The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

The oft-quoted Hippocrates once stated that physicians should be “clean in person, well-dressed, and anointed with sweet-smelling unguents.” So are hospitalists heeding the father of modern medicine’s counsel about physician appearance in the 21st century?

According to an informal survey about workplace attire conducted recently at the-hospitalist.org, a majority of hospitalists are wearing professional apparel while on the job.

In response to the question "What do you typically wear to work?" more than half (54%) of voters said they dress business casual, commonly defined as a dress shirt, slacks, belt, shoes, and socks for men, and a dress shirt, reasonable-length skirt or full-length trousers, shoes, and hosiery for women. Another 13% stated they wear a suit to work. Meanwhile, the other third of respondents said they dress in scrubs (22%), khakis and polo shirts (10%), and jeans and T-shirts (2%).

Most hospitalists at IPC: The Hospitalist Co., a national physician group practice based in North Hollywood, Calif., opt for business-casual dress, says Rafael Barretto, DO, the company's associate medical director for the Michigan region. While IPC does not have a strict dress code, it does give guidelines to its hospitalists and encourages them to avoid wearing sandals, tennis shoes, and jeans to work.

"IPC considers patients' attitudes on physician appearance to be very important. We want our patients to trust that we're going to do the best we can to take care of them," says Dr. Barretto, who cites several research studies, including a report published in the November 2005 issue of The American Journal of Medicine, that found patients favor physicians in professional attire.

"Fortunately or unfortunately, perception is reality and hospitalists need to be concerned with how a patient or a patient's family perceives them," says Chris Frost, MD, senior vice president of hospital medicine for TeamHealth Hospital Medicine, a national hospitalist management company in Knoxville, Tenn. TeamHealth has a company-wide policy that discourages its physicians from engaging in unprofessional dress.

"Hospitalists only have one chance to make a first impression. If a hospitalist is dressed poorly, that could overshadow any good patient care he or she provides," Dr. Frost says.

Click here to listen to the audio file

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Dr. Jaffer discusses HM10 keynote speakers Paul Levy and Bob Wachter

Click here to listen to the audio.

Dr. Jaffer explains what the average hospitalist should expect at HM10 in Washington, D.C.

Click here to listen to the audio.

Dr. Jaffer discusses how the national healthcare reform debate will backdrop HM10, and how new peer-reviewed, seat-limited workshops will enhance the HM10 experience.

Click here to listen to the audio.

Dr. Jaffer explains how first-time HM10 attendees can maximize their time in D.C.

Click here to listen to the audio.

Dr. Jaffer discusses HM10 keynote speakers Paul Levy and Bob Wachter

Click here to listen to the audio.

Dr. Jaffer explains what the average hospitalist should expect at HM10 in Washington, D.C.

Click here to listen to the audio.

Dr. Jaffer discusses how the national healthcare reform debate will backdrop HM10, and how new peer-reviewed, seat-limited workshops will enhance the HM10 experience.

Click here to listen to the audio.

Dr. Jaffer explains how first-time HM10 attendees can maximize their time in D.C.

Click here to listen to the audio.

Dr. Jaffer discusses HM10 keynote speakers Paul Levy and Bob Wachter

Click here to listen to the audio.

Dr. Jaffer explains what the average hospitalist should expect at HM10 in Washington, D.C.

Click here to listen to the audio.

Dr. Jaffer discusses how the national healthcare reform debate will backdrop HM10, and how new peer-reviewed, seat-limited workshops will enhance the HM10 experience.

Click here to listen to the audio.

Dr. Jaffer explains how first-time HM10 attendees can maximize their time in D.C.

Click here to listen to the audio.

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Massachusetts Update

With the ongoing debate about healthcare reform, I’m curious to know how it worked out in Massachusetts. Didn’t they give everyone health insurance several years ago?

R. McCoy, MD

Birmingham, Ala.

Dr. Hospitalist responds: In 2006, Massachusetts legislators took the same approach to healthcare insurance as they do to auto insurance: require everyone to purchase a plan. If you can’t afford to purchase health insurance, the state provides you insurance through a state-subsidized plan. The state covers individuals earning up to 100% of the federal poverty level (FPL) and partially subsidizes coverage for those earning up to 300% of the FPL.

So how did Massachusetts come up with the money to pay for healthcare insurance for all of its residents? The state traditionally utilized money from a “free-care pool” to partially reimburse hospitals and community health centers for the care provided to indigents. The money in the free-care pool was generated from state and federal taxes, and from assessments on hospitals and healthcare insurance providers. With expanded insurance coverage, Massachusetts estimated that the cost of healthcare delivered to the uninsured would decrease, and the free-care pool could offset the remaining costs of insuring those below the FPL.

Starting in 2007, residents of Massachusetts were required to demonstrate proof of health insurance on their state income tax returns. The state levied penalties on those who failed to obtain coverage. The legislation also required insurers’ family plans to cover young adults up to age 25 or at least two years after they were no longer dependent on their parents. Additionally, businesses with 10 or more employees had to contribute a reasonable amount to their employees’ health insurance premiums or risk a financial penalty.

The Massachusetts health plan has produced both intended and unintended consequences. The plan was successful in its primary goal of insuring its citizens. By the end of 2008, 97% of Massachusetts’ residents were covered. But the system has not increased access to providers because of a shortage of primary-care physicians (PCPs). (Critics also point out that the plan has done nothing to increase the numbers of PCPs in the state.)

Another unexpected outcome is that healthcare costs have increased. The initial expectation was that increasing the percentage of insured individuals would lower overall costs. However, this has not been realized. In fact, the reallocation of funds from the free-care pool has birthed other problems. The state’s “safety net” hospitals—which traditionally have served urban, low-income populations—have experienced financial hardships.

These unexpected findings have not deterred Massachusetts from further efforts to address healthcare reform. In 2008, a special commission was charged with recommendations for a “common payment methodology” that would apply to both public and private payors. The goal is to slow the growth of healthcare costs without adversely affecting the quality of care.

The commission issued its recommendations in July 2009 (www.mass.gov). It suggested “Massachusetts has among the highest healthcare costs in the U.S. … and based on recent history, are projected to grow faster than for the U.S. as a whole.” In its report, the commission was critical of the present fee-for-service reimbursement model and stated that the model was the primary reason for escalating healthcare costs.

The commission noted the fee-for-service model rewards providers for providing more, but not better, care and also encourages providers to provide more-costly services without regard to evidence-based guidelines or a patient’s need. The commission recommended that “global payments with adjustments to reward provision of accessible and high-quality care become the predominant form of payment to providers in Massachusetts.” For the record, the legislature has not acted on the commission recommendations. TH

IMAGE SOURCE: AMANE KANEKO

Editor’s note: Second of a three-part series.

As I mentioned last month, there isn’t a proven best method to use when distributing new referrals among your group’s providers. The popular methods fall along a continuum of being focused on daily, or continuous, leveling of patient loads between providers (“load leveling”) at one end; at the other end of the continuum is having a doctor be “on” for all new referrals for a predetermined time period, and accepting that patient volumes might be uneven day to day but tend to even out over long periods.

There might not be any reason to change your group’s approach to patient assignment, but you should always be thinking about how your own methods might be changed or improved. I have shared (“Bigger Isn’t Always Better,” June 2009, p. 46) my concern that some groups invest far too much time in a morning load-leveling and handoff conference. Make sure your group is using only as much time as needed.

Air-Traffic Controllers

Many large groups (e.g., more than 15 full-time equivalents) that assign patients to providers in sequence, like dealing a deck of cards, have a designated provider who holds the triage pager and serves as “air-traffic controller.” This person typically takes incoming calls about all new referrals, jots down the relevant clinical data, keeps track of which hospitalist is due to take the next patient, pages that person, and repeats the clinical information. As I’ve written before (“How to Hire and Use Clerical Staff,” June 2007, p. 73), many practices have found that during business hours, they can hand this role to a clerical person who simply takes down the name and phone number of the doctor making the referral, then pages that information to the hospitalist due to get the next patient. The hospitalist then calls and speaks directly with the referring doctor.

Small- to medium-sized groups can eliminate entirely the need for any such “air-traffic control” function if they assign all new referrals to a single doctor for specified periods of time. For example, from 7 a.m. to 3 p.m. today, all new referrals go to Dr. Glass, and from 3 p.m. to 11 p.m., they go to Dr. Cage.

Admitter-Rounder Duties

Many—maybe most?—large groups separate daytime admitter and rounder functions so that on any given day, a hospitalist does one but not both. The principal advantages of this approach are reducing the stress on, and possibly increasing the efficiency of, rounding doctors by shielding them from the unpredictable and time-consuming interruption of needing to admit a new patient. And a daytime doctor who only does admissions might be able to start seeing a patient in the ED more quickly than one who is busy making rounds.

Any increased availability of admitters to the ED could be offset by their lack of surge capacity leading to a bottleneck in ED throughput when there are many patients to admit at the same time and a limited number of admitters (often only one). Such a bottleneck would be much less likely if all daytime doctors (i.e., the rounders) were available to see admissions rather than just admitters.

Continuity of care suffers when a group has separate admitters and rounders, because no patients will be seen by the same doctor on the day of admission and the day following. This method requires a handoff from the day of admission to the next day. Such a handoff might be unavoidable for patients admitted during the night, but this doesn’t have to occur when patients are admitted during the daytime.

Who’s Seeing this Patient?

It seems to make sense to wait until each morning to distribute patients. That allows the practice to know just how many new patients there are, and they can be distributed according to complexity and whether a hospitalist has formed a previous relationship with that patient. But it means that no one at the hospital will know which hospitalist is caring for the patient until later in the morning. For example, if the radiologist is over-reading a study done during the night and finds something worthy of a phone call to the hospitalist, no one is sure who should get the call. A patient might develop hypoglycemia shortly after the hospitalist night shift is over, but the nurse doesn’t know which hospitalist to call.

And, perhaps most importantly, if patients aren’t distributed until the start of the day shift, the night hospitalist can’t tell the patient and family which hospitalist to expect the next morning. To test the significance of this issue, I conducted an experiment while working our group’s late-evening admitter shift. I concluded my visit with each admitted patient by explaining, “I am on-call for our group tonight, so I will be off recovering tomorrow. Therefore, I won’t see you again, but one of my partners will take over in the morning. Do you have any questions for me?” Every patient I admitted had the same question. “What is that doctor’s name?”

How does your group answer a patient who asks which hospitalist will be in the next day? If your method is load-leveling in the morning, then the best answer your night admitting doctor can give is probably to say: “I don’t know which of my partners will be in. There are several working tomorrow, and at the start of the day, they will divide up the patients who come in tonight depending on how busy each of them is. But all the doctors in our group are terrific and will take good care of you.”

I’m told the same thing when I get my hair cut: You’ll get whichever “hair artist” is up next. I put up with it at the hair place because it costs less than $15. But I still find it a little irritating. I’m sure all the barbers aren’t equally skilled or diligent, and I want the best one. (Maybe I shouldn’t care since there isn’t much that can be done with my hair.) I’m pretty sure patients feel the same way about which doctor they get. The public is convinced there is a wide variety in the quality of doctors, and they want a good one. If you have to tell them theirs is being assigned by lottery, they won’t be as happy than if you can provide the name and a little information about the doctor they can expect to see the next day.

When the patients I admit late last evening ask who would see them the next day, I’m glad when I can provide a name and a little more information. I say something like, “I won’t see you after tonight, but my partner, Dr. Shawn Lee, will be instead. That means you’re getting an upgrade! Not only is he a really nice guy, he’s voted one of Seattle’s best doctors every year. He’ll do a great job for you.”

To make this communication effective, the night doctor has to know which hospitalist takes over the next morning and has a list indicating which day doctor will get the first, second, third new patient, and so on, admitted during the night. This is possible if patients are assigned by a predetermined algorithm, or if the day doctors have their load-leveling meeting at the end of each day shift, rather than in the morning, to create a list telling the night doctor which day hospitalist he should admit the first and subsequent patents to. That way, the night doctor can write in the admitting orders at 1 a.m. “admit to Dr. X.” This eliminates confusion on the part of other hospital staff who need to know who to call about a patient after the start of the day shift.

Next month I will look at special circumstances, and some pros and cons of having an individual hospitalist take on the care of more patients at the beginning of consecutive day shifts, and exempting them from taking on new patients on the last day or two before rotating off. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Editor’s note: Second of a three-part series.

As I mentioned last month, there isn’t a proven best method to use when distributing new referrals among your group’s providers. The popular methods fall along a continuum of being focused on daily, or continuous, leveling of patient loads between providers (“load leveling”) at one end; at the other end of the continuum is having a doctor be “on” for all new referrals for a predetermined time period, and accepting that patient volumes might be uneven day to day but tend to even out over long periods.

There might not be any reason to change your group’s approach to patient assignment, but you should always be thinking about how your own methods might be changed or improved. I have shared (“Bigger Isn’t Always Better,” June 2009, p. 46) my concern that some groups invest far too much time in a morning load-leveling and handoff conference. Make sure your group is using only as much time as needed.

Air-Traffic Controllers

Many large groups (e.g., more than 15 full-time equivalents) that assign patients to providers in sequence, like dealing a deck of cards, have a designated provider who holds the triage pager and serves as “air-traffic controller.” This person typically takes incoming calls about all new referrals, jots down the relevant clinical data, keeps track of which hospitalist is due to take the next patient, pages that person, and repeats the clinical information. As I’ve written before (“How to Hire and Use Clerical Staff,” June 2007, p. 73), many practices have found that during business hours, they can hand this role to a clerical person who simply takes down the name and phone number of the doctor making the referral, then pages that information to the hospitalist due to get the next patient. The hospitalist then calls and speaks directly with the referring doctor.

Small- to medium-sized groups can eliminate entirely the need for any such “air-traffic control” function if they assign all new referrals to a single doctor for specified periods of time. For example, from 7 a.m. to 3 p.m. today, all new referrals go to Dr. Glass, and from 3 p.m. to 11 p.m., they go to Dr. Cage.

Admitter-Rounder Duties

Many—maybe most?—large groups separate daytime admitter and rounder functions so that on any given day, a hospitalist does one but not both. The principal advantages of this approach are reducing the stress on, and possibly increasing the efficiency of, rounding doctors by shielding them from the unpredictable and time-consuming interruption of needing to admit a new patient. And a daytime doctor who only does admissions might be able to start seeing a patient in the ED more quickly than one who is busy making rounds.

Any increased availability of admitters to the ED could be offset by their lack of surge capacity leading to a bottleneck in ED throughput when there are many patients to admit at the same time and a limited number of admitters (often only one). Such a bottleneck would be much less likely if all daytime doctors (i.e., the rounders) were available to see admissions rather than just admitters.

Continuity of care suffers when a group has separate admitters and rounders, because no patients will be seen by the same doctor on the day of admission and the day following. This method requires a handoff from the day of admission to the next day. Such a handoff might be unavoidable for patients admitted during the night, but this doesn’t have to occur when patients are admitted during the daytime.

Who’s Seeing this Patient?

It seems to make sense to wait until each morning to distribute patients. That allows the practice to know just how many new patients there are, and they can be distributed according to complexity and whether a hospitalist has formed a previous relationship with that patient. But it means that no one at the hospital will know which hospitalist is caring for the patient until later in the morning. For example, if the radiologist is over-reading a study done during the night and finds something worthy of a phone call to the hospitalist, no one is sure who should get the call. A patient might develop hypoglycemia shortly after the hospitalist night shift is over, but the nurse doesn’t know which hospitalist to call.

And, perhaps most importantly, if patients aren’t distributed until the start of the day shift, the night hospitalist can’t tell the patient and family which hospitalist to expect the next morning. To test the significance of this issue, I conducted an experiment while working our group’s late-evening admitter shift. I concluded my visit with each admitted patient by explaining, “I am on-call for our group tonight, so I will be off recovering tomorrow. Therefore, I won’t see you again, but one of my partners will take over in the morning. Do you have any questions for me?” Every patient I admitted had the same question. “What is that doctor’s name?”

How does your group answer a patient who asks which hospitalist will be in the next day? If your method is load-leveling in the morning, then the best answer your night admitting doctor can give is probably to say: “I don’t know which of my partners will be in. There are several working tomorrow, and at the start of the day, they will divide up the patients who come in tonight depending on how busy each of them is. But all the doctors in our group are terrific and will take good care of you.”

I’m told the same thing when I get my hair cut: You’ll get whichever “hair artist” is up next. I put up with it at the hair place because it costs less than $15. But I still find it a little irritating. I’m sure all the barbers aren’t equally skilled or diligent, and I want the best one. (Maybe I shouldn’t care since there isn’t much that can be done with my hair.) I’m pretty sure patients feel the same way about which doctor they get. The public is convinced there is a wide variety in the quality of doctors, and they want a good one. If you have to tell them theirs is being assigned by lottery, they won’t be as happy than if you can provide the name and a little information about the doctor they can expect to see the next day.

When the patients I admit late last evening ask who would see them the next day, I’m glad when I can provide a name and a little more information. I say something like, “I won’t see you after tonight, but my partner, Dr. Shawn Lee, will be instead. That means you’re getting an upgrade! Not only is he a really nice guy, he’s voted one of Seattle’s best doctors every year. He’ll do a great job for you.”

To make this communication effective, the night doctor has to know which hospitalist takes over the next morning and has a list indicating which day doctor will get the first, second, third new patient, and so on, admitted during the night. This is possible if patients are assigned by a predetermined algorithm, or if the day doctors have their load-leveling meeting at the end of each day shift, rather than in the morning, to create a list telling the night doctor which day hospitalist he should admit the first and subsequent patents to. That way, the night doctor can write in the admitting orders at 1 a.m. “admit to Dr. X.” This eliminates confusion on the part of other hospital staff who need to know who to call about a patient after the start of the day shift.

Next month I will look at special circumstances, and some pros and cons of having an individual hospitalist take on the care of more patients at the beginning of consecutive day shifts, and exempting them from taking on new patients on the last day or two before rotating off. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

Editor’s note: Second of a three-part series.

As I mentioned last month, there isn’t a proven best method to use when distributing new referrals among your group’s providers. The popular methods fall along a continuum of being focused on daily, or continuous, leveling of patient loads between providers (“load leveling”) at one end; at the other end of the continuum is having a doctor be “on” for all new referrals for a predetermined time period, and accepting that patient volumes might be uneven day to day but tend to even out over long periods.

There might not be any reason to change your group’s approach to patient assignment, but you should always be thinking about how your own methods might be changed or improved. I have shared (“Bigger Isn’t Always Better,” June 2009, p. 46) my concern that some groups invest far too much time in a morning load-leveling and handoff conference. Make sure your group is using only as much time as needed.

Air-Traffic Controllers

Many large groups (e.g., more than 15 full-time equivalents) that assign patients to providers in sequence, like dealing a deck of cards, have a designated provider who holds the triage pager and serves as “air-traffic controller.” This person typically takes incoming calls about all new referrals, jots down the relevant clinical data, keeps track of which hospitalist is due to take the next patient, pages that person, and repeats the clinical information. As I’ve written before (“How to Hire and Use Clerical Staff,” June 2007, p. 73), many practices have found that during business hours, they can hand this role to a clerical person who simply takes down the name and phone number of the doctor making the referral, then pages that information to the hospitalist due to get the next patient. The hospitalist then calls and speaks directly with the referring doctor.

Small- to medium-sized groups can eliminate entirely the need for any such “air-traffic control” function if they assign all new referrals to a single doctor for specified periods of time. For example, from 7 a.m. to 3 p.m. today, all new referrals go to Dr. Glass, and from 3 p.m. to 11 p.m., they go to Dr. Cage.

Admitter-Rounder Duties

Many—maybe most?—large groups separate daytime admitter and rounder functions so that on any given day, a hospitalist does one but not both. The principal advantages of this approach are reducing the stress on, and possibly increasing the efficiency of, rounding doctors by shielding them from the unpredictable and time-consuming interruption of needing to admit a new patient. And a daytime doctor who only does admissions might be able to start seeing a patient in the ED more quickly than one who is busy making rounds.

Any increased availability of admitters to the ED could be offset by their lack of surge capacity leading to a bottleneck in ED throughput when there are many patients to admit at the same time and a limited number of admitters (often only one). Such a bottleneck would be much less likely if all daytime doctors (i.e., the rounders) were available to see admissions rather than just admitters.

Continuity of care suffers when a group has separate admitters and rounders, because no patients will be seen by the same doctor on the day of admission and the day following. This method requires a handoff from the day of admission to the next day. Such a handoff might be unavoidable for patients admitted during the night, but this doesn’t have to occur when patients are admitted during the daytime.

Who’s Seeing this Patient?

It seems to make sense to wait until each morning to distribute patients. That allows the practice to know just how many new patients there are, and they can be distributed according to complexity and whether a hospitalist has formed a previous relationship with that patient. But it means that no one at the hospital will know which hospitalist is caring for the patient until later in the morning. For example, if the radiologist is over-reading a study done during the night and finds something worthy of a phone call to the hospitalist, no one is sure who should get the call. A patient might develop hypoglycemia shortly after the hospitalist night shift is over, but the nurse doesn’t know which hospitalist to call.

And, perhaps most importantly, if patients aren’t distributed until the start of the day shift, the night hospitalist can’t tell the patient and family which hospitalist to expect the next morning. To test the significance of this issue, I conducted an experiment while working our group’s late-evening admitter shift. I concluded my visit with each admitted patient by explaining, “I am on-call for our group tonight, so I will be off recovering tomorrow. Therefore, I won’t see you again, but one of my partners will take over in the morning. Do you have any questions for me?” Every patient I admitted had the same question. “What is that doctor’s name?”

How does your group answer a patient who asks which hospitalist will be in the next day? If your method is load-leveling in the morning, then the best answer your night admitting doctor can give is probably to say: “I don’t know which of my partners will be in. There are several working tomorrow, and at the start of the day, they will divide up the patients who come in tonight depending on how busy each of them is. But all the doctors in our group are terrific and will take good care of you.”

I’m told the same thing when I get my hair cut: You’ll get whichever “hair artist” is up next. I put up with it at the hair place because it costs less than $15. But I still find it a little irritating. I’m sure all the barbers aren’t equally skilled or diligent, and I want the best one. (Maybe I shouldn’t care since there isn’t much that can be done with my hair.) I’m pretty sure patients feel the same way about which doctor they get. The public is convinced there is a wide variety in the quality of doctors, and they want a good one. If you have to tell them theirs is being assigned by lottery, they won’t be as happy than if you can provide the name and a little information about the doctor they can expect to see the next day.

When the patients I admit late last evening ask who would see them the next day, I’m glad when I can provide a name and a little more information. I say something like, “I won’t see you after tonight, but my partner, Dr. Shawn Lee, will be instead. That means you’re getting an upgrade! Not only is he a really nice guy, he’s voted one of Seattle’s best doctors every year. He’ll do a great job for you.”

To make this communication effective, the night doctor has to know which hospitalist takes over the next morning and has a list indicating which day doctor will get the first, second, third new patient, and so on, admitted during the night. This is possible if patients are assigned by a predetermined algorithm, or if the day doctors have their load-leveling meeting at the end of each day shift, rather than in the morning, to create a list telling the night doctor which day hospitalist he should admit the first and subsequent patents to. That way, the night doctor can write in the admitting orders at 1 a.m. “admit to Dr. X.” This eliminates confusion on the part of other hospital staff who need to know who to call about a patient after the start of the day shift.

Next month I will look at special circumstances, and some pros and cons of having an individual hospitalist take on the care of more patients at the beginning of consecutive day shifts, and exempting them from taking on new patients on the last day or two before rotating off. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is co-founder and past president of SHM. He is a principal in Nelson Flores Hospital Medicine Consultants, a national hospitalist practice management consulting firm (www.nelsonflores.com). He is also course co-director and faculty for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. This column represents his views and is not intended to reflect an official position of SHM.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

O K, I’ll admit it: I like football. Call me a Neanderthal, but there is nothing quite like an afternoon with friends watching a tightly contested game of titans battling it out on the gridiron. Back in January, I enjoyed that glorious weekend in which the NFC and AFC crown their respective champions, each sending a team of combatants to the Super Bowl.

Fully enjoying the Sunday afternoon of ambrosia requires tons of preparation. Practically speaking, this means clearing my schedule of such clutter as child-rearing and housekeeping, along with dispatching my wife to the store minutes before my friends arrive to procure a second-chin’s worth of kettle chips and a potomaniac’s quantity of cheap beer. Then I settle into the butt-dented comfort of my overworked couch, where I’m surrounded by a rowdy pack of friends.

During hour three of the pre-game analysis, I can’t help but notice that my lovely wife, neither a fan of football or my friends spilling beer on her couch, has contracted a nasty case of the angry stink-eye, which she wields like a laser beam through my skull. I ponder the cost that all of this revelry, last-minute dispatching, and spilled beer will have on my marriage. Concluding that I indeed have at least three paws in the doghouse, I reflect on the facts that a) my wife is a saint; b) she reads this column—honey, read point “a” again; and c) Valentine’s Day is right around the corner.

Oh, well. The game must go on, and right now, it’s all about the NFL—hard-hitting, back-and-forth, in-your-face, smash-mouth action. Unbeatable. Unbeatable, that is, until you realize that a typical football game contains a lot of things, except for much actual football.

The Facts on Football

A recent Wall Street Journal analysis of NFL playoff games reported that the typical football game consists of many things, but not much real action. In fact, the average three-plus-hour telecast consists of just 10 minutes and 43 seconds of play. After subtracting about an hour of commercials, the rest of an average telecast consists of such things as players standing around (67 minutes), replays (17 minutes), and, of course, the all-important shots of cheerleaders—which is allotted, remarkably, only three seconds per game. Seems like more.

In percentage terms, the pie is doled out this way: standing around (58.5%), replays (14.5%), playing time (9.4%), coach shots (4.9%), sideline player shots (3.4%), referee shots (2.4%), crowd shots (0.9%), and other miscellany, such as footage of owners in their high-priced luxury suites (0.3%), the kicker warming up (0.2%), and, of course, cheerleaders (0.1%).

While this level of inaction has an enabling effect on convivial taunting, bet-brokering, and beer runs, it is, to be frank, a laughably low amount of action. How can an entire industry be built on such a level of inactivity? It’s a great question—one that induces a momentary chuckle until I consider how I spend much of my clinical days.

Inactivity in the Workplace

A 2006 paper in the Journal of Hospital Medicine tackled the issue of hospitalist workflow.1 Researchers followed 10 academic hospitalists through various parts of a routine day, all the while measuring to the minute how they spent their time. What they found would be as astounding to hospital outsiders as the NFL data, should anyone ever find themselves so deep in the boredom pit to be watching a hospitalist make rounds.

Which made me wonder: What would Brett Favre, the Minnesota Vikings’ future Hall of Fame quarterback, think if he were watching me ply my trade? Which led me to further wonder how far afield Brett Favre’s life would have to be derailed for him to watch me round. Finally, it left me wondering why I don’t spend my time wondering about more productive things.

Anyway, if Brett were to watch one of us, this is what he’d see: The average hospitalist in this study spent only 18% of their time in direct-patient-care activities, including taking a patient history, examining a patient, and meeting with a patient’s family. Eighteen percent! Isn’t seeing patients why I became a doctor?

While it’s more time than Brett Favre spends slinging the pigskin, it’s still an astonishingly low amount of time actually working with patients. Then there’s the “indirect patient care” category (e.g., reviewing tests, writing notes, making orders), where we spend 69% of our day. This is our time in the huddle, so to speak: lots of planning, little action. Further, these academic hospitalists spent 4% of their time on personal activities (e.g., lunch, bathroom breaks), and 3% of their time in each of the following endeavors: professional development (learning, conferences), teaching, and traveling from floor to floor seeing patients.

Another revealing find was that the average hospitalist spent 6% of their time paging other physicians and 7% returning pages from others (the average hospitalist received 3.4 pages an hour). That’s 13% of the day spent on the phone, or waiting for a phone to ring. That’s about 1.5 hours of a typical 12-hour shift. Over the course of a year, that equates to about 300 hours of time (25 shifts) spent in the paging process. If we could find a way to totally remove the paging process from hospital communication, the average hospitalist could accomplish the same amount of work they do now, and take an additional 20-25 days off per year. Perhaps we should wear high-tech helmets—you know, the kind quarterbacks like Brett Favre use to communicate with his coaches on the sidelines.

Efficient Solutions

Before my hospitalists hit me up for wireless communication devices and an extra three weeks of vacation, understand that much of the paging downtime likely is used for multitasking. In fact, in the study, 21% of a hospitalist’s time was spent working on more than one endeavor. Still, my experience tells me that there is a lot of time lost in the paging vortex.

Furthermore, the 3% of time hospitalists spent walking to other floors, 5% spent on discharge paperwork, and 1% of time spent on routine clerical work (did the researchers inadvertently report 1% instead of 10%?) adds up to nearly a tenth of the day that is either wasted, could be automated, or could be completed by ancillary staff.

To be clear, this happens through no fault of individual hospitalists. Rather, it results from the inefficiency of hospital care systems. And if we endeavor to enhance the revenue, efficiency, and satisfaction of our providers, we need to re-engineer our systems to alter that vast expanse of time spent on inactivity and inefficiency. This means adopting new modes of communication, moving toward geographic rounds, and generally retooling our operational inefficiencies.

Short of that, we risk becoming as idle as the NFL—without the cheerleaders. TH

Dr. Glasheen is The Hospitalist’s physician editor.

Reference

1. O’Leary KJ, Liebovitz DM, Baker DW. How hospitalists spend their time: insights on efficiency and safety. J Hosp Med. 2006;1(2):88-93.

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

While most of the focus has been on D.C. and the trillions of dollars to be spent on healthcare reform, HM has grown substantially in the last decade without any significant payment reform or new regulation. This is all the more incredible because the rise of HM has involved two institutions not synonymous with accepting or adapting to change: physicians and hospitals.

In the coming years, hospitals face important challenges, including their fiscal survival, public trust, workforce shortages, difficulty deciding whether their physicians are partners or competitors, and figuring out what to do about all this patient safety and performance improvement hubbub.

Although 2010’s version of healthcare reform will be about increasing access (see “An Imperfect Solution,” January 2010, p. 44), there are still the seeds planted to address the next two pillars of reform: reducing cost and rewarding performance. Together, they create the value proposition in healthcare. All this will make the coming decade one in which the hospital as an institution will need to evolve and adapt if it is to survive.

What is Quality?

As we enter a transitional phase, in some ways, we aren’t even clear on just what quality healthcare is:

• Is quality defined as a payment issue? We see this in discussions of not paying for “never events” or denying payment for readmissions.
• Is quality about being more satisfied? This is found in emphasis on the surveys of patient and family satisfaction that drive hospital CEO compensation and bonuses, as well as in efforts to improve staff retention or in recognition by business, insurers, and government.
• Is quality just checking things off on a clipboard? We all see the endless list of quality measures and increasing documentation that providers have told their patients to stop smoking or get a flu shot, but is that really the quality we are seeking in healthcare?
• Is quality just avoiding embarrassment? Is the best driver of performance improvement outraged hospital trustees wielding printouts comparing hospitals?

We do know that in some ways, the discussion at most of our hospitals has shifted from “Is quality important?” to “How do we do it?” And in this discussion, HM and SHM have taken a leading role in the “solutions” to the problem. Our innovative programs help reduce unnecessary DVTs, improve glycemic control, and refine the discharge process (see Project BOOST) for better patient/family satisfaction, reduced ED visits, and reduced readmissions.

New Ways to Deliver Care

The hospital of the future—I’m talking 2020—will not be defined by bricks and walls. The hospital stay will not end with a patient in a wheelchair being helped into their car. We already know that most patients don’t leave the hospital cured, but are discharged when they are not sick enough to need to stay recumbent in the most expensive hotel in the city. Often these patients are in midcourse of an acute illness, frequently imposed on top of chronic dysfunctions.

While the patient as the true “medical home” for their health and illness have always borne the potholes of slipped handoffs and information transfer deficits, hospitalists now have a clear view of the precarious nature of post-discharge care. Bundling and payment reform, designed to reward coordination of care and the reduction of readmissions to the ED, might be a revenue-driven boost to our ill-designed healthcare system, but the hospital, with the help of their hospitalists, can take the lead in fixing these problems. And we don’t have to wait for payment reform.

The good news is we aren’t alone in our efforts to change the culture, even the mission, of our hospitals. In a time of healthcarewide workforce shortages, there are increasing demands for direct inpatient care, coupled with the added time needed to document current performance and train and implement needed improvements. The only way to meet all of the volume and performance demands is with process change. We need a different way to deliver care to hospitalized patients.

All-Star Teams

High-performing organizations are composed of high-performance teams and a set of operating principles that create a widespread culture of motivated individuals who are focused on metrics, are execution-driven, and are committed to continual improvement and rapid adaptation.

The characteristics of high-performance teams are that they:

• Self-correct and reallocate resources;
• Have clear roles and responsibilities;
• Have clear, valued, and shared visions;
• Have strong team leadership;
• Develop a strong sense of “collective” trust and confidence; and
• Manage and optimize performance outcomes.

SHM has taken the lead at a national level in helping to organize the Hospital Care Collaborative (HCC), which is made up of CEOs and leaders in nursing, pharmacy, case management, social workers, and respiratory therapy. The HCC has published a set of “Common Principles” (see “Common Principles for the Hospital Care Collaborative”) and is planning to develop practical strategies for building high-performance teams at our nation’s hospitals.

SHM recently received support from Ortho-McNeil and has created a partnership with the American Hospital Association, American Organization of Nurse Executives, and American College of Physician Executives to develop principles and strategies to implement high-performance teams and to use this as a springboard to look at hospital care in the broadest sense (including transfers with medical home and accountable-care organizations). To start, SHM has convened a blue-ribbon group of hospital CMOs, CQOs, nursing executives, and other leaders in the hospital C-suite. Former SHM president Pat Cawley, MD, MBA, FHM, assistant professor and executive medical officer at the Medical University of South Carolina in Charleston, will chair this effort.

In these two initiatives, SHM and national hospital leaders are providing direction and innovation at two entry points—the C-suite and executive team—as well as on the front lines with the other healthcare professionals who care for our nation’s hospitalized patients.

More to Come

HM has had an interesting decade, growing to more than 30,000 hospitalists now practicing in 75% of our nation’s hospitals. We’ve taken on comanagement and are providing real success as change agents. But the decade to come will see the reinvention of our nation’s hospitals and distinct changes in workflow and responsibilities. We are moving from care based on the unit of the visit or the procedure to episodes of care. We are moving from a system that rewards just doing something to one that rewards doing the correct thing and doing it well. We are moving our hospitals from a swap meet where each physician has a booth and everyone supports those individual efforts to an institution with a culture that is patient-centered, based on quality measurement and performance, and provides care delivered by teams of health professionals working in concert.

This is a world that hospitalists can thrive in and, with your help and direction, SHM will provide the tools along the way. TH

Dr. Wellikson is CEO of SHM.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

Just when you thought you had heard the last about the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (HHS) has promulgated new rules for notifying individuals when their protected health information has been breached. These “breach notification” regulations implement provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, passed as part of the American Recovery and Reinvestment Act (ARRA) of 2009. The regulations became effective in September.

The regulations require covered entities (health plans, healthcare clearing houses, and healthcare providers) to promptly notify individuals affected by a breach, as well as the HHS secretary and the media in cases in which a breach affects more than 500 individuals.  Breaches affecting fewer than 500 individuals must be reported to HHS annually. Notably, breaches will be posted on the HHS Web site. The regulations also require business associates to notify covered entities with whom they work of breaches.

All Breaches Not Equal

Any impermissible acquisition, access, use, or disclosure of unsecured protected health information that compromises the security or privacy of the information triggers the new breach notification requirement. Health information is unsecured only if it is not encrypted or destroyed. Security or privacy is compromised when a breach poses a significant risk of financial, reputational, or other harm. To determine whether a significant risk of harm exists, a covered entity must document a fact-based assessment of the risk involved, including evaluation of:

• What happened to the information (e.g., Was a laptop stolen and never recovered or lost but subsequently found? Was an unauthorized access intentional or accidental?);
• The nature of the information (e.g., Did the information contain Social Security numbers and other data that could lead to identity theft? Did the information involve sensitive health information?);
• Steps that could mitigate the potential harm (e.g., call the recipient and request destruction of the information and confirmation); and
• The number of individual identifiers present in the information (e.g., Did the information have name, birth date, and Social Security number, or only a medical record number?).

Consequently, breaches that do not involve information that can be used to identify a specific individual are not reportable. Moreover, inadvertent breaches to other covered entities pose a low risk of harm. For example, if medical records are inadvertently faxed to the wrong pharmacy or other healthcare provider, there is low risk of harm because the recipient is independently required to comply with HIPAA.

Additionally, the regulations expressly exclude the following events from the definition of a breach:

• Unintentional, good-faith access by an employee or agent if the information has not been redisclosed. An example would be mail sent to or opened by the wrong staff member;
• Inadvertent disclosures among persons otherwise authorized to access protected health information within the same entity, provided the information is not redisclosed; and
• When an unauthorized recipient could not have retained the information (e.g., paperwork given to the wrong patient but returned immediately without being read).

In each of the examples above, a covered entity does not need to provide breach notification because a breach has not occurred under the regulations.

Notification Requirements

Unless law enforcement makes a written request for a covered entity to delay notification, covered entities must provide written notice to each individual affected by a breach as soon as possible but no later than 60 calendar days from discovery of the breach. Importantly, a covered entity is liable for appropriate notification if they know, or should know, of a breach. Moreover, the knowledge of an employee is imputed to an employer. Further, business associates must notify covered entities of any breaches. Thus, policies and procedures should include training of a covered entity’s workforce and ensuring business associates’ compliance.

While there is not a prescribed form for notice, the regulations do require some specific elements, including:

• Description of the breach and the dates, if known;
• Description of the protected health information involved;
• Steps the affected individual should take to protect themselves (e.g., cancel credit cards);
• Description of the steps being taken by the covered entity; and
• Contact information to obtain more information, which must include a toll-free telephone number, e-mail or postal address, or Web site.

If 10 or more individuals are involved for which the entity does not have adequate contact information, notice can be accomplished by a conspicuous posting on the entity’s Web site for at least 90 days, or a posting in print or broadcast media. In either case, an active toll-free telephone number where individuals can find out if they were affected must be available for 90 days.

If a breach involves more than 500 people from any one state, notification must include prominent media outlets. Moreover, the covered entity must notify the HHS secretary at the time notice is provided to affected individuals. Breaches involving fewer than 500 individuals must be reported annually through the Office of Civil Rights Web site.

Sanctions and Penalties

HHS is required to audit, investigate, and impose civil monetary penalties for offenses resulting from willful neglect. Fortunately, HHS has indicated that it will not be imposing sanctions for unintentional violations of the notification requirements until March. This gives providers some time to implement the necessary processes. Nonetheless, it is important to implement compliance processes now, as the penalties for noncompliance can be severe. Under the new law, penalties are tiered based on knowledge, and are capped at $1.5 million annually.

For more information about HIPAA, visit www.hhs.gov/ocr/privacy. TH

Patrick T. O’Rourke works in the Office of University Counsel at the University of Colorado Denver. Kari Hershey is a public relations consultant with Budman & Hershey, LLC, in Denver.

A 72-year-old male with a history of CHF is admitted for elective total hip arthroplasty. On postoperative day one, he develops dyspnea and hypoxia, and is diagnosed with acute pulmonary edema by the hospitalist co-managing his care. Furosemide is prescribed, and he improves, and by day four is ready for discharge following another dose of diuretics. Overnight, he develops acute onset of shortness of breath and is diagnosed with a pulmonary embolism (PE). Under new regulations, the hospital will not be reimbursed for the extra cost associated with subsequent patient care. Should the hospitalist be paid for the subsequent care?

PRO

Nonpayment won’t improve quality or significantly decrease costs

Dr. Grace is a hospitalist and area medical officer for the Schumacher Group Hospital Medicine Division in Lafayette, La. He is a member of Team Hospitalist.

The real essence of the question raised in the clinical case above is “Should doctors profit from errors?” The answer might be “It’s better than the alternative.” Allow me to explain. There essentially are two reasons to withhold payment in this scenario: one, as a mechanism for promoting quality; two, as a mechanism for decreasing costs to the payor.

The quality argument assumes the physician will deliver higher-quality care (i.e., prescribe chemical thromboprophylaxis) if a threat of nonpayment exists. This concept is simply hogwash. If expensive medical malpractice threats fail as quality-improvement (QI) mechanisms, it is absurd to think withholding a few subsequent-care charges will generate better results.

The key issue is the type of error involved. As defined by Lucien Leape, MD, in his celebrated 1994 article on medical errors, “mistakes” reflect failures during attentional behaviors, or incorrect choices.1 “Slips” reflect lapses in concentration. “Slips occur in the face of competing sensory or emotional distractions, fatigue, and stress,” and “reducing the risk of slips requires attention to the designs of protocols, devices, and work environments.”

Misjudging the type of error—in this case, a slip (find me a hospitalist who doesn’t know total hip arthroplasty requires thrombophrophylaxis)—and misapplying corrective actions will have little to no effect on outcomes. Thus, pay-withholding schemes can have a negative net effect by diverting resources from QI projects that truly improve patient outcomes.

Withholding payment in this case generates approximately $160 in direct savings to the payor (assuming Medicare payments for one 99233 and two 99232 subsequent care visits), yet the operational costs are not negligible and must be factored into the equation. The payor needs to first determine who is truly at fault: the hospitalist or the orthopedic surgeon. Answering that question requires the payor to review the co-management agreement, perhaps aided by an attorney. That’s a costly endeavor.

For the sake of argument, let’s assume in this case the hospitalist is at fault. The next step is determining if the hospitalist who failed to prescribe prophylaxis prior to the PE is the same hospitalist caring for the patient after the PE. It is inappropriate to withhold payment to hospitalist A if hospitalist B made the error. Again, significant manpower will be required to determine fault, as this is not information one finds on a UB-04 claim form submitted to Medicare.

Further eroding the $160 savings is the cost of determining whether a contraindication exists: Bleeding ulcer? Subdural hematoma? Heparinoid allergy? Let us not forget the additional costs in copying, shipping, warehousing, and eventual shredding of the records. One can readily see that the operational costs can quickly negate the $160 anticipated savings. In fact, it’s likely a negative return on investment.

Clearly, withholding payment in this scenario is an ineffective mechanism for improving quality or decreasing cost. I am not generally a proponent of rewarding failure, and perhaps as we usher in a new era of healthcare reform, the system will be redesigned in such a way that better aligns quality and cost-control measures. However, under the current system, payment denial as outlined above likely does more harm than good.

CON

Withhold payment when medical errors are easily identifiable

Dr. Axon is a hospitalist and assistant professor in the departments of Internal Medicine and Pediatrics at the Medical University of South Carolina in Charleston. He is a member of Team Hospitalist.

When I first learned of the proposal to withhold Medicare payment for hospital-acquired conditions (HACs), I had mixed emotions. On the one hand, I firmly believe that physicians should be accountable for their work; on the other hand, this policy seems to conflict sharply with the “no blame” mantra that has been prevalent in patient safety for more than a decade.2 More recently, though, many have argued for balancing the pursuit of system fixes for quality and patient-safety issues with the development of a culture of accountability.3

In theory, the HACs should meet the following criteria: They should be high-cost conditions, high-volume conditions, or both; they should be identifiable through ICD-9-CM coding as complicating conditions (CCs) or major complicating conditions (MCCs) that result in a higher-paying MS-DRG; and they should be reasonably preventable through the application of evidence-based guidelines. Some HACs are jaw-dropping lapses in care (e.g., leaving foreign bodies in during surgery). Other HACs seem to me to be much less preventable, especially fall injuries and catheter-associated urinary tract infections (UTIs). Several experts have written eloquently regarding the limitations of these new measures, particularly emphasizing the potential for increased administrative burden on hospitals and the potential for unintended consequences.4,5

However, in the case described above involving a hospitalist, I have no reservations in limiting payment to the provider. To me, failing to prescribe VTE prophylaxis in an elderly, immobilized, post-op hip replacement patient with a CHF exacerbation is the hospitalist’s equivalent to a surgeon leaving behind a sponge in an appendectomy. It also meets the elements outlined in the HAC withholding program:

• It is high-cost. The 2007 MS-DRG payment for elective hip arthroplasty was $9,863, but adding an MCC increased that cost by one-third.6
• It is readily identifiable, though one concern might be that hospitals would perform unnecessary pre-operative testing to identify asymptomatic DVT, incurring increased testing and treatment costs and increasing the incidence of bleeding complications.
• It is very preventable. Without thromboprophylaxis, 40% to 60% of hip arthroplasty patients will develop an asymptomatic DVT, and 1 in 300 will die from a PE. However, such fatal events are exceedingly rare with appropriate prevention.7

Ultimately, I think a policy of nonpayment for this case keeps with the culture of accountability we need to foster in healthcare. The financial implications of nonpayment will drive hospital innovation and force the hospital to police provider behavior in more effective ways. This is likely to be a painful process, similar to the tribulations experienced with implementing pay-for-performance programs. The Centers for Medicare and Medicaid Services (CMS) needs to be flexible in adding—and removing—new HACs based on good evidence.

Regardless, the goal of achieving a safer, more effective healthcare system remains.

References

1. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
2. Institute of Medicine. To Err Is Human: Building a Safer Healthcare System. Washington, D.C.: National Academies Press; 2000.
3. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361:1401-1406.
4. Saint S, Meddings JA, Calfee D, Kowalski CP, Krein SL. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. 2009;150(12):877-884.
5. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-2393.
6. Wachter RM, Foster NE, Dudley RA. Medicare’s decision to withhold payment for hospital errors: the devil is in the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-123.
7. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S.

The opinions expressed herein are those of the authors and do not represent those of SHM or The Hospitalist.

A 72-year-old male with a history of CHF is admitted for elective total hip arthroplasty. On postoperative day one, he develops dyspnea and hypoxia, and is diagnosed with acute pulmonary edema by the hospitalist co-managing his care. Furosemide is prescribed, and he improves, and by day four is ready for discharge following another dose of diuretics. Overnight, he develops acute onset of shortness of breath and is diagnosed with a pulmonary embolism (PE). Under new regulations, the hospital will not be reimbursed for the extra cost associated with subsequent patient care. Should the hospitalist be paid for the subsequent care?

PRO

Nonpayment won’t improve quality or significantly decrease costs

Dr. Grace is a hospitalist and area medical officer for the Schumacher Group Hospital Medicine Division in Lafayette, La. He is a member of Team Hospitalist.

The real essence of the question raised in the clinical case above is “Should doctors profit from errors?” The answer might be “It’s better than the alternative.” Allow me to explain. There essentially are two reasons to withhold payment in this scenario: one, as a mechanism for promoting quality; two, as a mechanism for decreasing costs to the payor.

The quality argument assumes the physician will deliver higher-quality care (i.e., prescribe chemical thromboprophylaxis) if a threat of nonpayment exists. This concept is simply hogwash. If expensive medical malpractice threats fail as quality-improvement (QI) mechanisms, it is absurd to think withholding a few subsequent-care charges will generate better results.

The key issue is the type of error involved. As defined by Lucien Leape, MD, in his celebrated 1994 article on medical errors, “mistakes” reflect failures during attentional behaviors, or incorrect choices.1 “Slips” reflect lapses in concentration. “Slips occur in the face of competing sensory or emotional distractions, fatigue, and stress,” and “reducing the risk of slips requires attention to the designs of protocols, devices, and work environments.”

Misjudging the type of error—in this case, a slip (find me a hospitalist who doesn’t know total hip arthroplasty requires thrombophrophylaxis)—and misapplying corrective actions will have little to no effect on outcomes. Thus, pay-withholding schemes can have a negative net effect by diverting resources from QI projects that truly improve patient outcomes.

Withholding payment in this case generates approximately $160 in direct savings to the payor (assuming Medicare payments for one 99233 and two 99232 subsequent care visits), yet the operational costs are not negligible and must be factored into the equation. The payor needs to first determine who is truly at fault: the hospitalist or the orthopedic surgeon. Answering that question requires the payor to review the co-management agreement, perhaps aided by an attorney. That’s a costly endeavor.

For the sake of argument, let’s assume in this case the hospitalist is at fault. The next step is determining if the hospitalist who failed to prescribe prophylaxis prior to the PE is the same hospitalist caring for the patient after the PE. It is inappropriate to withhold payment to hospitalist A if hospitalist B made the error. Again, significant manpower will be required to determine fault, as this is not information one finds on a UB-04 claim form submitted to Medicare.

Further eroding the $160 savings is the cost of determining whether a contraindication exists: Bleeding ulcer? Subdural hematoma? Heparinoid allergy? Let us not forget the additional costs in copying, shipping, warehousing, and eventual shredding of the records. One can readily see that the operational costs can quickly negate the $160 anticipated savings. In fact, it’s likely a negative return on investment.

Clearly, withholding payment in this scenario is an ineffective mechanism for improving quality or decreasing cost. I am not generally a proponent of rewarding failure, and perhaps as we usher in a new era of healthcare reform, the system will be redesigned in such a way that better aligns quality and cost-control measures. However, under the current system, payment denial as outlined above likely does more harm than good.

CON

Withhold payment when medical errors are easily identifiable

Dr. Axon is a hospitalist and assistant professor in the departments of Internal Medicine and Pediatrics at the Medical University of South Carolina in Charleston. He is a member of Team Hospitalist.

When I first learned of the proposal to withhold Medicare payment for hospital-acquired conditions (HACs), I had mixed emotions. On the one hand, I firmly believe that physicians should be accountable for their work; on the other hand, this policy seems to conflict sharply with the “no blame” mantra that has been prevalent in patient safety for more than a decade.2 More recently, though, many have argued for balancing the pursuit of system fixes for quality and patient-safety issues with the development of a culture of accountability.3

In theory, the HACs should meet the following criteria: They should be high-cost conditions, high-volume conditions, or both; they should be identifiable through ICD-9-CM coding as complicating conditions (CCs) or major complicating conditions (MCCs) that result in a higher-paying MS-DRG; and they should be reasonably preventable through the application of evidence-based guidelines. Some HACs are jaw-dropping lapses in care (e.g., leaving foreign bodies in during surgery). Other HACs seem to me to be much less preventable, especially fall injuries and catheter-associated urinary tract infections (UTIs). Several experts have written eloquently regarding the limitations of these new measures, particularly emphasizing the potential for increased administrative burden on hospitals and the potential for unintended consequences.4,5

However, in the case described above involving a hospitalist, I have no reservations in limiting payment to the provider. To me, failing to prescribe VTE prophylaxis in an elderly, immobilized, post-op hip replacement patient with a CHF exacerbation is the hospitalist’s equivalent to a surgeon leaving behind a sponge in an appendectomy. It also meets the elements outlined in the HAC withholding program:

• It is high-cost. The 2007 MS-DRG payment for elective hip arthroplasty was $9,863, but adding an MCC increased that cost by one-third.6
• It is readily identifiable, though one concern might be that hospitals would perform unnecessary pre-operative testing to identify asymptomatic DVT, incurring increased testing and treatment costs and increasing the incidence of bleeding complications.
• It is very preventable. Without thromboprophylaxis, 40% to 60% of hip arthroplasty patients will develop an asymptomatic DVT, and 1 in 300 will die from a PE. However, such fatal events are exceedingly rare with appropriate prevention.7

Ultimately, I think a policy of nonpayment for this case keeps with the culture of accountability we need to foster in healthcare. The financial implications of nonpayment will drive hospital innovation and force the hospital to police provider behavior in more effective ways. This is likely to be a painful process, similar to the tribulations experienced with implementing pay-for-performance programs. The Centers for Medicare and Medicaid Services (CMS) needs to be flexible in adding—and removing—new HACs based on good evidence.

Regardless, the goal of achieving a safer, more effective healthcare system remains.

References

1. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
2. Institute of Medicine. To Err Is Human: Building a Safer Healthcare System. Washington, D.C.: National Academies Press; 2000.
3. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361:1401-1406.
4. Saint S, Meddings JA, Calfee D, Kowalski CP, Krein SL. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. 2009;150(12):877-884.
5. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-2393.
6. Wachter RM, Foster NE, Dudley RA. Medicare’s decision to withhold payment for hospital errors: the devil is in the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-123.
7. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S.

The opinions expressed herein are those of the authors and do not represent those of SHM or The Hospitalist.

A 72-year-old male with a history of CHF is admitted for elective total hip arthroplasty. On postoperative day one, he develops dyspnea and hypoxia, and is diagnosed with acute pulmonary edema by the hospitalist co-managing his care. Furosemide is prescribed, and he improves, and by day four is ready for discharge following another dose of diuretics. Overnight, he develops acute onset of shortness of breath and is diagnosed with a pulmonary embolism (PE). Under new regulations, the hospital will not be reimbursed for the extra cost associated with subsequent patient care. Should the hospitalist be paid for the subsequent care?

PRO

Nonpayment won’t improve quality or significantly decrease costs

Dr. Grace is a hospitalist and area medical officer for the Schumacher Group Hospital Medicine Division in Lafayette, La. He is a member of Team Hospitalist.

The real essence of the question raised in the clinical case above is “Should doctors profit from errors?” The answer might be “It’s better than the alternative.” Allow me to explain. There essentially are two reasons to withhold payment in this scenario: one, as a mechanism for promoting quality; two, as a mechanism for decreasing costs to the payor.

The quality argument assumes the physician will deliver higher-quality care (i.e., prescribe chemical thromboprophylaxis) if a threat of nonpayment exists. This concept is simply hogwash. If expensive medical malpractice threats fail as quality-improvement (QI) mechanisms, it is absurd to think withholding a few subsequent-care charges will generate better results.

The key issue is the type of error involved. As defined by Lucien Leape, MD, in his celebrated 1994 article on medical errors, “mistakes” reflect failures during attentional behaviors, or incorrect choices.1 “Slips” reflect lapses in concentration. “Slips occur in the face of competing sensory or emotional distractions, fatigue, and stress,” and “reducing the risk of slips requires attention to the designs of protocols, devices, and work environments.”

Misjudging the type of error—in this case, a slip (find me a hospitalist who doesn’t know total hip arthroplasty requires thrombophrophylaxis)—and misapplying corrective actions will have little to no effect on outcomes. Thus, pay-withholding schemes can have a negative net effect by diverting resources from QI projects that truly improve patient outcomes.

Withholding payment in this case generates approximately $160 in direct savings to the payor (assuming Medicare payments for one 99233 and two 99232 subsequent care visits), yet the operational costs are not negligible and must be factored into the equation. The payor needs to first determine who is truly at fault: the hospitalist or the orthopedic surgeon. Answering that question requires the payor to review the co-management agreement, perhaps aided by an attorney. That’s a costly endeavor.

For the sake of argument, let’s assume in this case the hospitalist is at fault. The next step is determining if the hospitalist who failed to prescribe prophylaxis prior to the PE is the same hospitalist caring for the patient after the PE. It is inappropriate to withhold payment to hospitalist A if hospitalist B made the error. Again, significant manpower will be required to determine fault, as this is not information one finds on a UB-04 claim form submitted to Medicare.

Further eroding the $160 savings is the cost of determining whether a contraindication exists: Bleeding ulcer? Subdural hematoma? Heparinoid allergy? Let us not forget the additional costs in copying, shipping, warehousing, and eventual shredding of the records. One can readily see that the operational costs can quickly negate the $160 anticipated savings. In fact, it’s likely a negative return on investment.

Clearly, withholding payment in this scenario is an ineffective mechanism for improving quality or decreasing cost. I am not generally a proponent of rewarding failure, and perhaps as we usher in a new era of healthcare reform, the system will be redesigned in such a way that better aligns quality and cost-control measures. However, under the current system, payment denial as outlined above likely does more harm than good.

CON

Withhold payment when medical errors are easily identifiable

Dr. Axon is a hospitalist and assistant professor in the departments of Internal Medicine and Pediatrics at the Medical University of South Carolina in Charleston. He is a member of Team Hospitalist.

When I first learned of the proposal to withhold Medicare payment for hospital-acquired conditions (HACs), I had mixed emotions. On the one hand, I firmly believe that physicians should be accountable for their work; on the other hand, this policy seems to conflict sharply with the “no blame” mantra that has been prevalent in patient safety for more than a decade.2 More recently, though, many have argued for balancing the pursuit of system fixes for quality and patient-safety issues with the development of a culture of accountability.3

In theory, the HACs should meet the following criteria: They should be high-cost conditions, high-volume conditions, or both; they should be identifiable through ICD-9-CM coding as complicating conditions (CCs) or major complicating conditions (MCCs) that result in a higher-paying MS-DRG; and they should be reasonably preventable through the application of evidence-based guidelines. Some HACs are jaw-dropping lapses in care (e.g., leaving foreign bodies in during surgery). Other HACs seem to me to be much less preventable, especially fall injuries and catheter-associated urinary tract infections (UTIs). Several experts have written eloquently regarding the limitations of these new measures, particularly emphasizing the potential for increased administrative burden on hospitals and the potential for unintended consequences.4,5

However, in the case described above involving a hospitalist, I have no reservations in limiting payment to the provider. To me, failing to prescribe VTE prophylaxis in an elderly, immobilized, post-op hip replacement patient with a CHF exacerbation is the hospitalist’s equivalent to a surgeon leaving behind a sponge in an appendectomy. It also meets the elements outlined in the HAC withholding program:

• It is high-cost. The 2007 MS-DRG payment for elective hip arthroplasty was $9,863, but adding an MCC increased that cost by one-third.6
• It is readily identifiable, though one concern might be that hospitals would perform unnecessary pre-operative testing to identify asymptomatic DVT, incurring increased testing and treatment costs and increasing the incidence of bleeding complications.
• It is very preventable. Without thromboprophylaxis, 40% to 60% of hip arthroplasty patients will develop an asymptomatic DVT, and 1 in 300 will die from a PE. However, such fatal events are exceedingly rare with appropriate prevention.7

Ultimately, I think a policy of nonpayment for this case keeps with the culture of accountability we need to foster in healthcare. The financial implications of nonpayment will drive hospital innovation and force the hospital to police provider behavior in more effective ways. This is likely to be a painful process, similar to the tribulations experienced with implementing pay-for-performance programs. The Centers for Medicare and Medicaid Services (CMS) needs to be flexible in adding—and removing—new HACs based on good evidence.

Regardless, the goal of achieving a safer, more effective healthcare system remains.

References

1. Leape LL. Error in medicine. JAMA. 1994;272(23):1851-1857.
2. Institute of Medicine. To Err Is Human: Building a Safer Healthcare System. Washington, D.C.: National Academies Press; 2000.
3. Wachter RM, Pronovost PJ. Balancing “no blame” with accountability in patient safety. N Engl J Med. 2009;361:1401-1406.
4. Saint S, Meddings JA, Calfee D, Kowalski CP, Krein SL. Catheter-associated urinary tract infection and the Medicare rule changes. Ann Intern Med. 2009;150(12):877-884.
5. Inouye SK, Brown CJ, Tinetti ME. Medicare nonpayment, hospital falls, and unintended consequences. N Engl J Med. 2009;360(23):2390-2393.
6. Wachter RM, Foster NE, Dudley RA. Medicare’s decision to withhold payment for hospital errors: the devil is in the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-123.
7. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S.

The opinions expressed herein are those of the authors and do not represent those of SHM or The Hospitalist.