriguing, mainly because you won’t really know what everyone else is getting paid. There are several places to get some information. To begin, find out the general salary range for the market in which you want to work. Just because an annual salary might be $240,000 in Emporia, Kan., doesn’t mean a thing if you are looking for a job in Salt Lake City or Seattle. You can use the online resources through SHM (www.hospitalmedicine.org/survey) to paint a pretty good picture of salary by region, but remember that these are ranges only.

When I think of job offers, I like to take total compensation and break it down by category. For example, benefits are not negotiable—your employer cannot vary the health insurance coverage they provide by physician. Still, you need to consider benefits as an important part of the package. A good health insurance plan won’t mean as much to a single physician as it would to one with a family, so consider your individual needs. I strongly encourage you to make a line item for every potential benefit: health, dental, disability, life, continuing medical education (CME), professional dues, retirement plans (potentially with an employer match), malpractice insurance costs, and so on. A job with a “salary” of $300,000 but no benefits would pale in comparison to a job paying $250,000 with full benefits.

Don’t discount the value of benefits; get the numbers and assign a dollar amount. If the group is not being transparent on benefits, walk away.

With strict regard to salary, you probably will get little to no information as to what the rest of the group members are paid. Feel free to ask, but expect some vague answers. Most often, there is a fairly tight convergence of salaries within a given market, and it’s always better to interview for more than one job in the same location. You mentioned that you’d like to work as a nocturnist, which is good. These positions are recruited heavily and tend to command a higher initial salary.

Overall, your ability to negotiate a higher salary is going to be rather limited. However, there is another calculation worth mentioning: You need to find out how much you are being paid per unit of work so you can compare jobs. Here are some of the items to help you figure out a formula that works for you: annual salary, contracted shifts per year/month, pay per shift, admits/census per shift, number of weekends, and potential bonus thresholds. Use these numbers (metrics) to more accurately compare different jobs. There is no magic formula; it just depends on what is important to you, but you will get a much better picture if you combine these metrics with your benefit analysis.

As a nocturnist, I would not expect to hit any productivity metrics. If you are that busy, it’s probably a miserable job. In a business sense, nights almost always lose money.

One thing that can always be negotiated: a signing bonus and/or loan forgiveness. Often, a practice won’t want to continually offer higher starting salaries since eventually this causes wage creep across the practice. However, they can be much more flexible when it comes to “one-time” payments. This keeps the overall salary structure for the practice intact and is usually much more agreeable for your employer. As always, it’s a supply-and-demand issue, but if you are a nocturnist looking at a high-demand area, I would negotiate hard for a signing bonus and maybe even a contract-renewal bonus after your first year.

It never hurts to get creative, either. I remember negotiating my first job; I offered to sign a two-year contract (instead of one) if they would let me take off six months the first year. They said yes, I did some traveling that first year on my new salary, and I stayed with the practice for 11 years. Don’t get so caught up in salary numbers that you lose sight of what’s really important to you and whether the job would be the right fit.

Good luck and welcome to hospital medicine. You’ll love it.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I am a third-year internal-medicine resident and currently looking for a nocturnist opportunity. I have no experience in negotiating a job or salary. When I interview for a job, should I negotiate for salary? How do I know that the salary is correct and what others in the same group are getting? Thanks for the help.

–Santhosh Mannem, New York City

Dr. Hospitalist responds:

Salary discussions are always intriguing, mainly because you won’t really know what everyone else is getting paid. There are several places to get some information. To begin, find out the general salary range for the market in which you want to work. Just because an annual salary might be $240,000 in Emporia, Kan., doesn’t mean a thing if you are looking for a job in Salt Lake City or Seattle. You can use the online resources through SHM (www.hospitalmedicine.org/survey) to paint a pretty good picture of salary by region, but remember that these are ranges only.

When I think of job offers, I like to take total compensation and break it down by category. For example, benefits are not negotiable—your employer cannot vary the health insurance coverage they provide by physician. Still, you need to consider benefits as an important part of the package. A good health insurance plan won’t mean as much to a single physician as it would to one with a family, so consider your individual needs. I strongly encourage you to make a line item for every potential benefit: health, dental, disability, life, continuing medical education (CME), professional dues, retirement plans (potentially with an employer match), malpractice insurance costs, and so on. A job with a “salary” of $300,000 but no benefits would pale in comparison to a job paying $250,000 with full benefits.

Don’t discount the value of benefits; get the numbers and assign a dollar amount. If the group is not being transparent on benefits, walk away.

With strict regard to salary, you probably will get little to no information as to what the rest of the group members are paid. Feel free to ask, but expect some vague answers. Most often, there is a fairly tight convergence of salaries within a given market, and it’s always better to interview for more than one job in the same location. You mentioned that you’d like to work as a nocturnist, which is good. These positions are recruited heavily and tend to command a higher initial salary.

Overall, your ability to negotiate a higher salary is going to be rather limited. However, there is another calculation worth mentioning: You need to find out how much you are being paid per unit of work so you can compare jobs. Here are some of the items to help you figure out a formula that works for you: annual salary, contracted shifts per year/month, pay per shift, admits/census per shift, number of weekends, and potential bonus thresholds. Use these numbers (metrics) to more accurately compare different jobs. There is no magic formula; it just depends on what is important to you, but you will get a much better picture if you combine these metrics with your benefit analysis.

As a nocturnist, I would not expect to hit any productivity metrics. If you are that busy, it’s probably a miserable job. In a business sense, nights almost always lose money.

One thing that can always be negotiated: a signing bonus and/or loan forgiveness. Often, a practice won’t want to continually offer higher starting salaries since eventually this causes wage creep across the practice. However, they can be much more flexible when it comes to “one-time” payments. This keeps the overall salary structure for the practice intact and is usually much more agreeable for your employer. As always, it’s a supply-and-demand issue, but if you are a nocturnist looking at a high-demand area, I would negotiate hard for a signing bonus and maybe even a contract-renewal bonus after your first year.

It never hurts to get creative, either. I remember negotiating my first job; I offered to sign a two-year contract (instead of one) if they would let me take off six months the first year. They said yes, I did some traveling that first year on my new salary, and I stayed with the practice for 11 years. Don’t get so caught up in salary numbers that you lose sight of what’s really important to you and whether the job would be the right fit.

Good luck and welcome to hospital medicine. You’ll love it.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].

Dr. Hospitalist

I am a third-year internal-medicine resident and currently looking for a nocturnist opportunity. I have no experience in negotiating a job or salary. When I interview for a job, should I negotiate for salary? How do I know that the salary is correct and what others in the same group are getting? Thanks for the help.

–Santhosh Mannem, New York City

Dr. Hospitalist responds:

Salary discussions are always intriguing, mainly because you won’t really know what everyone else is getting paid. There are several places to get some information. To begin, find out the general salary range for the market in which you want to work. Just because an annual salary might be $240,000 in Emporia, Kan., doesn’t mean a thing if you are looking for a job in Salt Lake City or Seattle. You can use the online resources through SHM (www.hospitalmedicine.org/survey) to paint a pretty good picture of salary by region, but remember that these are ranges only.

When I think of job offers, I like to take total compensation and break it down by category. For example, benefits are not negotiable—your employer cannot vary the health insurance coverage they provide by physician. Still, you need to consider benefits as an important part of the package. A good health insurance plan won’t mean as much to a single physician as it would to one with a family, so consider your individual needs. I strongly encourage you to make a line item for every potential benefit: health, dental, disability, life, continuing medical education (CME), professional dues, retirement plans (potentially with an employer match), malpractice insurance costs, and so on. A job with a “salary” of $300,000 but no benefits would pale in comparison to a job paying $250,000 with full benefits.

Don’t discount the value of benefits; get the numbers and assign a dollar amount. If the group is not being transparent on benefits, walk away.

With strict regard to salary, you probably will get little to no information as to what the rest of the group members are paid. Feel free to ask, but expect some vague answers. Most often, there is a fairly tight convergence of salaries within a given market, and it’s always better to interview for more than one job in the same location. You mentioned that you’d like to work as a nocturnist, which is good. These positions are recruited heavily and tend to command a higher initial salary.

Overall, your ability to negotiate a higher salary is going to be rather limited. However, there is another calculation worth mentioning: You need to find out how much you are being paid per unit of work so you can compare jobs. Here are some of the items to help you figure out a formula that works for you: annual salary, contracted shifts per year/month, pay per shift, admits/census per shift, number of weekends, and potential bonus thresholds. Use these numbers (metrics) to more accurately compare different jobs. There is no magic formula; it just depends on what is important to you, but you will get a much better picture if you combine these metrics with your benefit analysis.

As a nocturnist, I would not expect to hit any productivity metrics. If you are that busy, it’s probably a miserable job. In a business sense, nights almost always lose money.

One thing that can always be negotiated: a signing bonus and/or loan forgiveness. Often, a practice won’t want to continually offer higher starting salaries since eventually this causes wage creep across the practice. However, they can be much more flexible when it comes to “one-time” payments. This keeps the overall salary structure for the practice intact and is usually much more agreeable for your employer. As always, it’s a supply-and-demand issue, but if you are a nocturnist looking at a high-demand area, I would negotiate hard for a signing bonus and maybe even a contract-renewal bonus after your first year.

It never hurts to get creative, either. I remember negotiating my first job; I offered to sign a two-year contract (instead of one) if they would let me take off six months the first year. They said yes, I did some traveling that first year on my new salary, and I stayed with the practice for 11 years. Don’t get so caught up in salary numbers that you lose sight of what’s really important to you and whether the job would be the right fit.

Good luck and welcome to hospital medicine. You’ll love it.

Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].