‐Sir William Osler

For a typical hospitalist in the 21^st century, going to sea is not a concern. Getting lost at sea, or worse yet, drowning, loom larger as threats to today's hospitals‐based providers. To help our readers navigate the rapidly changing waters that are today's hospitals, the Journal is launching a new feature. Starting with this issue of the Journal of Hospital Medicine, we are pleased to provide CME credits pertaining to articles published in the Journal at no additional cost to the reader. As the newly appointed CME Editor, I will be charged with identifying an article to be published in upcoming issues of the Journal that is likely to impact the practice of the majority of our readership. Based on the article, a series of multiple‐choice questions will be developed and readers interested in pursuing CME credit will be directed to an on‐line site to complete the questions and receive immediate CME credit along with the answers to the questions.

For our first article, CME questions have been developed for the well‐done review by Abu Jawdeh and colleagues, Evidence‐based approach for prevention of radiocontrast‐induced nephropathy,2 a topic encountered by hospitalists daily. While clinical topics will likely comprise the majority of selected topics, CME activity in the Journal will reflect the diverse roles filled by hospitalists as champions of quality improvement, patient safety, care transitions, teaching, research, and team leadership.

What may seem straightforward at first glance is actually a more complicated process behind the scenes. The Editorial Office and the production team at Wiley have worked hard to make the CME process as seamless as possible for our readers. User‐friendly features include: direct linking between the on‐line Journal and the Journal's web‐based CME activity; on‐line tracking of individual CME credits and certificates; answers to CME questions, along with explanations, available immediately upon submitting your responses; and performance measurement related to the program. In the future, we hope to take advantage of technology to enhance the CME process to reach our diverse readership. We hope you enjoy this new feature of the Journal, and please give us your feedback on it.

‐Sir William Osler

For a typical hospitalist in the 21^st century, going to sea is not a concern. Getting lost at sea, or worse yet, drowning, loom larger as threats to today's hospitals‐based providers. To help our readers navigate the rapidly changing waters that are today's hospitals, the Journal is launching a new feature. Starting with this issue of the Journal of Hospital Medicine, we are pleased to provide CME credits pertaining to articles published in the Journal at no additional cost to the reader. As the newly appointed CME Editor, I will be charged with identifying an article to be published in upcoming issues of the Journal that is likely to impact the practice of the majority of our readership. Based on the article, a series of multiple‐choice questions will be developed and readers interested in pursuing CME credit will be directed to an on‐line site to complete the questions and receive immediate CME credit along with the answers to the questions.

For our first article, CME questions have been developed for the well‐done review by Abu Jawdeh and colleagues, Evidence‐based approach for prevention of radiocontrast‐induced nephropathy,2 a topic encountered by hospitalists daily. While clinical topics will likely comprise the majority of selected topics, CME activity in the Journal will reflect the diverse roles filled by hospitalists as champions of quality improvement, patient safety, care transitions, teaching, research, and team leadership.

What may seem straightforward at first glance is actually a more complicated process behind the scenes. The Editorial Office and the production team at Wiley have worked hard to make the CME process as seamless as possible for our readers. User‐friendly features include: direct linking between the on‐line Journal and the Journal's web‐based CME activity; on‐line tracking of individual CME credits and certificates; answers to CME questions, along with explanations, available immediately upon submitting your responses; and performance measurement related to the program. In the future, we hope to take advantage of technology to enhance the CME process to reach our diverse readership. We hope you enjoy this new feature of the Journal, and please give us your feedback on it.

‐Sir William Osler

For a typical hospitalist in the 21^st century, going to sea is not a concern. Getting lost at sea, or worse yet, drowning, loom larger as threats to today's hospitals‐based providers. To help our readers navigate the rapidly changing waters that are today's hospitals, the Journal is launching a new feature. Starting with this issue of the Journal of Hospital Medicine, we are pleased to provide CME credits pertaining to articles published in the Journal at no additional cost to the reader. As the newly appointed CME Editor, I will be charged with identifying an article to be published in upcoming issues of the Journal that is likely to impact the practice of the majority of our readership. Based on the article, a series of multiple‐choice questions will be developed and readers interested in pursuing CME credit will be directed to an on‐line site to complete the questions and receive immediate CME credit along with the answers to the questions.

For our first article, CME questions have been developed for the well‐done review by Abu Jawdeh and colleagues, Evidence‐based approach for prevention of radiocontrast‐induced nephropathy,2 a topic encountered by hospitalists daily. While clinical topics will likely comprise the majority of selected topics, CME activity in the Journal will reflect the diverse roles filled by hospitalists as champions of quality improvement, patient safety, care transitions, teaching, research, and team leadership.

What may seem straightforward at first glance is actually a more complicated process behind the scenes. The Editorial Office and the production team at Wiley have worked hard to make the CME process as seamless as possible for our readers. User‐friendly features include: direct linking between the on‐line Journal and the Journal's web‐based CME activity; on‐line tracking of individual CME credits and certificates; answers to CME questions, along with explanations, available immediately upon submitting your responses; and performance measurement related to the program. In the future, we hope to take advantage of technology to enhance the CME process to reach our diverse readership. We hope you enjoy this new feature of the Journal, and please give us your feedback on it.

Maintaining a balance between productivity (what we do now), and production capacity (the ability to continue to do what we now do in the future) is one of the central tenets of successful organizations and societies. The economic benefits of industrialization (production) must be balanced with the needs of the environment (production capacity). It is appropriate then, that this issue of The Journal of Hospital Medicine juxtaposes Conway's1 article on hospitalists' current production of ensuring value, with articles addressing medical education, our production capacity.

What is the role of hospitalists in medical education? The article by Beasley et al.,2 confirms what has long been suspected: the growth of hospitalists in medical education has paralleled the growth of the movement as a whole. The meta‐analysis by Natarajan et al.3 further suggests that hospitalists are at the very least no worse in medical education than other specialists, and in some domains, may be superior. The theoretical fears of hospitalists as medical educators have not been borne out: utilizing hospitalists as educators does not lead to a decline in resident autonomy, nor does it lead to a decline in educational ability. But despite the fact that 73% of residency training programs utilize hospitalists, there are several reasons why the hospitalists' role in inpatient medical education should be even more robust.

The landscape of graduate medical education has dramatically changed in the past 10 years. The knowledge‐only paradigm has evolved to a comprehensive focus on the trainee's overall performance, including understanding the healthcare system in which she works (systems of care), self‐reflection on her practice (practice‐based learning), and an augmented emphasis on professionalism and interpersonal skills.4 Unfortunately, many systems have not undergone a similar paradigm change, opting instead to merely rearrange components of the old knowledge‐focused system. For example, practice‐based learning may remain relegated to journal clubs, where the focus is on the knowledge contained in the chosen article, instead of active exercises in which the resident self‐reflects on his patient care performance and seeks ways to improve that performance. Instruction in systems‐of‐care may remain within a knowledge‐only paradigm: a didactic lecture on Medicare/Medicaid and reimbursement instead of residents actively participating in quality improvement projects.

The article by Mazotti et al.,5 provides insight into the reason for this developmental arrest: there isn't enough time in the old system. The duty‐hours have decreased for residents, but since the work product has remained the same, the result has been an increase in work intensity. As work intensity increases, production capacity (medical education) is the first to be sacrificed in an effort to maintain production (getting the work done).

Here is the yet unrealized role of the hospitalist. The same degree of systems reengineering that brought about improved efficiency in patient care (shorter lengths of stay, fewer readmissions), must be applied to the inpatient education system if duty hours, a reasonable work intensity, and meaningful education in each of the core competencies are to coexist. But there is no panacea for these issues: each system is unique, and the solutions to improving the efficiency of the inpatient education environment are just as unique. Solutions require a systems architect (ie, the hospitalist) to redesign the educational environment in his particular system. It is natural to assume that the hospitalist educator, familiar with the strengths and weakness of the educational system in which he routinely works, will be best equipped to enact meaningful solutions that improve efficiency while protecting the principles of medical education.

What does it mean to change the educational system? Taiichi Ohno,6 Toyota's Chief Engineer, provides Seven Organizational Wastes, a framework for identifying areas of improvement in the educational work environment. Consider, for example, the following selected opportunities for improving the efficiency of the inpatient medical education system: (1) excessive testing or consultation leading to delayed discharge and more resident work effort (Overproduction); (2) the resident team waiting for the attending to arrive from a procedure or clinic (Waiting); (3) inadequate teaching about the principles of transitions of care, resulting in more readmissions to the teaching service (Transporting); (4) failure to have quality improvement conferences to discuss the appropriateness of admissions (Inappropriate processing); (5) failure to teach residents how to work with social work/placement services to facilitate early discharge (Unnecessary inventory); (6) failure to construct a training program that limits fragmentation, with residents moving from 1 task to the next and back again (Unnecessary motion); and (7) medical errors resulting in prolonged lengths of stay and resident work effort (Defects). There is no shortage of opportunities for improving the efficiency of the inpatient educational environment, but it requires that the systems architect is sufficiently familiar with the system to design interventions that are meaningful and effective. This is the unique advantage of the hospitalist.

But the greatest risk to inpatient medical education is yet to come, and it may be on the hospitalist's shoulders to reverse a dangerous trend. With the advent of more extensive electronic medical records, the locus of patient care has begun to shift from the bedside to a computer terminal. An unbridled drive to efficiency, without a steward to ensure the primacy of patient‐centered care, is likely to inspire the next generation of physicians to see Mr. A. Huxley as the i‐Patient, in which the entirety of his management is conducted from the safety of a computer terminal.7 Despite the need for efficiency, the patient has to remain the focal point. It is at the bedside that the resident learns that observing 5 bags of potato chips on the nightstand might obviate a million‐dollar workup for refractory hypertension. And it is at the bedside that the resident learns that despite our elaborate protocols and decision analyses, the ultimate testing and management decisions hinge upon the patient's preferences. The single best thing than can be done to augment patient safety and quality is to maximize the time the patient spends with his healthcare team; and the hospitalist, who is not in a rush to complete morning rounds in an effort to get to a clinic or an endoscopy suite, may be the person who has the time to prioritize bedside rounds as a part of the educational environment.

The article by Nazario8 establishes the urgency of integrating the humanities into patient management. For meaningful humanities instruction to occur, however, it has to occur at the bedside, not in the classroom. And this requires that the supervising physician has the time to reflect with the resident upon the humanism issues that are unique to each patient encounter. Once again, it is time that enables the luxury of this self‐reflection, a commodity that the hospitalist enjoys as a part of her job description. It is also a commodity that the hospitalist can generate by augmenting efficiency in the educational system, provided patient‐centered care remains the priority.

The role of the hospitalist has to be much more than merely patching the current paradigm of graduate medical education. Overseeing nonteaching services and serving as the night float physician are examples of these patches. While valuable, these roles are useful only in preserving production of the current system, not in enabling production capacity for the next generation of physicians. Continuing in this role without also becoming an active part of the teaching service sends a message to residents that a career as a hospitalist in a teaching environment is only to be a fourth‐year or fifth‐year resident. Why would any resident embark upon that career? Meeting the demand for 30,000 hospitalists by 2012 requires a pipeline of physicians, and answering this question will be central to achieving that goal. Residents must have hospitalist role models, occupying careers devoted to patient safety and quality; careers that are meaningful and fulfilling.

To this end, the hospital medicine community cannot be satisfied with being no worse than other specialists in medical education. As Natarajan et al.3 point out, the evaluation of inpatient medical education has, with few exceptions, been solely based upon learner's subjective opinions. Meaningful change in the educational system will require meaningful objective endpoints: participation in the quality improvement projects; patient‐centered evaluations of resident performance; end‐user evaluations of resident communication skills (clinic physicians, nurses, other services); metrics to assess the efficacy of the transition of care; and resident profiles that enable self‐assessment of their practice. It will be up to the hospitalist to assess the system to define these meaningful endpoints that ensure that inpatient education is advancing quality, safety, and patient‐centered care.

Despite all of the reasons for why hospitalists should be more involved in the teaching service, there remains the 1 reason that they are not: hospitalists on average are young, and they may not have the teaching skills that more experienced generalists or subspecialists possess. To bring about the benefits hospitalists can offer to the inpatient education environment, hospitalists must be willing to compensate for their lack of teaching experience by seeking out formal training courses in medical education. The Academic Hospitalist Academy cosponsored by the Society of Hospital Medicine (SHM), the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM) is 1 example.9

As experience is accumulated, more hospitalists have to actively seek out leadership positions in graduate medical education, aligning our strengths, in patient safety, efficiency, and systems change, with the goals and objectives of the residency and student programs. The fact that 73% of residency training programs utilize hospitalists is exciting; the fact that there are only 15 hospitalists as program directors is disappointing.2 As was the case in the clinical care environment, leadership will be just as important in the education environment, as it is important for enacting the changes that will transform the inpatient education environment to a system that is efficient, safe, and patient‐centered.

Hospitalists have been effective in their production, augmenting efficiency and quality of patient care. But the reality is that the task of ensuring value, as it pertains to patient safety and quality, is too onerous of a task to be accomplished with arithmetic gains. Generations of physicians will have to adopt a cultural change to reach the ultimate goal. It is of little consequence that we improve safety for a moment in time, only to have it fall by the wayside as successive generations of physicians take our place. Now is the time for hospitalists to fully embrace the inpatient education environment as our responsibility. Too much time has already been wasted in arguing against duty‐hours regulations. These regulations are now here to stay, and this has created a system that is currently unable to handle the strains of multiple demands. Only by using the hospitalist's expertise in systems improvements and efficiency will a new inpatient educational system evolve; one that is efficient, safe, and patient‐focused, thus ensuring current production. And also one that enables meaningful development of communication, practice‐based learning, and systems‐of‐care skills, ensuring our production capacity for years to come.

Maintaining a balance between productivity (what we do now), and production capacity (the ability to continue to do what we now do in the future) is one of the central tenets of successful organizations and societies. The economic benefits of industrialization (production) must be balanced with the needs of the environment (production capacity). It is appropriate then, that this issue of The Journal of Hospital Medicine juxtaposes Conway's1 article on hospitalists' current production of ensuring value, with articles addressing medical education, our production capacity.

What is the role of hospitalists in medical education? The article by Beasley et al.,2 confirms what has long been suspected: the growth of hospitalists in medical education has paralleled the growth of the movement as a whole. The meta‐analysis by Natarajan et al.3 further suggests that hospitalists are at the very least no worse in medical education than other specialists, and in some domains, may be superior. The theoretical fears of hospitalists as medical educators have not been borne out: utilizing hospitalists as educators does not lead to a decline in resident autonomy, nor does it lead to a decline in educational ability. But despite the fact that 73% of residency training programs utilize hospitalists, there are several reasons why the hospitalists' role in inpatient medical education should be even more robust.

The landscape of graduate medical education has dramatically changed in the past 10 years. The knowledge‐only paradigm has evolved to a comprehensive focus on the trainee's overall performance, including understanding the healthcare system in which she works (systems of care), self‐reflection on her practice (practice‐based learning), and an augmented emphasis on professionalism and interpersonal skills.4 Unfortunately, many systems have not undergone a similar paradigm change, opting instead to merely rearrange components of the old knowledge‐focused system. For example, practice‐based learning may remain relegated to journal clubs, where the focus is on the knowledge contained in the chosen article, instead of active exercises in which the resident self‐reflects on his patient care performance and seeks ways to improve that performance. Instruction in systems‐of‐care may remain within a knowledge‐only paradigm: a didactic lecture on Medicare/Medicaid and reimbursement instead of residents actively participating in quality improvement projects.

The article by Mazotti et al.,5 provides insight into the reason for this developmental arrest: there isn't enough time in the old system. The duty‐hours have decreased for residents, but since the work product has remained the same, the result has been an increase in work intensity. As work intensity increases, production capacity (medical education) is the first to be sacrificed in an effort to maintain production (getting the work done).

Here is the yet unrealized role of the hospitalist. The same degree of systems reengineering that brought about improved efficiency in patient care (shorter lengths of stay, fewer readmissions), must be applied to the inpatient education system if duty hours, a reasonable work intensity, and meaningful education in each of the core competencies are to coexist. But there is no panacea for these issues: each system is unique, and the solutions to improving the efficiency of the inpatient education environment are just as unique. Solutions require a systems architect (ie, the hospitalist) to redesign the educational environment in his particular system. It is natural to assume that the hospitalist educator, familiar with the strengths and weakness of the educational system in which he routinely works, will be best equipped to enact meaningful solutions that improve efficiency while protecting the principles of medical education.

What does it mean to change the educational system? Taiichi Ohno,6 Toyota's Chief Engineer, provides Seven Organizational Wastes, a framework for identifying areas of improvement in the educational work environment. Consider, for example, the following selected opportunities for improving the efficiency of the inpatient medical education system: (1) excessive testing or consultation leading to delayed discharge and more resident work effort (Overproduction); (2) the resident team waiting for the attending to arrive from a procedure or clinic (Waiting); (3) inadequate teaching about the principles of transitions of care, resulting in more readmissions to the teaching service (Transporting); (4) failure to have quality improvement conferences to discuss the appropriateness of admissions (Inappropriate processing); (5) failure to teach residents how to work with social work/placement services to facilitate early discharge (Unnecessary inventory); (6) failure to construct a training program that limits fragmentation, with residents moving from 1 task to the next and back again (Unnecessary motion); and (7) medical errors resulting in prolonged lengths of stay and resident work effort (Defects). There is no shortage of opportunities for improving the efficiency of the inpatient educational environment, but it requires that the systems architect is sufficiently familiar with the system to design interventions that are meaningful and effective. This is the unique advantage of the hospitalist.

But the greatest risk to inpatient medical education is yet to come, and it may be on the hospitalist's shoulders to reverse a dangerous trend. With the advent of more extensive electronic medical records, the locus of patient care has begun to shift from the bedside to a computer terminal. An unbridled drive to efficiency, without a steward to ensure the primacy of patient‐centered care, is likely to inspire the next generation of physicians to see Mr. A. Huxley as the i‐Patient, in which the entirety of his management is conducted from the safety of a computer terminal.7 Despite the need for efficiency, the patient has to remain the focal point. It is at the bedside that the resident learns that observing 5 bags of potato chips on the nightstand might obviate a million‐dollar workup for refractory hypertension. And it is at the bedside that the resident learns that despite our elaborate protocols and decision analyses, the ultimate testing and management decisions hinge upon the patient's preferences. The single best thing than can be done to augment patient safety and quality is to maximize the time the patient spends with his healthcare team; and the hospitalist, who is not in a rush to complete morning rounds in an effort to get to a clinic or an endoscopy suite, may be the person who has the time to prioritize bedside rounds as a part of the educational environment.

The article by Nazario8 establishes the urgency of integrating the humanities into patient management. For meaningful humanities instruction to occur, however, it has to occur at the bedside, not in the classroom. And this requires that the supervising physician has the time to reflect with the resident upon the humanism issues that are unique to each patient encounter. Once again, it is time that enables the luxury of this self‐reflection, a commodity that the hospitalist enjoys as a part of her job description. It is also a commodity that the hospitalist can generate by augmenting efficiency in the educational system, provided patient‐centered care remains the priority.

The role of the hospitalist has to be much more than merely patching the current paradigm of graduate medical education. Overseeing nonteaching services and serving as the night float physician are examples of these patches. While valuable, these roles are useful only in preserving production of the current system, not in enabling production capacity for the next generation of physicians. Continuing in this role without also becoming an active part of the teaching service sends a message to residents that a career as a hospitalist in a teaching environment is only to be a fourth‐year or fifth‐year resident. Why would any resident embark upon that career? Meeting the demand for 30,000 hospitalists by 2012 requires a pipeline of physicians, and answering this question will be central to achieving that goal. Residents must have hospitalist role models, occupying careers devoted to patient safety and quality; careers that are meaningful and fulfilling.

To this end, the hospital medicine community cannot be satisfied with being no worse than other specialists in medical education. As Natarajan et al.3 point out, the evaluation of inpatient medical education has, with few exceptions, been solely based upon learner's subjective opinions. Meaningful change in the educational system will require meaningful objective endpoints: participation in the quality improvement projects; patient‐centered evaluations of resident performance; end‐user evaluations of resident communication skills (clinic physicians, nurses, other services); metrics to assess the efficacy of the transition of care; and resident profiles that enable self‐assessment of their practice. It will be up to the hospitalist to assess the system to define these meaningful endpoints that ensure that inpatient education is advancing quality, safety, and patient‐centered care.

Despite all of the reasons for why hospitalists should be more involved in the teaching service, there remains the 1 reason that they are not: hospitalists on average are young, and they may not have the teaching skills that more experienced generalists or subspecialists possess. To bring about the benefits hospitalists can offer to the inpatient education environment, hospitalists must be willing to compensate for their lack of teaching experience by seeking out formal training courses in medical education. The Academic Hospitalist Academy cosponsored by the Society of Hospital Medicine (SHM), the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM) is 1 example.9

As experience is accumulated, more hospitalists have to actively seek out leadership positions in graduate medical education, aligning our strengths, in patient safety, efficiency, and systems change, with the goals and objectives of the residency and student programs. The fact that 73% of residency training programs utilize hospitalists is exciting; the fact that there are only 15 hospitalists as program directors is disappointing.2 As was the case in the clinical care environment, leadership will be just as important in the education environment, as it is important for enacting the changes that will transform the inpatient education environment to a system that is efficient, safe, and patient‐centered.

Hospitalists have been effective in their production, augmenting efficiency and quality of patient care. But the reality is that the task of ensuring value, as it pertains to patient safety and quality, is too onerous of a task to be accomplished with arithmetic gains. Generations of physicians will have to adopt a cultural change to reach the ultimate goal. It is of little consequence that we improve safety for a moment in time, only to have it fall by the wayside as successive generations of physicians take our place. Now is the time for hospitalists to fully embrace the inpatient education environment as our responsibility. Too much time has already been wasted in arguing against duty‐hours regulations. These regulations are now here to stay, and this has created a system that is currently unable to handle the strains of multiple demands. Only by using the hospitalist's expertise in systems improvements and efficiency will a new inpatient educational system evolve; one that is efficient, safe, and patient‐focused, thus ensuring current production. And also one that enables meaningful development of communication, practice‐based learning, and systems‐of‐care skills, ensuring our production capacity for years to come.

Maintaining a balance between productivity (what we do now), and production capacity (the ability to continue to do what we now do in the future) is one of the central tenets of successful organizations and societies. The economic benefits of industrialization (production) must be balanced with the needs of the environment (production capacity). It is appropriate then, that this issue of The Journal of Hospital Medicine juxtaposes Conway's1 article on hospitalists' current production of ensuring value, with articles addressing medical education, our production capacity.

What is the role of hospitalists in medical education? The article by Beasley et al.,2 confirms what has long been suspected: the growth of hospitalists in medical education has paralleled the growth of the movement as a whole. The meta‐analysis by Natarajan et al.3 further suggests that hospitalists are at the very least no worse in medical education than other specialists, and in some domains, may be superior. The theoretical fears of hospitalists as medical educators have not been borne out: utilizing hospitalists as educators does not lead to a decline in resident autonomy, nor does it lead to a decline in educational ability. But despite the fact that 73% of residency training programs utilize hospitalists, there are several reasons why the hospitalists' role in inpatient medical education should be even more robust.

The landscape of graduate medical education has dramatically changed in the past 10 years. The knowledge‐only paradigm has evolved to a comprehensive focus on the trainee's overall performance, including understanding the healthcare system in which she works (systems of care), self‐reflection on her practice (practice‐based learning), and an augmented emphasis on professionalism and interpersonal skills.4 Unfortunately, many systems have not undergone a similar paradigm change, opting instead to merely rearrange components of the old knowledge‐focused system. For example, practice‐based learning may remain relegated to journal clubs, where the focus is on the knowledge contained in the chosen article, instead of active exercises in which the resident self‐reflects on his patient care performance and seeks ways to improve that performance. Instruction in systems‐of‐care may remain within a knowledge‐only paradigm: a didactic lecture on Medicare/Medicaid and reimbursement instead of residents actively participating in quality improvement projects.

The article by Mazotti et al.,5 provides insight into the reason for this developmental arrest: there isn't enough time in the old system. The duty‐hours have decreased for residents, but since the work product has remained the same, the result has been an increase in work intensity. As work intensity increases, production capacity (medical education) is the first to be sacrificed in an effort to maintain production (getting the work done).

Here is the yet unrealized role of the hospitalist. The same degree of systems reengineering that brought about improved efficiency in patient care (shorter lengths of stay, fewer readmissions), must be applied to the inpatient education system if duty hours, a reasonable work intensity, and meaningful education in each of the core competencies are to coexist. But there is no panacea for these issues: each system is unique, and the solutions to improving the efficiency of the inpatient education environment are just as unique. Solutions require a systems architect (ie, the hospitalist) to redesign the educational environment in his particular system. It is natural to assume that the hospitalist educator, familiar with the strengths and weakness of the educational system in which he routinely works, will be best equipped to enact meaningful solutions that improve efficiency while protecting the principles of medical education.

What does it mean to change the educational system? Taiichi Ohno,6 Toyota's Chief Engineer, provides Seven Organizational Wastes, a framework for identifying areas of improvement in the educational work environment. Consider, for example, the following selected opportunities for improving the efficiency of the inpatient medical education system: (1) excessive testing or consultation leading to delayed discharge and more resident work effort (Overproduction); (2) the resident team waiting for the attending to arrive from a procedure or clinic (Waiting); (3) inadequate teaching about the principles of transitions of care, resulting in more readmissions to the teaching service (Transporting); (4) failure to have quality improvement conferences to discuss the appropriateness of admissions (Inappropriate processing); (5) failure to teach residents how to work with social work/placement services to facilitate early discharge (Unnecessary inventory); (6) failure to construct a training program that limits fragmentation, with residents moving from 1 task to the next and back again (Unnecessary motion); and (7) medical errors resulting in prolonged lengths of stay and resident work effort (Defects). There is no shortage of opportunities for improving the efficiency of the inpatient educational environment, but it requires that the systems architect is sufficiently familiar with the system to design interventions that are meaningful and effective. This is the unique advantage of the hospitalist.

But the greatest risk to inpatient medical education is yet to come, and it may be on the hospitalist's shoulders to reverse a dangerous trend. With the advent of more extensive electronic medical records, the locus of patient care has begun to shift from the bedside to a computer terminal. An unbridled drive to efficiency, without a steward to ensure the primacy of patient‐centered care, is likely to inspire the next generation of physicians to see Mr. A. Huxley as the i‐Patient, in which the entirety of his management is conducted from the safety of a computer terminal.7 Despite the need for efficiency, the patient has to remain the focal point. It is at the bedside that the resident learns that observing 5 bags of potato chips on the nightstand might obviate a million‐dollar workup for refractory hypertension. And it is at the bedside that the resident learns that despite our elaborate protocols and decision analyses, the ultimate testing and management decisions hinge upon the patient's preferences. The single best thing than can be done to augment patient safety and quality is to maximize the time the patient spends with his healthcare team; and the hospitalist, who is not in a rush to complete morning rounds in an effort to get to a clinic or an endoscopy suite, may be the person who has the time to prioritize bedside rounds as a part of the educational environment.

The article by Nazario8 establishes the urgency of integrating the humanities into patient management. For meaningful humanities instruction to occur, however, it has to occur at the bedside, not in the classroom. And this requires that the supervising physician has the time to reflect with the resident upon the humanism issues that are unique to each patient encounter. Once again, it is time that enables the luxury of this self‐reflection, a commodity that the hospitalist enjoys as a part of her job description. It is also a commodity that the hospitalist can generate by augmenting efficiency in the educational system, provided patient‐centered care remains the priority.

The role of the hospitalist has to be much more than merely patching the current paradigm of graduate medical education. Overseeing nonteaching services and serving as the night float physician are examples of these patches. While valuable, these roles are useful only in preserving production of the current system, not in enabling production capacity for the next generation of physicians. Continuing in this role without also becoming an active part of the teaching service sends a message to residents that a career as a hospitalist in a teaching environment is only to be a fourth‐year or fifth‐year resident. Why would any resident embark upon that career? Meeting the demand for 30,000 hospitalists by 2012 requires a pipeline of physicians, and answering this question will be central to achieving that goal. Residents must have hospitalist role models, occupying careers devoted to patient safety and quality; careers that are meaningful and fulfilling.

To this end, the hospital medicine community cannot be satisfied with being no worse than other specialists in medical education. As Natarajan et al.3 point out, the evaluation of inpatient medical education has, with few exceptions, been solely based upon learner's subjective opinions. Meaningful change in the educational system will require meaningful objective endpoints: participation in the quality improvement projects; patient‐centered evaluations of resident performance; end‐user evaluations of resident communication skills (clinic physicians, nurses, other services); metrics to assess the efficacy of the transition of care; and resident profiles that enable self‐assessment of their practice. It will be up to the hospitalist to assess the system to define these meaningful endpoints that ensure that inpatient education is advancing quality, safety, and patient‐centered care.

Despite all of the reasons for why hospitalists should be more involved in the teaching service, there remains the 1 reason that they are not: hospitalists on average are young, and they may not have the teaching skills that more experienced generalists or subspecialists possess. To bring about the benefits hospitalists can offer to the inpatient education environment, hospitalists must be willing to compensate for their lack of teaching experience by seeking out formal training courses in medical education. The Academic Hospitalist Academy cosponsored by the Society of Hospital Medicine (SHM), the Society of General Internal Medicine (SGIM), and the Association of Chiefs of General Internal Medicine (ACGIM) is 1 example.9

As experience is accumulated, more hospitalists have to actively seek out leadership positions in graduate medical education, aligning our strengths, in patient safety, efficiency, and systems change, with the goals and objectives of the residency and student programs. The fact that 73% of residency training programs utilize hospitalists is exciting; the fact that there are only 15 hospitalists as program directors is disappointing.2 As was the case in the clinical care environment, leadership will be just as important in the education environment, as it is important for enacting the changes that will transform the inpatient education environment to a system that is efficient, safe, and patient‐centered.

Hospitalists have been effective in their production, augmenting efficiency and quality of patient care. But the reality is that the task of ensuring value, as it pertains to patient safety and quality, is too onerous of a task to be accomplished with arithmetic gains. Generations of physicians will have to adopt a cultural change to reach the ultimate goal. It is of little consequence that we improve safety for a moment in time, only to have it fall by the wayside as successive generations of physicians take our place. Now is the time for hospitalists to fully embrace the inpatient education environment as our responsibility. Too much time has already been wasted in arguing against duty‐hours regulations. These regulations are now here to stay, and this has created a system that is currently unable to handle the strains of multiple demands. Only by using the hospitalist's expertise in systems improvements and efficiency will a new inpatient educational system evolve; one that is efficient, safe, and patient‐focused, thus ensuring current production. And also one that enables meaningful development of communication, practice‐based learning, and systems‐of‐care skills, ensuring our production capacity for years to come.

An important role of the internist is that of inpatient medical consultant.13 As consultants, internists make recommendations regarding the patient's medical care and help the primary team to care for the patient. This requires familiarity with the body of knowledge of consultative medicine, as well as process skills that relate to working with teams of providers.1, 4, 5 For some physicians, the knowledge and skills of medical consultation are acquired during residency; however, many internists feel inadequately prepared for their roles of consultants.68 Because no specific requirements for medical consultation curricula during graduate medical education have been set forth, internists and other physicians do not receive uniform or comprehensive training in this area.3, 57, 9 Although internal medicine residents may gain experience while performing consultations on subspecialty rotations (eg, cardiology), the teaching on these blocks tends to be focused on the specialty content and less so on consultative principles.1, 4

As inpatient care is increasingly being taken over by hospitalists, the role of the hospitalist has expanded to include medical consultation. It is estimated that 92% of hospitalists care for patients on medical consultation services.8 The Society of Hospital Medicine (SHM) has also included medical consultation as one of the core competencies of the hospitalist.2 Therefore, it is essential that hospitalists master the knowledge and skills that are required to serve as effective consultants.10, 11

An educational strategy that has been shown to be effective in improving medical practice is audit and feedback.1215 Providing physicians with feedback on their clinical practice has been shown to improve performance more so than other educational methods.12 Practice‐based learning and improvement (PBLI) utilizes this strategy and it has become one of the core competencies stressed by the Accreditation Council for Graduate Medical Education (ACGME). It involves analyzing one's patient care practices in order to identify areas for improvement. In this study, we tested the impact of a newly developed one‐on‐one medical consultation educational module that was combined with audit and feedback in an attempt to improve the quality of the consultations being performed by our hospitalists.

Materials and Methods

Results

Discussion

This curricular intervention using a case‐based module combined with audit and feedback appears to have resulted not only in improved knowledge, but also changed physician behavior in the form of higher‐quality written consultations. The teaching sessions were also well received and valued by busy hospitalists.

A review of randomized trials of audit and feedback12 revealed that this strategy is effective in improving professional practice in a variety of areas, including laboratory overutilization,13, 14 clinical practice guideline adherence,15, 17 and antibiotic utilization.13 In 1 study, internal medicine specialists audited their consultation letters and most believed that there had been lasting improvements to their notes.18 However, this study did not objectively compare the consultation letters from before audit and feedback to those written afterward but instead relied solely on the respondents' self‐assessment. It is known that many residents and recent graduates of internal medicine programs feel inadequately prepared in the role of consultant.6, 8 This work describes a curricular intervention that served to augment confidence, knowledge, and actual performance in consultation medicine of physicians. Goldman et al.'s10 Ten Commandments for Effective Consultations, which were later modified by Salerno et al.,11 were highlighted in our case‐based teachings: determine the question being asked or how you can help the requesting physician, establish the urgency of the consultation, gather primary data, be as brief as appropriate in your report, provide specific recommendations, provide contingency plans and discuss their execution, define your role in conjunction with the requesting physician, offer educational information, communicate recommendations directly to the requesting physician, and provide daily follow‐up. These tenets informed the development of the consultation scoring system that was used to assess the quality of the written consultations produced by our consultant hospitalists.

Audit and feedback is similar to PBLI, one of the ACGME core competencies for residency training. Both attempt to engage individuals by having them analyze their patient care practices, looking critically to: (1) identify areas needing improvement, and (2) consider strategies that can be implemented to enhance clinical performance. We now show that consultative medicine is an area that appears to be responsive to a mixed methodological educational intervention that includes audit and feedback.

Faculty and house‐staff knowledge of consultative medicine was assessed both before and after the case‐based educational module. Both groups scored very highly on the true/false pretest, suggesting either that their knowledge was excellent at baseline or the test was not sufficiently challenging. If their knowledge was truly very high, then the intervention need not have focused on improving knowledge. It is our interpretation that the true/false knowledge assessment was not challenging enough and therefore failed to comprehensively characterize their knowledge of consultative medicine.

Several limitations of this study should be considered. First, the sample size was small, including only 7 faculty and 12 house‐staff members. However, these numbers were sufficient to show statistically significant overall improvements in both knowledge and on the consultation scores. Second, few consultations were performed by each faculty member, ranging from 2 to 5, before and after the intervention. This may explain why only 1 out of 6 faculty members showed statistically significant improvement in the quality of consults after the intervention. Third, the true/false format of the knowledge tests allowed the subjects to score very high on the pretest, thereby making it difficult to detect knowledge gained after the intervention. Fourth, the scale used to evaluate consults has not been previously validated. The elements assessed by this scale were decided upon based on guidance from the literature10 and the authors' expertise, thereby affording it content validity evidence.19 The recommendations that guided the scale's development have been shown to improve compliance with the recommendations put forth by the consultant.1, 11 Internal structure validity evidence was conferred by the high level of agreement in scores between the independent raters. Relation to other variables validity evidence may be considered because doctors D and F scored highest on this scale and they are the 2 physicians most experienced in consult medicine. Finally, the educational intervention was time‐intensive for both learners and teacher. It consisted of a 1 hour‐long one‐on‐one session. This can be difficult to incorporate into a busy hospitalist program. The intervention can be made more efficient by having learners take the web‐based module online independently, and then meeting with the teacher for the audit and feedback component.

This consult medicine curricular intervention involving audit and feedback was beneficial to hospitalists and resulted in improved consultation notes. While resource intensive, the one‐on‐one teaching session appears to have worked and resulted in outcomes that are meaningful with respect to patient care.

An important role of the internist is that of inpatient medical consultant.13 As consultants, internists make recommendations regarding the patient's medical care and help the primary team to care for the patient. This requires familiarity with the body of knowledge of consultative medicine, as well as process skills that relate to working with teams of providers.1, 4, 5 For some physicians, the knowledge and skills of medical consultation are acquired during residency; however, many internists feel inadequately prepared for their roles of consultants.68 Because no specific requirements for medical consultation curricula during graduate medical education have been set forth, internists and other physicians do not receive uniform or comprehensive training in this area.3, 57, 9 Although internal medicine residents may gain experience while performing consultations on subspecialty rotations (eg, cardiology), the teaching on these blocks tends to be focused on the specialty content and less so on consultative principles.1, 4

As inpatient care is increasingly being taken over by hospitalists, the role of the hospitalist has expanded to include medical consultation. It is estimated that 92% of hospitalists care for patients on medical consultation services.8 The Society of Hospital Medicine (SHM) has also included medical consultation as one of the core competencies of the hospitalist.2 Therefore, it is essential that hospitalists master the knowledge and skills that are required to serve as effective consultants.10, 11

An educational strategy that has been shown to be effective in improving medical practice is audit and feedback.1215 Providing physicians with feedback on their clinical practice has been shown to improve performance more so than other educational methods.12 Practice‐based learning and improvement (PBLI) utilizes this strategy and it has become one of the core competencies stressed by the Accreditation Council for Graduate Medical Education (ACGME). It involves analyzing one's patient care practices in order to identify areas for improvement. In this study, we tested the impact of a newly developed one‐on‐one medical consultation educational module that was combined with audit and feedback in an attempt to improve the quality of the consultations being performed by our hospitalists.

Materials and Methods

Results

Discussion

This curricular intervention using a case‐based module combined with audit and feedback appears to have resulted not only in improved knowledge, but also changed physician behavior in the form of higher‐quality written consultations. The teaching sessions were also well received and valued by busy hospitalists.

A review of randomized trials of audit and feedback12 revealed that this strategy is effective in improving professional practice in a variety of areas, including laboratory overutilization,13, 14 clinical practice guideline adherence,15, 17 and antibiotic utilization.13 In 1 study, internal medicine specialists audited their consultation letters and most believed that there had been lasting improvements to their notes.18 However, this study did not objectively compare the consultation letters from before audit and feedback to those written afterward but instead relied solely on the respondents' self‐assessment. It is known that many residents and recent graduates of internal medicine programs feel inadequately prepared in the role of consultant.6, 8 This work describes a curricular intervention that served to augment confidence, knowledge, and actual performance in consultation medicine of physicians. Goldman et al.'s10 Ten Commandments for Effective Consultations, which were later modified by Salerno et al.,11 were highlighted in our case‐based teachings: determine the question being asked or how you can help the requesting physician, establish the urgency of the consultation, gather primary data, be as brief as appropriate in your report, provide specific recommendations, provide contingency plans and discuss their execution, define your role in conjunction with the requesting physician, offer educational information, communicate recommendations directly to the requesting physician, and provide daily follow‐up. These tenets informed the development of the consultation scoring system that was used to assess the quality of the written consultations produced by our consultant hospitalists.

Audit and feedback is similar to PBLI, one of the ACGME core competencies for residency training. Both attempt to engage individuals by having them analyze their patient care practices, looking critically to: (1) identify areas needing improvement, and (2) consider strategies that can be implemented to enhance clinical performance. We now show that consultative medicine is an area that appears to be responsive to a mixed methodological educational intervention that includes audit and feedback.

Faculty and house‐staff knowledge of consultative medicine was assessed both before and after the case‐based educational module. Both groups scored very highly on the true/false pretest, suggesting either that their knowledge was excellent at baseline or the test was not sufficiently challenging. If their knowledge was truly very high, then the intervention need not have focused on improving knowledge. It is our interpretation that the true/false knowledge assessment was not challenging enough and therefore failed to comprehensively characterize their knowledge of consultative medicine.

Several limitations of this study should be considered. First, the sample size was small, including only 7 faculty and 12 house‐staff members. However, these numbers were sufficient to show statistically significant overall improvements in both knowledge and on the consultation scores. Second, few consultations were performed by each faculty member, ranging from 2 to 5, before and after the intervention. This may explain why only 1 out of 6 faculty members showed statistically significant improvement in the quality of consults after the intervention. Third, the true/false format of the knowledge tests allowed the subjects to score very high on the pretest, thereby making it difficult to detect knowledge gained after the intervention. Fourth, the scale used to evaluate consults has not been previously validated. The elements assessed by this scale were decided upon based on guidance from the literature10 and the authors' expertise, thereby affording it content validity evidence.19 The recommendations that guided the scale's development have been shown to improve compliance with the recommendations put forth by the consultant.1, 11 Internal structure validity evidence was conferred by the high level of agreement in scores between the independent raters. Relation to other variables validity evidence may be considered because doctors D and F scored highest on this scale and they are the 2 physicians most experienced in consult medicine. Finally, the educational intervention was time‐intensive for both learners and teacher. It consisted of a 1 hour‐long one‐on‐one session. This can be difficult to incorporate into a busy hospitalist program. The intervention can be made more efficient by having learners take the web‐based module online independently, and then meeting with the teacher for the audit and feedback component.

This consult medicine curricular intervention involving audit and feedback was beneficial to hospitalists and resulted in improved consultation notes. While resource intensive, the one‐on‐one teaching session appears to have worked and resulted in outcomes that are meaningful with respect to patient care.

An important role of the internist is that of inpatient medical consultant.13 As consultants, internists make recommendations regarding the patient's medical care and help the primary team to care for the patient. This requires familiarity with the body of knowledge of consultative medicine, as well as process skills that relate to working with teams of providers.1, 4, 5 For some physicians, the knowledge and skills of medical consultation are acquired during residency; however, many internists feel inadequately prepared for their roles of consultants.68 Because no specific requirements for medical consultation curricula during graduate medical education have been set forth, internists and other physicians do not receive uniform or comprehensive training in this area.3, 57, 9 Although internal medicine residents may gain experience while performing consultations on subspecialty rotations (eg, cardiology), the teaching on these blocks tends to be focused on the specialty content and less so on consultative principles.1, 4

As inpatient care is increasingly being taken over by hospitalists, the role of the hospitalist has expanded to include medical consultation. It is estimated that 92% of hospitalists care for patients on medical consultation services.8 The Society of Hospital Medicine (SHM) has also included medical consultation as one of the core competencies of the hospitalist.2 Therefore, it is essential that hospitalists master the knowledge and skills that are required to serve as effective consultants.10, 11

An educational strategy that has been shown to be effective in improving medical practice is audit and feedback.1215 Providing physicians with feedback on their clinical practice has been shown to improve performance more so than other educational methods.12 Practice‐based learning and improvement (PBLI) utilizes this strategy and it has become one of the core competencies stressed by the Accreditation Council for Graduate Medical Education (ACGME). It involves analyzing one's patient care practices in order to identify areas for improvement. In this study, we tested the impact of a newly developed one‐on‐one medical consultation educational module that was combined with audit and feedback in an attempt to improve the quality of the consultations being performed by our hospitalists.

Materials and Methods

Results

Discussion

This curricular intervention using a case‐based module combined with audit and feedback appears to have resulted not only in improved knowledge, but also changed physician behavior in the form of higher‐quality written consultations. The teaching sessions were also well received and valued by busy hospitalists.

A review of randomized trials of audit and feedback12 revealed that this strategy is effective in improving professional practice in a variety of areas, including laboratory overutilization,13, 14 clinical practice guideline adherence,15, 17 and antibiotic utilization.13 In 1 study, internal medicine specialists audited their consultation letters and most believed that there had been lasting improvements to their notes.18 However, this study did not objectively compare the consultation letters from before audit and feedback to those written afterward but instead relied solely on the respondents' self‐assessment. It is known that many residents and recent graduates of internal medicine programs feel inadequately prepared in the role of consultant.6, 8 This work describes a curricular intervention that served to augment confidence, knowledge, and actual performance in consultation medicine of physicians. Goldman et al.'s10 Ten Commandments for Effective Consultations, which were later modified by Salerno et al.,11 were highlighted in our case‐based teachings: determine the question being asked or how you can help the requesting physician, establish the urgency of the consultation, gather primary data, be as brief as appropriate in your report, provide specific recommendations, provide contingency plans and discuss their execution, define your role in conjunction with the requesting physician, offer educational information, communicate recommendations directly to the requesting physician, and provide daily follow‐up. These tenets informed the development of the consultation scoring system that was used to assess the quality of the written consultations produced by our consultant hospitalists.

Audit and feedback is similar to PBLI, one of the ACGME core competencies for residency training. Both attempt to engage individuals by having them analyze their patient care practices, looking critically to: (1) identify areas needing improvement, and (2) consider strategies that can be implemented to enhance clinical performance. We now show that consultative medicine is an area that appears to be responsive to a mixed methodological educational intervention that includes audit and feedback.

Faculty and house‐staff knowledge of consultative medicine was assessed both before and after the case‐based educational module. Both groups scored very highly on the true/false pretest, suggesting either that their knowledge was excellent at baseline or the test was not sufficiently challenging. If their knowledge was truly very high, then the intervention need not have focused on improving knowledge. It is our interpretation that the true/false knowledge assessment was not challenging enough and therefore failed to comprehensively characterize their knowledge of consultative medicine.

Several limitations of this study should be considered. First, the sample size was small, including only 7 faculty and 12 house‐staff members. However, these numbers were sufficient to show statistically significant overall improvements in both knowledge and on the consultation scores. Second, few consultations were performed by each faculty member, ranging from 2 to 5, before and after the intervention. This may explain why only 1 out of 6 faculty members showed statistically significant improvement in the quality of consults after the intervention. Third, the true/false format of the knowledge tests allowed the subjects to score very high on the pretest, thereby making it difficult to detect knowledge gained after the intervention. Fourth, the scale used to evaluate consults has not been previously validated. The elements assessed by this scale were decided upon based on guidance from the literature10 and the authors' expertise, thereby affording it content validity evidence.19 The recommendations that guided the scale's development have been shown to improve compliance with the recommendations put forth by the consultant.1, 11 Internal structure validity evidence was conferred by the high level of agreement in scores between the independent raters. Relation to other variables validity evidence may be considered because doctors D and F scored highest on this scale and they are the 2 physicians most experienced in consult medicine. Finally, the educational intervention was time‐intensive for both learners and teacher. It consisted of a 1 hour‐long one‐on‐one session. This can be difficult to incorporate into a busy hospitalist program. The intervention can be made more efficient by having learners take the web‐based module online independently, and then meeting with the teacher for the audit and feedback component.

This consult medicine curricular intervention involving audit and feedback was beneficial to hospitalists and resulted in improved consultation notes. While resource intensive, the one‐on‐one teaching session appears to have worked and resulted in outcomes that are meaningful with respect to patient care.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.

Inpatient pediatrics is undergoing a paradigm shift in at least 3 ways. First, more children with chronic disease are being cared for in the hospital over time.1 Second, previous inpatient conditions are treated at home with advancing technology such as peripherally‐inserted catheters.2 Third, there are new areas of growing specialization, such as hospital medicine, in which the practitioners deliver more efficient care.3, 4

Nationwide, there is increasing pressure to improve inpatient quality of care. The Institute of Medicine defines 6 aims for improvement, including timeliness (reducing waits and sometimes harmful delays for both those who receive and those who give care) and efficiency of care (avoiding waste, including waste of equipment, supplies, ideas, and energy).5 Reducing unnecessary stays in the hospital is a potential quality measure that hospitals may use to address the timeliness and efficiency of care delivered to hospitalized children.

Delays in discharge have been used as markers of unnecessary stays in the hospital for inpatient adult and pediatric care,6, 7 but these are limited to inpatient systems from almost 20 years ago. Current reasons why patients are delayed from discharge, if at all, are not well described. We undertook this study to describe delays in hospital discharges at a tertiary‐care children's hospital in terms of number of patients, length of days of delay, and type of delay. In addition, we sought to characterize the impact of discharge delays on overall length of stay (LOS) and costs.

Methods

Results

During the 31 days of the study, 171 patients occupied hospital beds an average of 7.3 days on the 2 inpatient medical teams, for a total of 911 inpatient days. Seven patients were admitted prior to August 1; 6 of these were discharged during the month of August and 1 stayed through the entire month and was discharged in September. Three additional patients were admitted in August and discharged in September. There were 6 readmissions during the month of August, and 1 patient was excluded from the study because of lack of sufficient information. All patients with delays were able to be classified according to the Delay Tool taxonomy. Interrater reliability for the 2 study physicians was 98%.

The characteristics between the patients who did and did not experience a delay in discharge are shown in Table 1. Thirty‐nine of 171 patients (22.8%), experienced at least 1 delay day. Eighteen of 39 patients had only 1 delay day (46.2%) and 11 patients experienced 2 delayed days (28.2%) (Figure 1). The average length of delay was 2.1 days.

Figure 1

Delays attributed to physician responsibility accounted for 42.3% (16.5/39) of patient delays (conservative management or clinical decision‐making), with discharge planning delays accounting for 21.8% (family‐related, patient‐related, and hospital‐related problems), consultation for 14.1% (delay in obtaining or lack of follow‐up), test scheduling for 12.8%, and obtaining test results for 5.1% (ordering and weekend scheduling). There were no primary delays due to surgery, education and research, or unavailability of outside resources such as a skilled nursing bed. Four patients had a single additional secondary cause of delay assigned to them, related to physician responsibility, consultation, surgery and test scheduling; these were split, attributing 0.5 patients to each delay type (thus, the 17/39 patients delayed for physician responsibility was analyzed as 16.5/39) (Table 2).

There were 82 delay‐related hospital days of 911 total inpatient days on the 2 medical teams for August 2004 (9%). More than $170,000 in excess costs was incurred due to delay days from a total of approximately 1.9 million dollars in patient costs for the month (8.9%).

Discussion

This study finds that discharge delays in a tertiary care children's hospital are common; almost 1 in 4 patients experienced a medically unnecessary excess hospital stay of at least 1 day. The average length of a delay was 2.1 days, and overall, delays consumed 9% of pediatric hospital days and 8.9% of total costs. The most common reason for a delay was related to physician clinical care, including excessively conservative management and variability in clinical decision‐making.

Our study results are similar to the other 2 published studies that use the Delay Tool. In the adult and pediatric studies, between 10% and 30% of patients experienced a delay in discharge, with the average length of delay between 2.9 and 3 days.6, 7 Although both studies were conducted at teaching hospitals, what is particularly interesting is that they were conducted almost 20 years ago. During this period of time, there has been a shift in the inpatient pediatric patient population. In recent years, children who are cared for in the hospital have more chronic illnesses.1 In addition, there has been a shift in the types of conditions that may be cared for at home and those that now require inpatient stay.2 Despite this, delays continue at a similar proportion, but the cause of delays have shifted from scheduling and consultation to physician responsibility.

There is another tool in the literature which is more widely used, the Pediatric Appropriateness Evaluation Protocol (PAEP), which is based on the Appropriateness Evaluation Protocol for adults.1417 This tool is used to determine the appropriateness of ongoing hospitalization, not the cause of delay if ongoing hospitalization is inappropriate. The 3 areas that are evaluated (medical services, nursing and ancillary services, and patient's condition) have objective criteria that dictate if the hospitalization is appropriate or not (eg, parenteral (intravenous) therapy for at least 8 hours on that day, under nursing and ancillary services). The PAEP may be less sensitive given today's healthcare resource utilization climate. Many clinicians and families would agree that insertion of a peripheral central catheter is an acceptable form of outpatient treatment for many pediatric conditions. In conjunction with the Delay Tool, the PAEP could be used to determine if a delay occurred, then the Delay Tool used to categorize the cause of the delay. We choose to use expert clinician judgment to determine if a delay had occurred. We were more interested in why patients who are admitted (appropriately or inappropriately) cannot be discharged sooner, thus allowing for future intervention studies targeted to impact delays in discharge, as elucidated in this study. The Delay Tool specifically allowed us to categorize the reasons for delays. Given that the average LOS for patients in the nondelayed group was over 4 days, despite not using a tool such as the PAEP, we believe that these were likely to be appropriate admissions.

A recent study reported the first use of the Medical Care Appropriateness Protocol (MCAP) in a tertiary‐care children's hospital. The authors used the MCAP to determine the impact of an intervention on reducing inappropriate hospitals days for children. This tool is similarly labor‐intensive to the Delay Tool. Interestingly, this Canadian study found a high rate of inappropriate hospital days (47%), which may be in part attributable to a different outcome measurement tool and/or a different health care system.18

There are several limitations to our study that deserve mention. The Delay Tool requires clinician judgment regarding whether or not there was a delay in discharge for that day. We may have introduced some bias in our study, as hospitalist investigators assigned the delay and blinding to the attending physician specialty of record was not feasible. However, our results are similar to the other 2 published studies that have used this tool, and we specifically chose not to analyze or report results in terms of hospitalist and nonhospitalist attending physicians. The Delay Tool is not designed to differentiate shorter delays in terms of hours instead of days (eg, due to the inability for the patient to get a ride home). Shorter delays may be of particular importance depending on the occupancy rate of the hospital, the demand for beds, and other patient and hospital factors. We could not capture these shorter delays (although they did occur frequently) due to the original description of the Delay Tool. In addition, we would not have been able to report data on the impact on LOS and costs, as these are attributed to whole days in the hospital. However, if we had been able to differentiate shorter delays, this would bias our results to show a greater percentage of delays over smaller increments of time. Generalizability is an issue, given that this was a single‐center study. This study sample included over 80 different attending physicians participating in community pediatrician, subspecialty, and hospitalist practice groups. However, the patient population at PCMC is similar to other medium and large children's hospitals in the United States. The month observed may not reflect the entire year of hospitalizationsthere may be seasonal variations with delays depending on the volume and type of illness seen. The study was conducted in August, when there are newer house staff present. However, physician responsibility, which was the largest source of delays in our study, had little attribution to house staff. Most of the decisions were those of attending physicians, which would largely be unaffected by the time of year of the study. Finally, we were unable to assess the safety of the potential earlier discharge, as this was an observational study. However, in any future intervention studies examining processes to discharge patients sooner, measures of safety to the patient are a necessity. Finally, given the potential of ongoing admission, even on the date of discharge of our most fragile patients, this approach to discovering causes of delay may not apply to this important group, which is responsible for significant and growing resource utilization.

Despite these limitations, our findings demonstrate that in an era of children staying in the hospital less, and more medically‐complex children being admitted,10 a substantial number of children who are hospitalized at a children's hospital may have been discharged sooner. The majority of these decisions were directly related to physician responsibility. As consumers, providers, and hospitals work together to develop quality measures that are reflective of inpatient pediatric care, the Delay Tool may be able to highlight 2 aims of quality (ie, timeliness and efficiency of care) that could be used to assess the impact of interventions designed to safely discharge patients sooner. Interventions such as audit‐feedback,18 clinical guideline deployment,19 and hospitalist systems of care4 continue to hold the promise of earlier discharge; however, tools designed to measure inappropriate use of hospital days should be employed to demonstrate their effectiveness. Our study demonstrates ongoing waste in children's hospitals.

Conclusions

Almost 1 out of 4 patients in this 1‐month period could have been discharged sooner than they were. The impact of delays on costs and LOS are substantial and should provide strong incentives to develop effective interventions. Such interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing.