1. Carratala J, FernandezSabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142: 165-72.

The appropriate triage and management of patients with community-acquired pneumonia (CAP) has important implications for patient outcomes and the allocation of health care resources. Despite the availability of validated risk stratification tools significant variability in clinical practice which results in hospitalization rates that are often inconsistent with the severity of illness. In this unblinded, randomized controlled trial, 224 patients with CAP and a low-risk pneumonia severity index (PSI) score between 51 and 90 (class II and III) were randomized to outpatient oral levofloxacin therapy versus inpatient sequential intravenous and oral levofloxacin therapy. Exclusion criteria included quinolone allergy or use within the previous 3 months, PaO₂ < 60 mm Hg, complicated pleural effusion, lung abscess, metastatic infection, inability to maintain oral intake, and severe psychosocial problems precluding outpatient therapy. In an intention-to-treat analysis, the primary endpoints, of cure of pneumonia (resolution of signs, symptoms, and radiographic changes at 30 days), absence of adverse drug reactions, medical complications, or need for hospitalization at 30 days were achieved in 83.6% of outpatients and in 80.7% of hospitalized patients. For the secondary endpoint of patient satisfaction, 91.2% of outpatients versus 79.1% of hospitalized patients (p=.03) were satisfied, but there were no differences between groups with respect to the secondary endpoint of health-related quality of life. Mortality was similar between the 2 groups, and although the study was not sufficiently powered to address this outcome, and interestingly there was trend toward increased medical complications in the hospitalized patients.

Limitations of this study include lack of blinding by investigators and questions about whether the results can be generalized given the geographic variation in microbial susceptibility to quinolone antibiotics. As the authors suggest, this study also highlights limitations in the PSI scoring system, given that patients with clinical findings and comorbidities who would never be treated in the outpatient setting may in fact fall into low-risk PSI categories. These concerns notwithstanding, this study adds to our ability to identify an additional subset of patients with CAP who can be safely managed as outpatients.

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care.Ann Intern Med. 2005;142:260-73.

Early in the hospital medicine movement, when it was clear that hospitalists provided more efficient care than their colleagues, experience was cited as a reason for this difference. If, for example, a hospitalist cares for patients with community-acquired pneumonia daily, he or she is more likely to make the transition to oral antibiotics sooner, resulting in a shorter length of stay. Everyone recognized the hospitalists were younger, but is it plausible their “inexperience” explained the difference in care?

Choudhry and colleagues explored the available data surrounding clinical experience and quality of care delivered by physicians. They found few studies that specifically evaluated the effects of experience on quality of care. They did find articles that looked at quality of care and included experience or age as part of the physician characteristics

that possibly explained the differences. They reviewed 59 articles, available on MEDLINE, published since 1966. Forty-five studies found an inverse relationship between increasing experience and performance. For example, physicians more recently out of training programs were more familiar with evidence-based therapies for myocardial infarction and more familiar with NIH recommendations for treatment of breast cancer. Experienced physicians were less likely to screen for hypertension and more likely to prescribe inappropriate medications for elderly patients. This led them to the unexpected conclusion that experienced physicians may be at risk for providing lower-quality care and may need improvement interventions. An accompanying editorial by Drs. Weinberger, Duffy, and Cassel of the American Board of Internal Medicine stated, “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care.” They urged all physicians to “embrace the concepts behind maintenance of (board) certification.”

The image of Marcus Welby, MD, would lead one to believe that experience promotes higher quality care. But don’t ask a hospitalist: Many aren’t old enough to remember seeing him on television.

3. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969-77.

March was DVT (deep vein thrombosis) Awareness Month. Despite the availability of numerous guidelines, providers fail to consistently prescribe prophylactic measures against venous thromboembolism (VTE) for their hospitalized patients who meet criteria for prophylaxis.

Kucher and colleagues tested an innovative approach to remind providers to undertake such measures for their patients. They designed a computer program to identify hospitalized patients at increased risk for VTE who were not presently receiving VTE prophylaxis. The program reviewed the records of inpatients on the medical and surgical services and assigned a VTE risk score for each patient based on their history (i.e., history of cancer, hypercoagulability, etc.) and their present medical treatment (i.e., hormone therapy, prescribed bed rest, etc.). For patients considered “high risk” for VTE, the computer reviewed orders to identify ongoing use of VTE prophylactic measures. High-risk patients not receiving prophylactic therapies were randomized into 2 groups. The responsible physician in the intervention group received an electronic alert about the risk of VTE in their patient. No alerts were sent to the physicians in the control group. Physicians who received the alerts were forced to acknowledge the alert by either actively withholding prophylaxis or ordering prophylaxis (mechanical or pharmacologic measures). Patients were followed for 90 days with a primary endpoint of clinically diagnosed, objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). The primary endpoint occurred in 8.2% of the control group versus 4.9% in the invention group (p<.001). The alert reduced the risk of DVT or PE at 90 days by 41% (p=.001).

The results of the study are interesting. The authors acknowledged that many physicians had patients in both groups. So receiving 1 alert may have affected their use of prophylaxis in both groups. They also could not eliminate the possibility of diagnostic bias. Prophylaxis was not blinded and VTE testing was not routinely performed. Would physicians be more likely to order an imaging study for symptomatic patients on no prophylaxis than patients on prophylaxis? Nevertheless, for hospitals that have sufficient computer resources, implementation of such alerts can elevate physician awareness about VTE and other clinical conditions.

4. Lau DT, Kasper JD, Pofer DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165: 68-74.

Lau and colleagues studied the impact of potentially inappropriate medications among residents of longtermcare facilities. They used information from a 1996 national survey of home residents. The sample included 3372 residents, 65 years and older, who lived in a nursing home for 3 months or longer. Over half of the residents were older than 85 years old and 75% were female. Only 10% were black. Nearly two thirds had dementia or other mental disorders. The study used the Beers Criteria to define potentially inappropriate medications. The potential errors in medications were categorized as 1 of 3 types:

1. inappropriate choice of medication
2. excessive medication dosage
3. drug–disease interactions

Residents were considered to have a potentially inappropriate medication if their medication administration records revealed any of the above findings.

A univariate analysis showed that the risk of hospitalization was almost 30% higher among residents who received potentially inappropriate medications in the preceding month and 33% higher among residents who received potentially inappropriate medications for 2 consecutive months, compared with residents with no inappropriate medication exposure. The odds of death in any month were 21% higher among residents who had inappropriate medication exposure during the month of death or the preceeding month, compared with those with no inappropriate medication exposure.

These findings can be generalized to the inpatient setting, where hospitalists have the opportunity to influence and modify prescribing practices in the elderly population.

5. Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triplelumen catheter in the right internal jugular vein, using the anterior approach? Chest. 2005;127:220-3.

The routine use of chest radiography to confirm proper triplelumen catheter (TLC) placement may be an unnecessary and costly intervention. Lessnau conducted a prospective observational study of 100 consecutive patients over a 4-month period who required non-urgent TLC placement. The primary operators of the procedure included 18 medical residents, 3 pulmonary fellows, and a pulmonary attending with supervision provided for more junior clinicians. Operators followed a standardized approach to TLC placement utilizing the anterior approach to the right internal jugular vein. Complicated procedures were predefined as any procedure that required more than 3 needle passes, resulted in hemorrhage or hematoma formation (where there was concern for pneumothorax), or an absence of blood return in any of the TLC’s lumens. All subjects underwent routine post-procedure chest radiography to determine proper placement of the catheter and to exclude pneumothorax. A blinded radiologist reviewed these images.

Ninety-eight of the 100 catheters were in proper position. One malpositioned catheter was 7 cm above the right atrium in a patient who was 215 cm (>7 feet) tall. The second was noted to be in an S-shaped position on chest radiography. This procedure had required 20 needle passes and 5 slides of the catheter; additionally, blood return was inadequate in 2 lumens of the catheter. An operator reported a possible complication in 10 other procedures, but the only clinical finding in these cases was the development of a local hematoma in 1 patient. Eighty-eight patients had uncomplicated insertions and had normal chest radiographs. There were no pneumothoraces.

This study demonstrates that in carefully controlled and supervised situations, as described in the study, routine chest radiography may be omitted if the insertion goes smoothly. It is important to note that these results are specific to the technique described in the study (using the anterior approach to the right internal jugular, using a short finder needle to initially locate the vein) and cannot be extrapolated to other methods of TLC insertion. Important limitations of the study include the sample size of only 100 patients and the use of only a single anatomic approach to TLC insertion. These findings, although an important first step, will need to be reproduced on a larger scale before we can recommend the cessation of routine chest radiography after TLC placement on a more widespread basis.

6. Safdar N, Fine JP, Maki DG. Metaanalysis: methods for diagnosing intravascular devicerelated bloodstream infection. Ann Intern Med. 2005;142:451-66.

Intravascular device (IVD)–related blood stream infections are a frequent cause of morbidity and mortality, and yet there is lack of a clear consensus on the most accurate method to make this diagnosis.

In this metaanalysis, Safdar et al. reviewed 185 studies, including 8 different diagnostic tests, for the detection of IVD-related bloodstream infections, of which 51 studies met the inclusion criteria. Tests were divided into IVD-sparing and those requiring IVD removal. Pooled sensitivity and specificity, summary measures of accuracy, and the mean log odds ratio were determined. The most accurate IVD-sparing test was paired quantitative blood cultures (simultaneous blood cultures from the IVD and a peripheral site, with a positive result defined as an IVD-site microorganism concentration 3–5 times greater than peripheral site) with a sensitivity of 0.87 (95% CI: 0.83–0.91) and specificity of 0.98 (95% CI: 0.97–0.99). This was followed by quantitative IVD-drawn blood cultures alone (positive result defined as growth of ≥100 CFU), with a sensitivity of 0.77 (95% CI: 0.69–0.85) and a specificity of 0.90 (95% CI: 0.88–0.92). IVD-drawn qualitative blood cultures had a sensitivity of 0.87 (95% CI: 0.80–0.94) and a specificity of 0.83 (95% CI: 0.78–0.88), and IVD- and peripheral-drawn qualitative blood cultures with differential time to positivity had a sensitivity of 0.85 (95% CI: 0.78–0.92) and specificity of 0.81 (95% CI: 0.81–0.97).

The most accurate test requiring IVD removal was quantitative catheter segment culture (segment of catheter is flushed or sonicated and plated, positive if ≥1000 CFU), with sensitivity of 0.83 (95% CI: 0.78–0.88) and specificity of 0.87 (95% CI: 0.85–0.89), followed by semi-quantitative catheter segment culture (5cm segment plated, positive if ≥ 15 CFU) with sensitivity of 0.82 (95% CI: 0.81–0.89) and specificity of 0.82 (95% CI: 0.80–0.84). The least accurate was qualitative catheter segment culture (positive if any growth) with a sensitivity of 0.90 (95% CI: 0.83–0.97) and specificity of 0.72 (95% CI: 0.66–0.78).

The limitations of this study include heterogeneity of study design, including limited data on the use of antibiotics before culture data was obtained and the baseline prevalence of bacteremia in the study populations. In addition, all data was obtained prior to the widespread use of antibiotic-coated catheters. While these results support the catheter-tip quantitative culture techniques that are already widely in use, they are less applicable to blood culture testing techniques, because quantitative assays are rarely used. Fortunately, all of these assays have a high negative predictive value, and false-positive results can be minimized by reserving testing for patients in whom there is moderate-to-high pretest probability of IVD related bloodstream infection.

7. Sopena N, Sabria M, Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest. 2005;127:213-9.

A growing body of literature exists on hospital-acquired pneumonia (HAP) in the ICU setting. Sopena and colleagues extend the HAP literature to the non-ICU setting in a multicenter cross-sectional study. Cases of HAP were identified if clinical or radiographic evidence of pneumonia developed 72 hours after admission or within 10 days of a previous discharge. Patients who developed pneumonia in the ICU were excluded from analysis.

During an 18-month study period, 165 cases were identified with complete clinical and microbiologic data. The incidence of HAP was 3.1 ± 1.4 per 1000 hospital admissions. Ninety-eight (59.4%) patients diagnosed with HAP had severe underlying diseases that were classified as fatal (<1 year) or ultimately fatal (in 5 years). Extrinsic risk factors observed in patients with HAP included concurrent steroid use (29%), antibiotic therapy (53.3%), use of H2 blockers (37%), and hospitalization greater than 5 days (76%). Microbiologic data were positive in 60 (36.4%) cases. Streptococcus pneumoniae was diagnosed in 16 cases (9.7%), enterobacteriaceae in 8 (4.8%), Legionella pneumophila in 7 (4.2%), Aspergillus sp in 7 (4.2%), Pseudomonas aeruginosa in 7 (4.2%). Four cases of Staphylococcus aureus were diagnosed (3%), only one of which was methicillin resistant.

Complications of HAP occurred in 52.1% of cases and included respiratory failure (34.5%), pleural effusion (20.6%), septic shock (9.6%), renal failure (4.8%), and empyema (2.4%). Forty-three (26%) patients died during the hospitalization; 23 of these cases were directly attributed to HAP.

A limitation of the study is that the incidence of HAP was somewhat lower than reported in the literature and thus might represent an unintended sampling bias. Moreover, the study demonstrated underlying factors seen in patients with HAP, but these are not necessarily causative. Results useful to hospitalists include a higher than expected rate of Legionella and Aspergillus sp causing HAP in this population. A Legionella outbreak was not the explanation, as these cases were diagnosed in 5 different hospitals. The high frequency of adverse outcomes associated with HAP should alert hospitalists to the risk of nosocomial pneumonia in the non-ICU setting.

1. Carratala J, FernandezSabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142: 165-72.

The appropriate triage and management of patients with community-acquired pneumonia (CAP) has important implications for patient outcomes and the allocation of health care resources. Despite the availability of validated risk stratification tools significant variability in clinical practice which results in hospitalization rates that are often inconsistent with the severity of illness. In this unblinded, randomized controlled trial, 224 patients with CAP and a low-risk pneumonia severity index (PSI) score between 51 and 90 (class II and III) were randomized to outpatient oral levofloxacin therapy versus inpatient sequential intravenous and oral levofloxacin therapy. Exclusion criteria included quinolone allergy or use within the previous 3 months, PaO₂ < 60 mm Hg, complicated pleural effusion, lung abscess, metastatic infection, inability to maintain oral intake, and severe psychosocial problems precluding outpatient therapy. In an intention-to-treat analysis, the primary endpoints, of cure of pneumonia (resolution of signs, symptoms, and radiographic changes at 30 days), absence of adverse drug reactions, medical complications, or need for hospitalization at 30 days were achieved in 83.6% of outpatients and in 80.7% of hospitalized patients. For the secondary endpoint of patient satisfaction, 91.2% of outpatients versus 79.1% of hospitalized patients (p=.03) were satisfied, but there were no differences between groups with respect to the secondary endpoint of health-related quality of life. Mortality was similar between the 2 groups, and although the study was not sufficiently powered to address this outcome, and interestingly there was trend toward increased medical complications in the hospitalized patients.

Limitations of this study include lack of blinding by investigators and questions about whether the results can be generalized given the geographic variation in microbial susceptibility to quinolone antibiotics. As the authors suggest, this study also highlights limitations in the PSI scoring system, given that patients with clinical findings and comorbidities who would never be treated in the outpatient setting may in fact fall into low-risk PSI categories. These concerns notwithstanding, this study adds to our ability to identify an additional subset of patients with CAP who can be safely managed as outpatients.

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care.Ann Intern Med. 2005;142:260-73.

Early in the hospital medicine movement, when it was clear that hospitalists provided more efficient care than their colleagues, experience was cited as a reason for this difference. If, for example, a hospitalist cares for patients with community-acquired pneumonia daily, he or she is more likely to make the transition to oral antibiotics sooner, resulting in a shorter length of stay. Everyone recognized the hospitalists were younger, but is it plausible their “inexperience” explained the difference in care?

Choudhry and colleagues explored the available data surrounding clinical experience and quality of care delivered by physicians. They found few studies that specifically evaluated the effects of experience on quality of care. They did find articles that looked at quality of care and included experience or age as part of the physician characteristics

that possibly explained the differences. They reviewed 59 articles, available on MEDLINE, published since 1966. Forty-five studies found an inverse relationship between increasing experience and performance. For example, physicians more recently out of training programs were more familiar with evidence-based therapies for myocardial infarction and more familiar with NIH recommendations for treatment of breast cancer. Experienced physicians were less likely to screen for hypertension and more likely to prescribe inappropriate medications for elderly patients. This led them to the unexpected conclusion that experienced physicians may be at risk for providing lower-quality care and may need improvement interventions. An accompanying editorial by Drs. Weinberger, Duffy, and Cassel of the American Board of Internal Medicine stated, “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care.” They urged all physicians to “embrace the concepts behind maintenance of (board) certification.”

The image of Marcus Welby, MD, would lead one to believe that experience promotes higher quality care. But don’t ask a hospitalist: Many aren’t old enough to remember seeing him on television.

3. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969-77.

March was DVT (deep vein thrombosis) Awareness Month. Despite the availability of numerous guidelines, providers fail to consistently prescribe prophylactic measures against venous thromboembolism (VTE) for their hospitalized patients who meet criteria for prophylaxis.

Kucher and colleagues tested an innovative approach to remind providers to undertake such measures for their patients. They designed a computer program to identify hospitalized patients at increased risk for VTE who were not presently receiving VTE prophylaxis. The program reviewed the records of inpatients on the medical and surgical services and assigned a VTE risk score for each patient based on their history (i.e., history of cancer, hypercoagulability, etc.) and their present medical treatment (i.e., hormone therapy, prescribed bed rest, etc.). For patients considered “high risk” for VTE, the computer reviewed orders to identify ongoing use of VTE prophylactic measures. High-risk patients not receiving prophylactic therapies were randomized into 2 groups. The responsible physician in the intervention group received an electronic alert about the risk of VTE in their patient. No alerts were sent to the physicians in the control group. Physicians who received the alerts were forced to acknowledge the alert by either actively withholding prophylaxis or ordering prophylaxis (mechanical or pharmacologic measures). Patients were followed for 90 days with a primary endpoint of clinically diagnosed, objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). The primary endpoint occurred in 8.2% of the control group versus 4.9% in the invention group (p<.001). The alert reduced the risk of DVT or PE at 90 days by 41% (p=.001).

The results of the study are interesting. The authors acknowledged that many physicians had patients in both groups. So receiving 1 alert may have affected their use of prophylaxis in both groups. They also could not eliminate the possibility of diagnostic bias. Prophylaxis was not blinded and VTE testing was not routinely performed. Would physicians be more likely to order an imaging study for symptomatic patients on no prophylaxis than patients on prophylaxis? Nevertheless, for hospitals that have sufficient computer resources, implementation of such alerts can elevate physician awareness about VTE and other clinical conditions.

4. Lau DT, Kasper JD, Pofer DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165: 68-74.

Lau and colleagues studied the impact of potentially inappropriate medications among residents of longtermcare facilities. They used information from a 1996 national survey of home residents. The sample included 3372 residents, 65 years and older, who lived in a nursing home for 3 months or longer. Over half of the residents were older than 85 years old and 75% were female. Only 10% were black. Nearly two thirds had dementia or other mental disorders. The study used the Beers Criteria to define potentially inappropriate medications. The potential errors in medications were categorized as 1 of 3 types:

1. inappropriate choice of medication
2. excessive medication dosage
3. drug–disease interactions

Residents were considered to have a potentially inappropriate medication if their medication administration records revealed any of the above findings.

A univariate analysis showed that the risk of hospitalization was almost 30% higher among residents who received potentially inappropriate medications in the preceding month and 33% higher among residents who received potentially inappropriate medications for 2 consecutive months, compared with residents with no inappropriate medication exposure. The odds of death in any month were 21% higher among residents who had inappropriate medication exposure during the month of death or the preceeding month, compared with those with no inappropriate medication exposure.

These findings can be generalized to the inpatient setting, where hospitalists have the opportunity to influence and modify prescribing practices in the elderly population.

5. Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triplelumen catheter in the right internal jugular vein, using the anterior approach? Chest. 2005;127:220-3.

The routine use of chest radiography to confirm proper triplelumen catheter (TLC) placement may be an unnecessary and costly intervention. Lessnau conducted a prospective observational study of 100 consecutive patients over a 4-month period who required non-urgent TLC placement. The primary operators of the procedure included 18 medical residents, 3 pulmonary fellows, and a pulmonary attending with supervision provided for more junior clinicians. Operators followed a standardized approach to TLC placement utilizing the anterior approach to the right internal jugular vein. Complicated procedures were predefined as any procedure that required more than 3 needle passes, resulted in hemorrhage or hematoma formation (where there was concern for pneumothorax), or an absence of blood return in any of the TLC’s lumens. All subjects underwent routine post-procedure chest radiography to determine proper placement of the catheter and to exclude pneumothorax. A blinded radiologist reviewed these images.

Ninety-eight of the 100 catheters were in proper position. One malpositioned catheter was 7 cm above the right atrium in a patient who was 215 cm (>7 feet) tall. The second was noted to be in an S-shaped position on chest radiography. This procedure had required 20 needle passes and 5 slides of the catheter; additionally, blood return was inadequate in 2 lumens of the catheter. An operator reported a possible complication in 10 other procedures, but the only clinical finding in these cases was the development of a local hematoma in 1 patient. Eighty-eight patients had uncomplicated insertions and had normal chest radiographs. There were no pneumothoraces.

This study demonstrates that in carefully controlled and supervised situations, as described in the study, routine chest radiography may be omitted if the insertion goes smoothly. It is important to note that these results are specific to the technique described in the study (using the anterior approach to the right internal jugular, using a short finder needle to initially locate the vein) and cannot be extrapolated to other methods of TLC insertion. Important limitations of the study include the sample size of only 100 patients and the use of only a single anatomic approach to TLC insertion. These findings, although an important first step, will need to be reproduced on a larger scale before we can recommend the cessation of routine chest radiography after TLC placement on a more widespread basis.

6. Safdar N, Fine JP, Maki DG. Metaanalysis: methods for diagnosing intravascular devicerelated bloodstream infection. Ann Intern Med. 2005;142:451-66.

Intravascular device (IVD)–related blood stream infections are a frequent cause of morbidity and mortality, and yet there is lack of a clear consensus on the most accurate method to make this diagnosis.

In this metaanalysis, Safdar et al. reviewed 185 studies, including 8 different diagnostic tests, for the detection of IVD-related bloodstream infections, of which 51 studies met the inclusion criteria. Tests were divided into IVD-sparing and those requiring IVD removal. Pooled sensitivity and specificity, summary measures of accuracy, and the mean log odds ratio were determined. The most accurate IVD-sparing test was paired quantitative blood cultures (simultaneous blood cultures from the IVD and a peripheral site, with a positive result defined as an IVD-site microorganism concentration 3–5 times greater than peripheral site) with a sensitivity of 0.87 (95% CI: 0.83–0.91) and specificity of 0.98 (95% CI: 0.97–0.99). This was followed by quantitative IVD-drawn blood cultures alone (positive result defined as growth of ≥100 CFU), with a sensitivity of 0.77 (95% CI: 0.69–0.85) and a specificity of 0.90 (95% CI: 0.88–0.92). IVD-drawn qualitative blood cultures had a sensitivity of 0.87 (95% CI: 0.80–0.94) and a specificity of 0.83 (95% CI: 0.78–0.88), and IVD- and peripheral-drawn qualitative blood cultures with differential time to positivity had a sensitivity of 0.85 (95% CI: 0.78–0.92) and specificity of 0.81 (95% CI: 0.81–0.97).

The most accurate test requiring IVD removal was quantitative catheter segment culture (segment of catheter is flushed or sonicated and plated, positive if ≥1000 CFU), with sensitivity of 0.83 (95% CI: 0.78–0.88) and specificity of 0.87 (95% CI: 0.85–0.89), followed by semi-quantitative catheter segment culture (5cm segment plated, positive if ≥ 15 CFU) with sensitivity of 0.82 (95% CI: 0.81–0.89) and specificity of 0.82 (95% CI: 0.80–0.84). The least accurate was qualitative catheter segment culture (positive if any growth) with a sensitivity of 0.90 (95% CI: 0.83–0.97) and specificity of 0.72 (95% CI: 0.66–0.78).

The limitations of this study include heterogeneity of study design, including limited data on the use of antibiotics before culture data was obtained and the baseline prevalence of bacteremia in the study populations. In addition, all data was obtained prior to the widespread use of antibiotic-coated catheters. While these results support the catheter-tip quantitative culture techniques that are already widely in use, they are less applicable to blood culture testing techniques, because quantitative assays are rarely used. Fortunately, all of these assays have a high negative predictive value, and false-positive results can be minimized by reserving testing for patients in whom there is moderate-to-high pretest probability of IVD related bloodstream infection.

7. Sopena N, Sabria M, Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest. 2005;127:213-9.

A growing body of literature exists on hospital-acquired pneumonia (HAP) in the ICU setting. Sopena and colleagues extend the HAP literature to the non-ICU setting in a multicenter cross-sectional study. Cases of HAP were identified if clinical or radiographic evidence of pneumonia developed 72 hours after admission or within 10 days of a previous discharge. Patients who developed pneumonia in the ICU were excluded from analysis.

During an 18-month study period, 165 cases were identified with complete clinical and microbiologic data. The incidence of HAP was 3.1 ± 1.4 per 1000 hospital admissions. Ninety-eight (59.4%) patients diagnosed with HAP had severe underlying diseases that were classified as fatal (<1 year) or ultimately fatal (in 5 years). Extrinsic risk factors observed in patients with HAP included concurrent steroid use (29%), antibiotic therapy (53.3%), use of H2 blockers (37%), and hospitalization greater than 5 days (76%). Microbiologic data were positive in 60 (36.4%) cases. Streptococcus pneumoniae was diagnosed in 16 cases (9.7%), enterobacteriaceae in 8 (4.8%), Legionella pneumophila in 7 (4.2%), Aspergillus sp in 7 (4.2%), Pseudomonas aeruginosa in 7 (4.2%). Four cases of Staphylococcus aureus were diagnosed (3%), only one of which was methicillin resistant.

Complications of HAP occurred in 52.1% of cases and included respiratory failure (34.5%), pleural effusion (20.6%), septic shock (9.6%), renal failure (4.8%), and empyema (2.4%). Forty-three (26%) patients died during the hospitalization; 23 of these cases were directly attributed to HAP.

A limitation of the study is that the incidence of HAP was somewhat lower than reported in the literature and thus might represent an unintended sampling bias. Moreover, the study demonstrated underlying factors seen in patients with HAP, but these are not necessarily causative. Results useful to hospitalists include a higher than expected rate of Legionella and Aspergillus sp causing HAP in this population. A Legionella outbreak was not the explanation, as these cases were diagnosed in 5 different hospitals. The high frequency of adverse outcomes associated with HAP should alert hospitalists to the risk of nosocomial pneumonia in the non-ICU setting.

1. Carratala J, FernandezSabe N, Ortega L, et al. Outpatient care compared with hospitalization for community-acquired pneumonia: a randomized trial in low-risk patients. Ann Intern Med. 2005;142: 165-72.

The appropriate triage and management of patients with community-acquired pneumonia (CAP) has important implications for patient outcomes and the allocation of health care resources. Despite the availability of validated risk stratification tools significant variability in clinical practice which results in hospitalization rates that are often inconsistent with the severity of illness. In this unblinded, randomized controlled trial, 224 patients with CAP and a low-risk pneumonia severity index (PSI) score between 51 and 90 (class II and III) were randomized to outpatient oral levofloxacin therapy versus inpatient sequential intravenous and oral levofloxacin therapy. Exclusion criteria included quinolone allergy or use within the previous 3 months, PaO₂ < 60 mm Hg, complicated pleural effusion, lung abscess, metastatic infection, inability to maintain oral intake, and severe psychosocial problems precluding outpatient therapy. In an intention-to-treat analysis, the primary endpoints, of cure of pneumonia (resolution of signs, symptoms, and radiographic changes at 30 days), absence of adverse drug reactions, medical complications, or need for hospitalization at 30 days were achieved in 83.6% of outpatients and in 80.7% of hospitalized patients. For the secondary endpoint of patient satisfaction, 91.2% of outpatients versus 79.1% of hospitalized patients (p=.03) were satisfied, but there were no differences between groups with respect to the secondary endpoint of health-related quality of life. Mortality was similar between the 2 groups, and although the study was not sufficiently powered to address this outcome, and interestingly there was trend toward increased medical complications in the hospitalized patients.

Limitations of this study include lack of blinding by investigators and questions about whether the results can be generalized given the geographic variation in microbial susceptibility to quinolone antibiotics. As the authors suggest, this study also highlights limitations in the PSI scoring system, given that patients with clinical findings and comorbidities who would never be treated in the outpatient setting may in fact fall into low-risk PSI categories. These concerns notwithstanding, this study adds to our ability to identify an additional subset of patients with CAP who can be safely managed as outpatients.

2. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care.Ann Intern Med. 2005;142:260-73.

Early in the hospital medicine movement, when it was clear that hospitalists provided more efficient care than their colleagues, experience was cited as a reason for this difference. If, for example, a hospitalist cares for patients with community-acquired pneumonia daily, he or she is more likely to make the transition to oral antibiotics sooner, resulting in a shorter length of stay. Everyone recognized the hospitalists were younger, but is it plausible their “inexperience” explained the difference in care?

Choudhry and colleagues explored the available data surrounding clinical experience and quality of care delivered by physicians. They found few studies that specifically evaluated the effects of experience on quality of care. They did find articles that looked at quality of care and included experience or age as part of the physician characteristics

that possibly explained the differences. They reviewed 59 articles, available on MEDLINE, published since 1966. Forty-five studies found an inverse relationship between increasing experience and performance. For example, physicians more recently out of training programs were more familiar with evidence-based therapies for myocardial infarction and more familiar with NIH recommendations for treatment of breast cancer. Experienced physicians were less likely to screen for hypertension and more likely to prescribe inappropriate medications for elderly patients. This led them to the unexpected conclusion that experienced physicians may be at risk for providing lower-quality care and may need improvement interventions. An accompanying editorial by Drs. Weinberger, Duffy, and Cassel of the American Board of Internal Medicine stated, “The profession cannot ignore this striking finding and its implications: Practice does not make perfect, but it must be accompanied by ongoing active effort to maintain competence and quality of care.” They urged all physicians to “embrace the concepts behind maintenance of (board) certification.”

The image of Marcus Welby, MD, would lead one to believe that experience promotes higher quality care. But don’t ask a hospitalist: Many aren’t old enough to remember seeing him on television.

3. Kucher N, Koo S, Quiroz R, et al. Electronic alerts to prevent venous thromboembolism among hospitalized patients. N Engl J Med. 2005;352:969-77.

March was DVT (deep vein thrombosis) Awareness Month. Despite the availability of numerous guidelines, providers fail to consistently prescribe prophylactic measures against venous thromboembolism (VTE) for their hospitalized patients who meet criteria for prophylaxis.

Kucher and colleagues tested an innovative approach to remind providers to undertake such measures for their patients. They designed a computer program to identify hospitalized patients at increased risk for VTE who were not presently receiving VTE prophylaxis. The program reviewed the records of inpatients on the medical and surgical services and assigned a VTE risk score for each patient based on their history (i.e., history of cancer, hypercoagulability, etc.) and their present medical treatment (i.e., hormone therapy, prescribed bed rest, etc.). For patients considered “high risk” for VTE, the computer reviewed orders to identify ongoing use of VTE prophylactic measures. High-risk patients not receiving prophylactic therapies were randomized into 2 groups. The responsible physician in the intervention group received an electronic alert about the risk of VTE in their patient. No alerts were sent to the physicians in the control group. Physicians who received the alerts were forced to acknowledge the alert by either actively withholding prophylaxis or ordering prophylaxis (mechanical or pharmacologic measures). Patients were followed for 90 days with a primary endpoint of clinically diagnosed, objectively confirmed deep vein thrombosis (DVT) or pulmonary embolism (PE). The primary endpoint occurred in 8.2% of the control group versus 4.9% in the invention group (p<.001). The alert reduced the risk of DVT or PE at 90 days by 41% (p=.001).

The results of the study are interesting. The authors acknowledged that many physicians had patients in both groups. So receiving 1 alert may have affected their use of prophylaxis in both groups. They also could not eliminate the possibility of diagnostic bias. Prophylaxis was not blinded and VTE testing was not routinely performed. Would physicians be more likely to order an imaging study for symptomatic patients on no prophylaxis than patients on prophylaxis? Nevertheless, for hospitals that have sufficient computer resources, implementation of such alerts can elevate physician awareness about VTE and other clinical conditions.

4. Lau DT, Kasper JD, Pofer DE, et al. Hospitalization and death associated with potentially inappropriate medication prescriptions among elderly nursing home residents. Arch Intern Med. 2005;165: 68-74.

Lau and colleagues studied the impact of potentially inappropriate medications among residents of longtermcare facilities. They used information from a 1996 national survey of home residents. The sample included 3372 residents, 65 years and older, who lived in a nursing home for 3 months or longer. Over half of the residents were older than 85 years old and 75% were female. Only 10% were black. Nearly two thirds had dementia or other mental disorders. The study used the Beers Criteria to define potentially inappropriate medications. The potential errors in medications were categorized as 1 of 3 types:

1. inappropriate choice of medication
2. excessive medication dosage
3. drug–disease interactions

Residents were considered to have a potentially inappropriate medication if their medication administration records revealed any of the above findings.

A univariate analysis showed that the risk of hospitalization was almost 30% higher among residents who received potentially inappropriate medications in the preceding month and 33% higher among residents who received potentially inappropriate medications for 2 consecutive months, compared with residents with no inappropriate medication exposure. The odds of death in any month were 21% higher among residents who had inappropriate medication exposure during the month of death or the preceeding month, compared with those with no inappropriate medication exposure.

These findings can be generalized to the inpatient setting, where hospitalists have the opportunity to influence and modify prescribing practices in the elderly population.

5. Lessnau KD. Is chest radiography necessary after uncomplicated insertion of a triplelumen catheter in the right internal jugular vein, using the anterior approach? Chest. 2005;127:220-3.

The routine use of chest radiography to confirm proper triplelumen catheter (TLC) placement may be an unnecessary and costly intervention. Lessnau conducted a prospective observational study of 100 consecutive patients over a 4-month period who required non-urgent TLC placement. The primary operators of the procedure included 18 medical residents, 3 pulmonary fellows, and a pulmonary attending with supervision provided for more junior clinicians. Operators followed a standardized approach to TLC placement utilizing the anterior approach to the right internal jugular vein. Complicated procedures were predefined as any procedure that required more than 3 needle passes, resulted in hemorrhage or hematoma formation (where there was concern for pneumothorax), or an absence of blood return in any of the TLC’s lumens. All subjects underwent routine post-procedure chest radiography to determine proper placement of the catheter and to exclude pneumothorax. A blinded radiologist reviewed these images.

Ninety-eight of the 100 catheters were in proper position. One malpositioned catheter was 7 cm above the right atrium in a patient who was 215 cm (>7 feet) tall. The second was noted to be in an S-shaped position on chest radiography. This procedure had required 20 needle passes and 5 slides of the catheter; additionally, blood return was inadequate in 2 lumens of the catheter. An operator reported a possible complication in 10 other procedures, but the only clinical finding in these cases was the development of a local hematoma in 1 patient. Eighty-eight patients had uncomplicated insertions and had normal chest radiographs. There were no pneumothoraces.

This study demonstrates that in carefully controlled and supervised situations, as described in the study, routine chest radiography may be omitted if the insertion goes smoothly. It is important to note that these results are specific to the technique described in the study (using the anterior approach to the right internal jugular, using a short finder needle to initially locate the vein) and cannot be extrapolated to other methods of TLC insertion. Important limitations of the study include the sample size of only 100 patients and the use of only a single anatomic approach to TLC insertion. These findings, although an important first step, will need to be reproduced on a larger scale before we can recommend the cessation of routine chest radiography after TLC placement on a more widespread basis.

6. Safdar N, Fine JP, Maki DG. Metaanalysis: methods for diagnosing intravascular devicerelated bloodstream infection. Ann Intern Med. 2005;142:451-66.

Intravascular device (IVD)–related blood stream infections are a frequent cause of morbidity and mortality, and yet there is lack of a clear consensus on the most accurate method to make this diagnosis.

In this metaanalysis, Safdar et al. reviewed 185 studies, including 8 different diagnostic tests, for the detection of IVD-related bloodstream infections, of which 51 studies met the inclusion criteria. Tests were divided into IVD-sparing and those requiring IVD removal. Pooled sensitivity and specificity, summary measures of accuracy, and the mean log odds ratio were determined. The most accurate IVD-sparing test was paired quantitative blood cultures (simultaneous blood cultures from the IVD and a peripheral site, with a positive result defined as an IVD-site microorganism concentration 3–5 times greater than peripheral site) with a sensitivity of 0.87 (95% CI: 0.83–0.91) and specificity of 0.98 (95% CI: 0.97–0.99). This was followed by quantitative IVD-drawn blood cultures alone (positive result defined as growth of ≥100 CFU), with a sensitivity of 0.77 (95% CI: 0.69–0.85) and a specificity of 0.90 (95% CI: 0.88–0.92). IVD-drawn qualitative blood cultures had a sensitivity of 0.87 (95% CI: 0.80–0.94) and a specificity of 0.83 (95% CI: 0.78–0.88), and IVD- and peripheral-drawn qualitative blood cultures with differential time to positivity had a sensitivity of 0.85 (95% CI: 0.78–0.92) and specificity of 0.81 (95% CI: 0.81–0.97).

The most accurate test requiring IVD removal was quantitative catheter segment culture (segment of catheter is flushed or sonicated and plated, positive if ≥1000 CFU), with sensitivity of 0.83 (95% CI: 0.78–0.88) and specificity of 0.87 (95% CI: 0.85–0.89), followed by semi-quantitative catheter segment culture (5cm segment plated, positive if ≥ 15 CFU) with sensitivity of 0.82 (95% CI: 0.81–0.89) and specificity of 0.82 (95% CI: 0.80–0.84). The least accurate was qualitative catheter segment culture (positive if any growth) with a sensitivity of 0.90 (95% CI: 0.83–0.97) and specificity of 0.72 (95% CI: 0.66–0.78).

The limitations of this study include heterogeneity of study design, including limited data on the use of antibiotics before culture data was obtained and the baseline prevalence of bacteremia in the study populations. In addition, all data was obtained prior to the widespread use of antibiotic-coated catheters. While these results support the catheter-tip quantitative culture techniques that are already widely in use, they are less applicable to blood culture testing techniques, because quantitative assays are rarely used. Fortunately, all of these assays have a high negative predictive value, and false-positive results can be minimized by reserving testing for patients in whom there is moderate-to-high pretest probability of IVD related bloodstream infection.

7. Sopena N, Sabria M, Neunos 2000 Study Group. Multicenter study of hospital-acquired pneumonia in non-ICU patients. Chest. 2005;127:213-9.

A growing body of literature exists on hospital-acquired pneumonia (HAP) in the ICU setting. Sopena and colleagues extend the HAP literature to the non-ICU setting in a multicenter cross-sectional study. Cases of HAP were identified if clinical or radiographic evidence of pneumonia developed 72 hours after admission or within 10 days of a previous discharge. Patients who developed pneumonia in the ICU were excluded from analysis.

During an 18-month study period, 165 cases were identified with complete clinical and microbiologic data. The incidence of HAP was 3.1 ± 1.4 per 1000 hospital admissions. Ninety-eight (59.4%) patients diagnosed with HAP had severe underlying diseases that were classified as fatal (<1 year) or ultimately fatal (in 5 years). Extrinsic risk factors observed in patients with HAP included concurrent steroid use (29%), antibiotic therapy (53.3%), use of H2 blockers (37%), and hospitalization greater than 5 days (76%). Microbiologic data were positive in 60 (36.4%) cases. Streptococcus pneumoniae was diagnosed in 16 cases (9.7%), enterobacteriaceae in 8 (4.8%), Legionella pneumophila in 7 (4.2%), Aspergillus sp in 7 (4.2%), Pseudomonas aeruginosa in 7 (4.2%). Four cases of Staphylococcus aureus were diagnosed (3%), only one of which was methicillin resistant.

Complications of HAP occurred in 52.1% of cases and included respiratory failure (34.5%), pleural effusion (20.6%), septic shock (9.6%), renal failure (4.8%), and empyema (2.4%). Forty-three (26%) patients died during the hospitalization; 23 of these cases were directly attributed to HAP.

A limitation of the study is that the incidence of HAP was somewhat lower than reported in the literature and thus might represent an unintended sampling bias. Moreover, the study demonstrated underlying factors seen in patients with HAP, but these are not necessarily causative. Results useful to hospitalists include a higher than expected rate of Legionella and Aspergillus sp causing HAP in this population. A Legionella outbreak was not the explanation, as these cases were diagnosed in 5 different hospitals. The high frequency of adverse outcomes associated with HAP should alert hospitalists to the risk of nosocomial pneumonia in the non-ICU setting.

The Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary programs focused on improving the quality of care and quality of life for beneficiaries with multiple chronic illnesses. These Chronic Care Improvement Programs (CCIPs) represent the first large-scale chronic care improvement initiative under the Medicare fee-for-service (FFS) program. The programs also may represent an opportunity for SHM members to partner with the selected organizations.

CMS selected organizations that will offer self-care guidance and support to chronically ill beneficiaries. These organizations will help beneficiaries manage their health, adhere to their physicians’ plans of care, and assure that they seek or obtain medical care as needed to reduce their health risks. Chronic conditions are currently a leading cause of illness, disability, and death among beneficiaries and account for a disproportionate share of health care expenditures.

Each selected organization may design its own program, with the potential for a variety of unique models. Some vendors are partnering with physician groups and others may reach out to physicians in their regions. The selected regions and respective vendors are:

• Brooklyn and Queens in New York City (Visiting Nurse Service of New York in partnership with United-Healthcare Services, Inc.–Evercare)
• Chicago (Aetna Health Management)
• District of Columbia and Maryland (American Healthways, Inc.)
• Central Florida (Humana, Inc.)
• Georgia (CIGNA HealthCare)
• Mississippi (McKesson Health Solutions)
• Oklahoma (LifeMasters Supported SelfCare, Inc.)
• Pennsylvania (Health Dialog Services Corporation)
• Tennessee (XLHealth)

Performance-based contracting is one of the most important features of the CCIP design. The CCIPs will be paid based on achieving measurable improvements in clinical and financial outcomes, as well as satisfaction levels across their assigned populations. Payment is not based on services provided. CCIP organizations will be paid monthly fees, but those fees will be fully at risk. The organizations will be required to refund some or all of their fees to the federal government if they do not meet agreed-upon standards for quality improvement, savings to Medicare, and increased beneficiary satisfaction levels.

Phase I programs will collectively serve 150,000 to 300,000 chronically ill beneficiaries who are enrolled in traditional fee-for-service Medicare. This is the phase currentlyunder development, with the first programs expected to begin implementation in spring 2005. The programs are intended to help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications and comorbidities. With attention to reducing hospital costs, hospitalists may play an important role in CCIPs.

CCIPs include collaboration with participants’ providers to improve communication regarding relevant clinical information. The programs are being designed to assist beneficiaries in managing all of their health problems (not just a single disease). The programs to be tested vary in types of interventions to be used to improve outcomes. Across all programs, payments will be based on performance results.

Patient participation will be entirely voluntary. Eligible beneficiaries do not have to change plans or providers to participate, and there is no charge to the beneficiaries to participate. Once the program begins, beneficiaries may stop participating at any time. These programs may not restrict access to care. CMS will use historical claims data to identify beneficiaries by geographic area and screen them for eligibility. The selected beneficiaries will be assigned randomly to either an intervention group or a control group. Those in the intervention group will be notified of the opportunity to participate via a letter from the Medicare program. The letter will describe the CCIP and give the beneficiary the opportunity to decline to participate.

Phase II, which is the expansion of successful CCIPs, may begin within 2 to 31/2 years after Phase I. Entire CCIPs, or components of programs, may be expanded either regionally or nationally. SHM will continue to track the progress of the CCIPs and to encourage members to participate in the development and implementation of this exciting new chapter of Medicare services.

Please check the list above. If you are interested in partnering with any of the organizations, please email Lillian Higgins at [email protected]. She will provide you with contact information for the CCIP vendor.

The Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary programs focused on improving the quality of care and quality of life for beneficiaries with multiple chronic illnesses. These Chronic Care Improvement Programs (CCIPs) represent the first large-scale chronic care improvement initiative under the Medicare fee-for-service (FFS) program. The programs also may represent an opportunity for SHM members to partner with the selected organizations.

CMS selected organizations that will offer self-care guidance and support to chronically ill beneficiaries. These organizations will help beneficiaries manage their health, adhere to their physicians’ plans of care, and assure that they seek or obtain medical care as needed to reduce their health risks. Chronic conditions are currently a leading cause of illness, disability, and death among beneficiaries and account for a disproportionate share of health care expenditures.

Each selected organization may design its own program, with the potential for a variety of unique models. Some vendors are partnering with physician groups and others may reach out to physicians in their regions. The selected regions and respective vendors are:

• Brooklyn and Queens in New York City (Visiting Nurse Service of New York in partnership with United-Healthcare Services, Inc.–Evercare)
• Chicago (Aetna Health Management)
• District of Columbia and Maryland (American Healthways, Inc.)
• Central Florida (Humana, Inc.)
• Georgia (CIGNA HealthCare)
• Mississippi (McKesson Health Solutions)
• Oklahoma (LifeMasters Supported SelfCare, Inc.)
• Pennsylvania (Health Dialog Services Corporation)
• Tennessee (XLHealth)

Performance-based contracting is one of the most important features of the CCIP design. The CCIPs will be paid based on achieving measurable improvements in clinical and financial outcomes, as well as satisfaction levels across their assigned populations. Payment is not based on services provided. CCIP organizations will be paid monthly fees, but those fees will be fully at risk. The organizations will be required to refund some or all of their fees to the federal government if they do not meet agreed-upon standards for quality improvement, savings to Medicare, and increased beneficiary satisfaction levels.

Phase I programs will collectively serve 150,000 to 300,000 chronically ill beneficiaries who are enrolled in traditional fee-for-service Medicare. This is the phase currentlyunder development, with the first programs expected to begin implementation in spring 2005. The programs are intended to help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications and comorbidities. With attention to reducing hospital costs, hospitalists may play an important role in CCIPs.

CCIPs include collaboration with participants’ providers to improve communication regarding relevant clinical information. The programs are being designed to assist beneficiaries in managing all of their health problems (not just a single disease). The programs to be tested vary in types of interventions to be used to improve outcomes. Across all programs, payments will be based on performance results.

Patient participation will be entirely voluntary. Eligible beneficiaries do not have to change plans or providers to participate, and there is no charge to the beneficiaries to participate. Once the program begins, beneficiaries may stop participating at any time. These programs may not restrict access to care. CMS will use historical claims data to identify beneficiaries by geographic area and screen them for eligibility. The selected beneficiaries will be assigned randomly to either an intervention group or a control group. Those in the intervention group will be notified of the opportunity to participate via a letter from the Medicare program. The letter will describe the CCIP and give the beneficiary the opportunity to decline to participate.

Phase II, which is the expansion of successful CCIPs, may begin within 2 to 31/2 years after Phase I. Entire CCIPs, or components of programs, may be expanded either regionally or nationally. SHM will continue to track the progress of the CCIPs and to encourage members to participate in the development and implementation of this exciting new chapter of Medicare services.

Please check the list above. If you are interested in partnering with any of the organizations, please email Lillian Higgins at [email protected]. She will provide you with contact information for the CCIP vendor.

The Medicare Modernization Act of 2003 (MMA) authorized development and testing of voluntary programs focused on improving the quality of care and quality of life for beneficiaries with multiple chronic illnesses. These Chronic Care Improvement Programs (CCIPs) represent the first large-scale chronic care improvement initiative under the Medicare fee-for-service (FFS) program. The programs also may represent an opportunity for SHM members to partner with the selected organizations.

CMS selected organizations that will offer self-care guidance and support to chronically ill beneficiaries. These organizations will help beneficiaries manage their health, adhere to their physicians’ plans of care, and assure that they seek or obtain medical care as needed to reduce their health risks. Chronic conditions are currently a leading cause of illness, disability, and death among beneficiaries and account for a disproportionate share of health care expenditures.

Each selected organization may design its own program, with the potential for a variety of unique models. Some vendors are partnering with physician groups and others may reach out to physicians in their regions. The selected regions and respective vendors are:

• Brooklyn and Queens in New York City (Visiting Nurse Service of New York in partnership with United-Healthcare Services, Inc.–Evercare)
• Chicago (Aetna Health Management)
• District of Columbia and Maryland (American Healthways, Inc.)
• Central Florida (Humana, Inc.)
• Georgia (CIGNA HealthCare)
• Mississippi (McKesson Health Solutions)
• Oklahoma (LifeMasters Supported SelfCare, Inc.)
• Pennsylvania (Health Dialog Services Corporation)
• Tennessee (XLHealth)

Performance-based contracting is one of the most important features of the CCIP design. The CCIPs will be paid based on achieving measurable improvements in clinical and financial outcomes, as well as satisfaction levels across their assigned populations. Payment is not based on services provided. CCIP organizations will be paid monthly fees, but those fees will be fully at risk. The organizations will be required to refund some or all of their fees to the federal government if they do not meet agreed-upon standards for quality improvement, savings to Medicare, and increased beneficiary satisfaction levels.

Phase I programs will collectively serve 150,000 to 300,000 chronically ill beneficiaries who are enrolled in traditional fee-for-service Medicare. This is the phase currentlyunder development, with the first programs expected to begin implementation in spring 2005. The programs are intended to help increase adherence to evidence-based care, reduce unnecessary hospital stays and emergency room visits, and help beneficiaries avoid costly and debilitating complications and comorbidities. With attention to reducing hospital costs, hospitalists may play an important role in CCIPs.

CCIPs include collaboration with participants’ providers to improve communication regarding relevant clinical information. The programs are being designed to assist beneficiaries in managing all of their health problems (not just a single disease). The programs to be tested vary in types of interventions to be used to improve outcomes. Across all programs, payments will be based on performance results.

Patient participation will be entirely voluntary. Eligible beneficiaries do not have to change plans or providers to participate, and there is no charge to the beneficiaries to participate. Once the program begins, beneficiaries may stop participating at any time. These programs may not restrict access to care. CMS will use historical claims data to identify beneficiaries by geographic area and screen them for eligibility. The selected beneficiaries will be assigned randomly to either an intervention group or a control group. Those in the intervention group will be notified of the opportunity to participate via a letter from the Medicare program. The letter will describe the CCIP and give the beneficiary the opportunity to decline to participate.

Phase II, which is the expansion of successful CCIPs, may begin within 2 to 31/2 years after Phase I. Entire CCIPs, or components of programs, may be expanded either regionally or nationally. SHM will continue to track the progress of the CCIPs and to encourage members to participate in the development and implementation of this exciting new chapter of Medicare services.

Please check the list above. If you are interested in partnering with any of the organizations, please email Lillian Higgins at [email protected]. She will provide you with contact information for the CCIP vendor.

SHM has created a new seat on the Board of Directors that must be filled by a pediatric hospitalist and has elected Jack Percelay, MD, FAAP as its new pediatric board member. Dr. Percelay began serving a 1-year term on the SHM board beginning April 29, 2005. In the Fall of 2005, during the next board elections, the new position will become a 3-year pediatric board seat.

“The addition of a pediatrics seat to the board is important because pediatric hospitalists have a unique and important perspective on our growing specialty of hospital medicine,” said new SHM President, Steven Pantilat, MD, FACP. “Jack Percelay has long been a leader in field of pediatric hospital medicine, has nurtured the development of pediatric hospitalists, and has been a key link in our work with the American Academy of Pediatrics for many years now. We welcome his insights and vision as we continue to expand the role of education and leadership for pediatric hospitalists.”

“For many years SHM has had a pediatrician represented on the board―first with Mike Ruhlen from Toledo and more recently with David Zipes from Indianapolis,“ added SHM immediate past President Jeanne Huddleston. “At this stage in the growth of hospital medicine, the SHM board felt it was important to ensure that we continue to have a pediatric voice represented on the board.”

Dr. Percelay currently is director, Virtua Inpatient Pediatrics and CARES at Children’s Health Associates in Vorhees, NJ. Virtua Inpatient Pediatrics is a 13-person pediatric hospitalist group providing coverage at West Jersey Vorhees and Burlington Memorial Hospitals in southern New Jersey. The group covers the pediatric ward, pediatric ICU and emergency room.

In 2003, Dr. Percelay coauthored a survey initiated by the American Association of Pediatrics entitled “Attitudes Toward and Experiences with Pediatric Hospitalists: A National Survey.” The goal of the survey was to explore the extent to which the pediatric hospitalist practice has developed and to examine pediatricians’ attitudes and experiences with pediatric hospitalists. It was the first survey the AAP has conducted on hospitalists.

Dr. Percelay also was a lead author for the recent AAP Policy statement “Guiding Principles for Pediatric Hospitalist Programs” (Pediatrics 2005;115: 11012).

A charter member of SHM, Dr. Percelay has served on numerous committees, including chair of the Pediatric Committee and a member of the Public Policy committee.

SHM has created a new seat on the Board of Directors that must be filled by a pediatric hospitalist and has elected Jack Percelay, MD, FAAP as its new pediatric board member. Dr. Percelay began serving a 1-year term on the SHM board beginning April 29, 2005. In the Fall of 2005, during the next board elections, the new position will become a 3-year pediatric board seat.

“The addition of a pediatrics seat to the board is important because pediatric hospitalists have a unique and important perspective on our growing specialty of hospital medicine,” said new SHM President, Steven Pantilat, MD, FACP. “Jack Percelay has long been a leader in field of pediatric hospital medicine, has nurtured the development of pediatric hospitalists, and has been a key link in our work with the American Academy of Pediatrics for many years now. We welcome his insights and vision as we continue to expand the role of education and leadership for pediatric hospitalists.”

“For many years SHM has had a pediatrician represented on the board―first with Mike Ruhlen from Toledo and more recently with David Zipes from Indianapolis,“ added SHM immediate past President Jeanne Huddleston. “At this stage in the growth of hospital medicine, the SHM board felt it was important to ensure that we continue to have a pediatric voice represented on the board.”

Dr. Percelay currently is director, Virtua Inpatient Pediatrics and CARES at Children’s Health Associates in Vorhees, NJ. Virtua Inpatient Pediatrics is a 13-person pediatric hospitalist group providing coverage at West Jersey Vorhees and Burlington Memorial Hospitals in southern New Jersey. The group covers the pediatric ward, pediatric ICU and emergency room.

In 2003, Dr. Percelay coauthored a survey initiated by the American Association of Pediatrics entitled “Attitudes Toward and Experiences with Pediatric Hospitalists: A National Survey.” The goal of the survey was to explore the extent to which the pediatric hospitalist practice has developed and to examine pediatricians’ attitudes and experiences with pediatric hospitalists. It was the first survey the AAP has conducted on hospitalists.

Dr. Percelay also was a lead author for the recent AAP Policy statement “Guiding Principles for Pediatric Hospitalist Programs” (Pediatrics 2005;115: 11012).

A charter member of SHM, Dr. Percelay has served on numerous committees, including chair of the Pediatric Committee and a member of the Public Policy committee.

SHM has created a new seat on the Board of Directors that must be filled by a pediatric hospitalist and has elected Jack Percelay, MD, FAAP as its new pediatric board member. Dr. Percelay began serving a 1-year term on the SHM board beginning April 29, 2005. In the Fall of 2005, during the next board elections, the new position will become a 3-year pediatric board seat.

“The addition of a pediatrics seat to the board is important because pediatric hospitalists have a unique and important perspective on our growing specialty of hospital medicine,” said new SHM President, Steven Pantilat, MD, FACP. “Jack Percelay has long been a leader in field of pediatric hospital medicine, has nurtured the development of pediatric hospitalists, and has been a key link in our work with the American Academy of Pediatrics for many years now. We welcome his insights and vision as we continue to expand the role of education and leadership for pediatric hospitalists.”

“For many years SHM has had a pediatrician represented on the board―first with Mike Ruhlen from Toledo and more recently with David Zipes from Indianapolis,“ added SHM immediate past President Jeanne Huddleston. “At this stage in the growth of hospital medicine, the SHM board felt it was important to ensure that we continue to have a pediatric voice represented on the board.”

Dr. Percelay currently is director, Virtua Inpatient Pediatrics and CARES at Children’s Health Associates in Vorhees, NJ. Virtua Inpatient Pediatrics is a 13-person pediatric hospitalist group providing coverage at West Jersey Vorhees and Burlington Memorial Hospitals in southern New Jersey. The group covers the pediatric ward, pediatric ICU and emergency room.

In 2003, Dr. Percelay coauthored a survey initiated by the American Association of Pediatrics entitled “Attitudes Toward and Experiences with Pediatric Hospitalists: A National Survey.” The goal of the survey was to explore the extent to which the pediatric hospitalist practice has developed and to examine pediatricians’ attitudes and experiences with pediatric hospitalists. It was the first survey the AAP has conducted on hospitalists.

Dr. Percelay also was a lead author for the recent AAP Policy statement “Guiding Principles for Pediatric Hospitalist Programs” (Pediatrics 2005;115: 11012).

A charter member of SHM, Dr. Percelay has served on numerous committees, including chair of the Pediatric Committee and a member of the Public Policy committee.

Joel Barker describes leadership as “…the ability to take people where they otherwise would not go.” In other words, leadership is about creating change in something that exists today. Management, on the other hand, may be considered a series of steps to ensure that things happen the desired and consistent way. Although this article is not of scope sufficient to explore the differences between management and leadership, it will address a domain in which the 2 intimately intersect. Managing others relies upon many foundations of leadership, such as establishing the group’s vision and setting key strategic goals. In like manner, successful leadership in stimulating change is dependent on the effective management of personnel to ensure that the culture, work habits, outcomes, and behaviors are consistent with the change efforts. This article will focus on the management of physicians in hospital medicine groups. The 8 steps outlined are applicable regardless of employer type, group size, or mission. Almost all of the skills necessary to effectively implement a performance management system can be learned and are best practiced on a regular basis. Furthermore, there are many existing resources for further education and development in these areas based on one’s current level of competency.

The author wishes to acknowledge the faculty of the American College of Physician Executives for their work in assembling many of the concepts found in this article. The course “Managing Physician Performance in Organizations” serves to underscore an integrated model of performance management and explores some of the theoretical bases of human behavior not included here.

Defining Your Group

Before you can manage performance, you must know the parameters by which the group is defined. The prerequisites for performance management include salient statements of mission, vision, and values. The mission defines the purpose for the group being in place and usually reflects the interests of the hospital(s) or medical group affiliated with or actually employing the hospital medicine group. The mission statement should be able to answer the questions “Why does our hospital medicine group exist? What purpose does it serve? In very broad terms, what scope of services do we provide?” The vision is a concise summary of what the group would like to be or achieve in the future, and it may relate to growth, range of services, outcomes, or other dimensions. Most often the vision is the leader’s platform for change in order to articulate the rationale for creating a better future. Values are those characteristics that guide decision making and provide guidance for everyone’s expected behavior and conduct in the group. Values can be thought of as the “lens” through which the vision is carried out and the mission upheld.

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From the mission, vision, and values come strategies for achieving successful change and the more specific goals that the group is to attain. In some cases the group may have undertaken a formal strategic planning process that rendered a series of goals, objectives, and/or programs to be carried out in the immediate to intermediate term. We now reach the vital area in which a well structured and supported performance management system can play a pivotal role in ensuring the successful implementation of strategic thinking. Until now, the thought and planning process had focused on the right thing to do. From here, the focus becomes doing things right. Once you have completely answered the questions above and have a confident sense of where your group is heading and why, then the steps that follow will enable you to stack the deck in favor of achieving the level of performance you desire. Note that each step is embedded in action. Figure 1 represents the pyramid of performance management, a prioritized approach to managing others.

Recruiting the Right People

Not everyone has the luxury of personally hiring each physician in their group, much less having a surplus of candidates that are outstanding in every dimension. The reality in 2005 is that there continues to be demand for hospitalists far exceeding the available supply. This “seller’s market” (i.e., a hospitalist “sells” his or her services to an employer) represents a challenging dynamic for new or growing hospital medicine groups attempting to recruit the top candidates. It gets even worse when you consider hospital medicine as a new specialty, often finding itself in hospitals where the medical staff are skeptical or apprehensive in accepting the new group, and one bad hire can undermine the group’s chances of success. Furthermore, there may not be adequate experience or expertise in recruiting new physicians or correctly identifying those who would be a proper fit for the group. So how does one go about recruiting the right people?

Planning begins with having defined the group in terms of the mission and values. Knowing the vision and specific strategies to be employed lends insight into what type of individual would best fit with the needs and culture of the group. It is important to list the desired qualities on paper and plan for assessing each one, knowing that there is no perfect candidate and these characteristics must therefore be prioritized. Remember, what makes a good hospitalist in your group does not mean they will be good somewhere else; be sure you define very clearly what exactly “good” means. At the same time, it is also critical to outline the selling points of potentially joining your group in terms of 3 areas: the practice itself, compensation, and location.

The next step consists of preparing a slate of candidates for interviews. There are many methods of finding (i.e., sourcing) strong candidates, one of the best of which is to ask members of your current group or other trusted colleagues for referrals. If you are interested in filling a position with a more specific skill set such as information technology, palliative care, or clinical teaching, then a “make or buy” decision needs to be made to either recruit for the individual already in possession of such credentials or to hire more generically and then train accordingly. Once candidates are identified, a deliberate process of reviewing their written materials and interviewing them by telephone will determine the appropriateness of an in person interview. Speaking with references can occur at any time, and some advocate for this to occur prior to bringing a candidate for formal interview, as another mechanism of screening and to focus interview questions on site. The formal interview itself should be well structured and enable your key stakeholders to meet with the candidate and submit an immediate assessment. The shorter the turnaround time to extend an offer, the more decisive and committed to the candidate you will appear. Likewise, if you have a diverse composition of interviewers who weigh in with their perspectives, then there should be little to delay a hiring decision.

There are 3 additional points to remember when looking to hire an additional hospitalist into your group. First, it is estimated that 70% of physicians who leave a job do so because of spousal discontent. To mitigate this possibility, invite the spouse to accompany the candidate to the interview location, and assemble a parallel agenda for him or her.. Do not consider yourself on a “best behavior” basis during courtship alone; you need to continue nurturing the candidate and family well into the first year of employment to ensure a good transition. Second, be realistic about your expectations. There is no perfect candidate, so you must prioritize those qualities you want most from them. If you wait for perfection, the delay will cause you to overlook many very good physicians. Finally, take another look at the performance management pyramid. The reason the area for recruitment is so large is because of the disproportionate amount of time that one should invest in recruitment processes. Hiring the right people up front will make the rest of the steps far easier and minimize the likelihood of your being drawn into the nadir of the pyramid.

Setting Clear Expectations

Do you have a job description? When you read it, does it adequately describe what is expected of your hospitalists? Do you have an orientation for new members to your group? How long does it last? Is additional training offered? Are there outcomes that you expect from this training? And once you have oriented, trained, and offered a job description, does the actual work environment support or negate your efforts―i.e., does culture trump your formal process?

The cycle of setting clear expectations about work performance begins during the recruitment phase. Being absolutely forthcoming about what it is like to work in your group and what you expect from each and every member is paramount to allow both you and the candidate to determine a good fit. Once the physician has joined your group, orientation and training should hardly be a 1-, 2- or 3-day exercise. These are continuous and ongoing processes, given our rapidly changing practice environment. In fact, change is one of the only reliable characteristics of what we do, and extending the welcome “The job you take today is unlikely to be the job you will have next year” is hardly inappropriate. Be mindful that setting clear expectations with all of your hospitalists is the bedrock of a functional performance management system. Defining expectations alone will often improve performance, vis-à-vis the Hawthorne effect.

Expectations should always be depersonalized and focus on behavior. Behavior itself may be regarded in 2 distinct domains: those behaviors that are observed, and those outcomes that are measurable. Examples of observable behaviors include interpersonal interactions with nurses and consultants, pager response times, and attendance at monthly team meetings. Measurable outcomes include work RVU productivity, patient satisfaction, readmission rates, and compliance with coding and documentation guidelines. There are many ways to organize dimensions of performance that you may expect from your physicians―the 6 aims of quality (safe, timely, effective, efficient, equitable, and patient centered, as outlined in the IOM report Crossing the Quality Chasm), maintenance of a healthy workplace, citizenship, relationships with others, etc.―yet the key is to define and communicate them, then check often for understanding.

Measuring Actual Performance

Be the first to admit “the numbers are wrong,” and you will save hearing it from many others. There are many inherent problems in measuring actual performance, and the data may never be perfect. As an exercise, try assigning individual readmission rates within your group, and you will find that because of handoffs within the group and lack of precision in identifying who actually discharged the patient, there will be many arguments over whether the data is valid. However, in most circumstances, if the data is flawed, it still may serve a strong purpose to highlight the relative variation within the group. Searching for quantifiable systemic data and being transparent about the limitations of the data will be an exercise worth undertaking. In like manner, behavioral observation data are potentially fraught with conflict if the data are focused on judgment of character traits (I believe this hospitalist has a good bedside manner) rather than on observable behaviors (This hospitalist always/sometimes/never comes to meetings on time). Measures are best when they are objective, relevant to the position, and interpretable. Remember: All measures are flawed; some are useful.

Aligning Compensation With Expectations

Conventional wisdom states that people will do more of what they are incentivized to do. The corollary to this is to be sure what you incentivize is actually what you want. For the group that is trying to improve individual productivity and reduce length of stay, providing financial rewards for work RVU’s alone may result in less assertiveness in managing timely discharges and bickering over who picks up the 11 p.m. vs. 2 a.m. overnight admission the following morning. Ultimately, compensation must be intimately linked with the mission of the group, and tremendous care must be taken in determining the construct of any system. Although it is well beyond the scope of this article to detail the many considerations of designing a compensation system, one must understand that it is only one component―and not the most important component―of a performance management program.

Here are a few points to consider as you integrate your compensation system into the rest of the steps in the pyramid:

1. A straight salary with or without a “guaranteed” bonus is unlikely to reward or motivate any new behaviors.
2. For a performance-based compensation plan to have sufficient impact, at least 20%–30% of compensation must be tied to performance.
3. Consider having both group and individual measures as part of your plan to engender a sense of teamwork and collective effort in performing well.
4. Limit the number of variables in the plan to 3–5; otherwise, measures are too diluted to carry meaningful weight.
5. Perform a local market comparison for benchmarking your goal median compensation; often administrative staff are more willing to share this information with other administrative staff if the understanding is that all market results will be shared.
6. The process of constructing or evolving your plan, being inclusive of members of your group as well as any group sponsors, ends up being far more valuable than the final plan itself.

Providing Regular Feedback

Have you ever had a complaint that sounded like “I get way too much feedback around here?” Probably not. More likely is the case that your hospitalists wonder how they stand in terms of being compared to others and to themselves over time. The creed “no news must be good news” is hardly supportive of promoting top performance. Feedback itself can be highly influential and reflects the expectations explained by the group leader. Expectations not measured or fed back to the individual hospitalists will be expectations soon forgotten or ignored, because they may be felt not to matter.

Effective feedback is both formal and informal. The annual performance review is a common example of the former, but it is in no way meant to be the only feedback a hospitalist should receive, nor is it the most powerful. The annual review should be well structured, can outline longer term goals and ideas for self-improvement, and may serve in some key administrative functions like compensation and promotion. Informal, regular feedback, however, may serve you much better in driving performance, because it is timelier, more relevant to daily work, and more specific to the individual. Individuals also respond much more constructively to positive feedback, and some experts believe the ratio of positive to negative feedback should be on the order of 9 to 1. Be sure that feedback is done in a coaching manner and focuses on the behavior (You may try sitting down when you talk with patients as a way of making them feel more at ease) rather than on the person themselves (You’re really not a good communicator).

Managing Marginal Performance

Marginal performance can be defined as a physician whose observed behaviors or measured outcomes are at significant variance from what is expected. This pattern takes place over time and happens in spite of having in place all the other elements of a performance management system. Consider the “clock puncher” who rarely helps out the rest of the team on busy days and never shows up to group meetings or committees. Or the “tortoise” that has wonderful staff relations but chronically arrives at work late and repeatedly forgets to submit inpatient charges. Then there’s the “hothead” who is clinically adept and has high patient satisfaction but loses his or her temper with nursing and is pervasively confrontational with consultants. The steps to be taken in these and other cases like them include ensuring adequate documentation, reaching an agreement with the individual in recognizing that there is a problem, generating options for causality, negotiating a contract for improvement, and then letting future behavior determine the consequences.

Taking Corrective Action

Sometimes you simply cannot fix everything, and you need to be easy on yourself for having reached the point where the situation is no longer remediable in spite of your best efforts. In the end, everyone will be better off. When physician conduct becomes detrimental to patient safety, staff safety or quality patient care; is disruptive to the organization; or is otherwise chronically aberrant, then it is time to take adverse action. Since there are many pitfalls that have HR and legal implications, it is advisable to consult with relevant personnel to avoid problems with inadequate documentation and the potential need to report actions to state agencies and the National Practitioner Data Bank (per the Healthcare Quality Improvement Act of 1986).

Resources

1. Ury W, Fisher R. Getting to Yes: Negotiating Agreement Without Giving In. 2nd ed. New York: Penguin Books; 1991.
2. Reinertsen J. Physicians as leaders in the improvement of health care systems. Ann Intern Med. 1998;128:833-8.
3. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
4. American College of Physician Executives. Managing Physician Performance in Organizations. Ongoing courses available at www.acpe.org.

Joel Barker describes leadership as “…the ability to take people where they otherwise would not go.” In other words, leadership is about creating change in something that exists today. Management, on the other hand, may be considered a series of steps to ensure that things happen the desired and consistent way. Although this article is not of scope sufficient to explore the differences between management and leadership, it will address a domain in which the 2 intimately intersect. Managing others relies upon many foundations of leadership, such as establishing the group’s vision and setting key strategic goals. In like manner, successful leadership in stimulating change is dependent on the effective management of personnel to ensure that the culture, work habits, outcomes, and behaviors are consistent with the change efforts. This article will focus on the management of physicians in hospital medicine groups. The 8 steps outlined are applicable regardless of employer type, group size, or mission. Almost all of the skills necessary to effectively implement a performance management system can be learned and are best practiced on a regular basis. Furthermore, there are many existing resources for further education and development in these areas based on one’s current level of competency.

The author wishes to acknowledge the faculty of the American College of Physician Executives for their work in assembling many of the concepts found in this article. The course “Managing Physician Performance in Organizations” serves to underscore an integrated model of performance management and explores some of the theoretical bases of human behavior not included here.

Defining Your Group

Before you can manage performance, you must know the parameters by which the group is defined. The prerequisites for performance management include salient statements of mission, vision, and values. The mission defines the purpose for the group being in place and usually reflects the interests of the hospital(s) or medical group affiliated with or actually employing the hospital medicine group. The mission statement should be able to answer the questions “Why does our hospital medicine group exist? What purpose does it serve? In very broad terms, what scope of services do we provide?” The vision is a concise summary of what the group would like to be or achieve in the future, and it may relate to growth, range of services, outcomes, or other dimensions. Most often the vision is the leader’s platform for change in order to articulate the rationale for creating a better future. Values are those characteristics that guide decision making and provide guidance for everyone’s expected behavior and conduct in the group. Values can be thought of as the “lens” through which the vision is carried out and the mission upheld.

click for large version

From the mission, vision, and values come strategies for achieving successful change and the more specific goals that the group is to attain. In some cases the group may have undertaken a formal strategic planning process that rendered a series of goals, objectives, and/or programs to be carried out in the immediate to intermediate term. We now reach the vital area in which a well structured and supported performance management system can play a pivotal role in ensuring the successful implementation of strategic thinking. Until now, the thought and planning process had focused on the right thing to do. From here, the focus becomes doing things right. Once you have completely answered the questions above and have a confident sense of where your group is heading and why, then the steps that follow will enable you to stack the deck in favor of achieving the level of performance you desire. Note that each step is embedded in action. Figure 1 represents the pyramid of performance management, a prioritized approach to managing others.

Recruiting the Right People

Not everyone has the luxury of personally hiring each physician in their group, much less having a surplus of candidates that are outstanding in every dimension. The reality in 2005 is that there continues to be demand for hospitalists far exceeding the available supply. This “seller’s market” (i.e., a hospitalist “sells” his or her services to an employer) represents a challenging dynamic for new or growing hospital medicine groups attempting to recruit the top candidates. It gets even worse when you consider hospital medicine as a new specialty, often finding itself in hospitals where the medical staff are skeptical or apprehensive in accepting the new group, and one bad hire can undermine the group’s chances of success. Furthermore, there may not be adequate experience or expertise in recruiting new physicians or correctly identifying those who would be a proper fit for the group. So how does one go about recruiting the right people?

Planning begins with having defined the group in terms of the mission and values. Knowing the vision and specific strategies to be employed lends insight into what type of individual would best fit with the needs and culture of the group. It is important to list the desired qualities on paper and plan for assessing each one, knowing that there is no perfect candidate and these characteristics must therefore be prioritized. Remember, what makes a good hospitalist in your group does not mean they will be good somewhere else; be sure you define very clearly what exactly “good” means. At the same time, it is also critical to outline the selling points of potentially joining your group in terms of 3 areas: the practice itself, compensation, and location.

The next step consists of preparing a slate of candidates for interviews. There are many methods of finding (i.e., sourcing) strong candidates, one of the best of which is to ask members of your current group or other trusted colleagues for referrals. If you are interested in filling a position with a more specific skill set such as information technology, palliative care, or clinical teaching, then a “make or buy” decision needs to be made to either recruit for the individual already in possession of such credentials or to hire more generically and then train accordingly. Once candidates are identified, a deliberate process of reviewing their written materials and interviewing them by telephone will determine the appropriateness of an in person interview. Speaking with references can occur at any time, and some advocate for this to occur prior to bringing a candidate for formal interview, as another mechanism of screening and to focus interview questions on site. The formal interview itself should be well structured and enable your key stakeholders to meet with the candidate and submit an immediate assessment. The shorter the turnaround time to extend an offer, the more decisive and committed to the candidate you will appear. Likewise, if you have a diverse composition of interviewers who weigh in with their perspectives, then there should be little to delay a hiring decision.

There are 3 additional points to remember when looking to hire an additional hospitalist into your group. First, it is estimated that 70% of physicians who leave a job do so because of spousal discontent. To mitigate this possibility, invite the spouse to accompany the candidate to the interview location, and assemble a parallel agenda for him or her.. Do not consider yourself on a “best behavior” basis during courtship alone; you need to continue nurturing the candidate and family well into the first year of employment to ensure a good transition. Second, be realistic about your expectations. There is no perfect candidate, so you must prioritize those qualities you want most from them. If you wait for perfection, the delay will cause you to overlook many very good physicians. Finally, take another look at the performance management pyramid. The reason the area for recruitment is so large is because of the disproportionate amount of time that one should invest in recruitment processes. Hiring the right people up front will make the rest of the steps far easier and minimize the likelihood of your being drawn into the nadir of the pyramid.

Setting Clear Expectations

Do you have a job description? When you read it, does it adequately describe what is expected of your hospitalists? Do you have an orientation for new members to your group? How long does it last? Is additional training offered? Are there outcomes that you expect from this training? And once you have oriented, trained, and offered a job description, does the actual work environment support or negate your efforts―i.e., does culture trump your formal process?

The cycle of setting clear expectations about work performance begins during the recruitment phase. Being absolutely forthcoming about what it is like to work in your group and what you expect from each and every member is paramount to allow both you and the candidate to determine a good fit. Once the physician has joined your group, orientation and training should hardly be a 1-, 2- or 3-day exercise. These are continuous and ongoing processes, given our rapidly changing practice environment. In fact, change is one of the only reliable characteristics of what we do, and extending the welcome “The job you take today is unlikely to be the job you will have next year” is hardly inappropriate. Be mindful that setting clear expectations with all of your hospitalists is the bedrock of a functional performance management system. Defining expectations alone will often improve performance, vis-à-vis the Hawthorne effect.

Expectations should always be depersonalized and focus on behavior. Behavior itself may be regarded in 2 distinct domains: those behaviors that are observed, and those outcomes that are measurable. Examples of observable behaviors include interpersonal interactions with nurses and consultants, pager response times, and attendance at monthly team meetings. Measurable outcomes include work RVU productivity, patient satisfaction, readmission rates, and compliance with coding and documentation guidelines. There are many ways to organize dimensions of performance that you may expect from your physicians―the 6 aims of quality (safe, timely, effective, efficient, equitable, and patient centered, as outlined in the IOM report Crossing the Quality Chasm), maintenance of a healthy workplace, citizenship, relationships with others, etc.―yet the key is to define and communicate them, then check often for understanding.

Measuring Actual Performance

Be the first to admit “the numbers are wrong,” and you will save hearing it from many others. There are many inherent problems in measuring actual performance, and the data may never be perfect. As an exercise, try assigning individual readmission rates within your group, and you will find that because of handoffs within the group and lack of precision in identifying who actually discharged the patient, there will be many arguments over whether the data is valid. However, in most circumstances, if the data is flawed, it still may serve a strong purpose to highlight the relative variation within the group. Searching for quantifiable systemic data and being transparent about the limitations of the data will be an exercise worth undertaking. In like manner, behavioral observation data are potentially fraught with conflict if the data are focused on judgment of character traits (I believe this hospitalist has a good bedside manner) rather than on observable behaviors (This hospitalist always/sometimes/never comes to meetings on time). Measures are best when they are objective, relevant to the position, and interpretable. Remember: All measures are flawed; some are useful.

Aligning Compensation With Expectations

Conventional wisdom states that people will do more of what they are incentivized to do. The corollary to this is to be sure what you incentivize is actually what you want. For the group that is trying to improve individual productivity and reduce length of stay, providing financial rewards for work RVU’s alone may result in less assertiveness in managing timely discharges and bickering over who picks up the 11 p.m. vs. 2 a.m. overnight admission the following morning. Ultimately, compensation must be intimately linked with the mission of the group, and tremendous care must be taken in determining the construct of any system. Although it is well beyond the scope of this article to detail the many considerations of designing a compensation system, one must understand that it is only one component―and not the most important component―of a performance management program.

Here are a few points to consider as you integrate your compensation system into the rest of the steps in the pyramid:

1. A straight salary with or without a “guaranteed” bonus is unlikely to reward or motivate any new behaviors.
2. For a performance-based compensation plan to have sufficient impact, at least 20%–30% of compensation must be tied to performance.
3. Consider having both group and individual measures as part of your plan to engender a sense of teamwork and collective effort in performing well.
4. Limit the number of variables in the plan to 3–5; otherwise, measures are too diluted to carry meaningful weight.
5. Perform a local market comparison for benchmarking your goal median compensation; often administrative staff are more willing to share this information with other administrative staff if the understanding is that all market results will be shared.
6. The process of constructing or evolving your plan, being inclusive of members of your group as well as any group sponsors, ends up being far more valuable than the final plan itself.

Providing Regular Feedback

Have you ever had a complaint that sounded like “I get way too much feedback around here?” Probably not. More likely is the case that your hospitalists wonder how they stand in terms of being compared to others and to themselves over time. The creed “no news must be good news” is hardly supportive of promoting top performance. Feedback itself can be highly influential and reflects the expectations explained by the group leader. Expectations not measured or fed back to the individual hospitalists will be expectations soon forgotten or ignored, because they may be felt not to matter.

Effective feedback is both formal and informal. The annual performance review is a common example of the former, but it is in no way meant to be the only feedback a hospitalist should receive, nor is it the most powerful. The annual review should be well structured, can outline longer term goals and ideas for self-improvement, and may serve in some key administrative functions like compensation and promotion. Informal, regular feedback, however, may serve you much better in driving performance, because it is timelier, more relevant to daily work, and more specific to the individual. Individuals also respond much more constructively to positive feedback, and some experts believe the ratio of positive to negative feedback should be on the order of 9 to 1. Be sure that feedback is done in a coaching manner and focuses on the behavior (You may try sitting down when you talk with patients as a way of making them feel more at ease) rather than on the person themselves (You’re really not a good communicator).

Managing Marginal Performance

Marginal performance can be defined as a physician whose observed behaviors or measured outcomes are at significant variance from what is expected. This pattern takes place over time and happens in spite of having in place all the other elements of a performance management system. Consider the “clock puncher” who rarely helps out the rest of the team on busy days and never shows up to group meetings or committees. Or the “tortoise” that has wonderful staff relations but chronically arrives at work late and repeatedly forgets to submit inpatient charges. Then there’s the “hothead” who is clinically adept and has high patient satisfaction but loses his or her temper with nursing and is pervasively confrontational with consultants. The steps to be taken in these and other cases like them include ensuring adequate documentation, reaching an agreement with the individual in recognizing that there is a problem, generating options for causality, negotiating a contract for improvement, and then letting future behavior determine the consequences.

Taking Corrective Action

Sometimes you simply cannot fix everything, and you need to be easy on yourself for having reached the point where the situation is no longer remediable in spite of your best efforts. In the end, everyone will be better off. When physician conduct becomes detrimental to patient safety, staff safety or quality patient care; is disruptive to the organization; or is otherwise chronically aberrant, then it is time to take adverse action. Since there are many pitfalls that have HR and legal implications, it is advisable to consult with relevant personnel to avoid problems with inadequate documentation and the potential need to report actions to state agencies and the National Practitioner Data Bank (per the Healthcare Quality Improvement Act of 1986).

Resources

1. Ury W, Fisher R. Getting to Yes: Negotiating Agreement Without Giving In. 2nd ed. New York: Penguin Books; 1991.
2. Reinertsen J. Physicians as leaders in the improvement of health care systems. Ann Intern Med. 1998;128:833-8.
3. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
4. American College of Physician Executives. Managing Physician Performance in Organizations. Ongoing courses available at www.acpe.org.

Joel Barker describes leadership as “…the ability to take people where they otherwise would not go.” In other words, leadership is about creating change in something that exists today. Management, on the other hand, may be considered a series of steps to ensure that things happen the desired and consistent way. Although this article is not of scope sufficient to explore the differences between management and leadership, it will address a domain in which the 2 intimately intersect. Managing others relies upon many foundations of leadership, such as establishing the group’s vision and setting key strategic goals. In like manner, successful leadership in stimulating change is dependent on the effective management of personnel to ensure that the culture, work habits, outcomes, and behaviors are consistent with the change efforts. This article will focus on the management of physicians in hospital medicine groups. The 8 steps outlined are applicable regardless of employer type, group size, or mission. Almost all of the skills necessary to effectively implement a performance management system can be learned and are best practiced on a regular basis. Furthermore, there are many existing resources for further education and development in these areas based on one’s current level of competency.

The author wishes to acknowledge the faculty of the American College of Physician Executives for their work in assembling many of the concepts found in this article. The course “Managing Physician Performance in Organizations” serves to underscore an integrated model of performance management and explores some of the theoretical bases of human behavior not included here.

Defining Your Group

Before you can manage performance, you must know the parameters by which the group is defined. The prerequisites for performance management include salient statements of mission, vision, and values. The mission defines the purpose for the group being in place and usually reflects the interests of the hospital(s) or medical group affiliated with or actually employing the hospital medicine group. The mission statement should be able to answer the questions “Why does our hospital medicine group exist? What purpose does it serve? In very broad terms, what scope of services do we provide?” The vision is a concise summary of what the group would like to be or achieve in the future, and it may relate to growth, range of services, outcomes, or other dimensions. Most often the vision is the leader’s platform for change in order to articulate the rationale for creating a better future. Values are those characteristics that guide decision making and provide guidance for everyone’s expected behavior and conduct in the group. Values can be thought of as the “lens” through which the vision is carried out and the mission upheld.

click for large version

From the mission, vision, and values come strategies for achieving successful change and the more specific goals that the group is to attain. In some cases the group may have undertaken a formal strategic planning process that rendered a series of goals, objectives, and/or programs to be carried out in the immediate to intermediate term. We now reach the vital area in which a well structured and supported performance management system can play a pivotal role in ensuring the successful implementation of strategic thinking. Until now, the thought and planning process had focused on the right thing to do. From here, the focus becomes doing things right. Once you have completely answered the questions above and have a confident sense of where your group is heading and why, then the steps that follow will enable you to stack the deck in favor of achieving the level of performance you desire. Note that each step is embedded in action. Figure 1 represents the pyramid of performance management, a prioritized approach to managing others.

Recruiting the Right People

Not everyone has the luxury of personally hiring each physician in their group, much less having a surplus of candidates that are outstanding in every dimension. The reality in 2005 is that there continues to be demand for hospitalists far exceeding the available supply. This “seller’s market” (i.e., a hospitalist “sells” his or her services to an employer) represents a challenging dynamic for new or growing hospital medicine groups attempting to recruit the top candidates. It gets even worse when you consider hospital medicine as a new specialty, often finding itself in hospitals where the medical staff are skeptical or apprehensive in accepting the new group, and one bad hire can undermine the group’s chances of success. Furthermore, there may not be adequate experience or expertise in recruiting new physicians or correctly identifying those who would be a proper fit for the group. So how does one go about recruiting the right people?

Planning begins with having defined the group in terms of the mission and values. Knowing the vision and specific strategies to be employed lends insight into what type of individual would best fit with the needs and culture of the group. It is important to list the desired qualities on paper and plan for assessing each one, knowing that there is no perfect candidate and these characteristics must therefore be prioritized. Remember, what makes a good hospitalist in your group does not mean they will be good somewhere else; be sure you define very clearly what exactly “good” means. At the same time, it is also critical to outline the selling points of potentially joining your group in terms of 3 areas: the practice itself, compensation, and location.

The next step consists of preparing a slate of candidates for interviews. There are many methods of finding (i.e., sourcing) strong candidates, one of the best of which is to ask members of your current group or other trusted colleagues for referrals. If you are interested in filling a position with a more specific skill set such as information technology, palliative care, or clinical teaching, then a “make or buy” decision needs to be made to either recruit for the individual already in possession of such credentials or to hire more generically and then train accordingly. Once candidates are identified, a deliberate process of reviewing their written materials and interviewing them by telephone will determine the appropriateness of an in person interview. Speaking with references can occur at any time, and some advocate for this to occur prior to bringing a candidate for formal interview, as another mechanism of screening and to focus interview questions on site. The formal interview itself should be well structured and enable your key stakeholders to meet with the candidate and submit an immediate assessment. The shorter the turnaround time to extend an offer, the more decisive and committed to the candidate you will appear. Likewise, if you have a diverse composition of interviewers who weigh in with their perspectives, then there should be little to delay a hiring decision.

There are 3 additional points to remember when looking to hire an additional hospitalist into your group. First, it is estimated that 70% of physicians who leave a job do so because of spousal discontent. To mitigate this possibility, invite the spouse to accompany the candidate to the interview location, and assemble a parallel agenda for him or her.. Do not consider yourself on a “best behavior” basis during courtship alone; you need to continue nurturing the candidate and family well into the first year of employment to ensure a good transition. Second, be realistic about your expectations. There is no perfect candidate, so you must prioritize those qualities you want most from them. If you wait for perfection, the delay will cause you to overlook many very good physicians. Finally, take another look at the performance management pyramid. The reason the area for recruitment is so large is because of the disproportionate amount of time that one should invest in recruitment processes. Hiring the right people up front will make the rest of the steps far easier and minimize the likelihood of your being drawn into the nadir of the pyramid.

Setting Clear Expectations

Do you have a job description? When you read it, does it adequately describe what is expected of your hospitalists? Do you have an orientation for new members to your group? How long does it last? Is additional training offered? Are there outcomes that you expect from this training? And once you have oriented, trained, and offered a job description, does the actual work environment support or negate your efforts―i.e., does culture trump your formal process?

The cycle of setting clear expectations about work performance begins during the recruitment phase. Being absolutely forthcoming about what it is like to work in your group and what you expect from each and every member is paramount to allow both you and the candidate to determine a good fit. Once the physician has joined your group, orientation and training should hardly be a 1-, 2- or 3-day exercise. These are continuous and ongoing processes, given our rapidly changing practice environment. In fact, change is one of the only reliable characteristics of what we do, and extending the welcome “The job you take today is unlikely to be the job you will have next year” is hardly inappropriate. Be mindful that setting clear expectations with all of your hospitalists is the bedrock of a functional performance management system. Defining expectations alone will often improve performance, vis-à-vis the Hawthorne effect.

Expectations should always be depersonalized and focus on behavior. Behavior itself may be regarded in 2 distinct domains: those behaviors that are observed, and those outcomes that are measurable. Examples of observable behaviors include interpersonal interactions with nurses and consultants, pager response times, and attendance at monthly team meetings. Measurable outcomes include work RVU productivity, patient satisfaction, readmission rates, and compliance with coding and documentation guidelines. There are many ways to organize dimensions of performance that you may expect from your physicians―the 6 aims of quality (safe, timely, effective, efficient, equitable, and patient centered, as outlined in the IOM report Crossing the Quality Chasm), maintenance of a healthy workplace, citizenship, relationships with others, etc.―yet the key is to define and communicate them, then check often for understanding.

Measuring Actual Performance

Be the first to admit “the numbers are wrong,” and you will save hearing it from many others. There are many inherent problems in measuring actual performance, and the data may never be perfect. As an exercise, try assigning individual readmission rates within your group, and you will find that because of handoffs within the group and lack of precision in identifying who actually discharged the patient, there will be many arguments over whether the data is valid. However, in most circumstances, if the data is flawed, it still may serve a strong purpose to highlight the relative variation within the group. Searching for quantifiable systemic data and being transparent about the limitations of the data will be an exercise worth undertaking. In like manner, behavioral observation data are potentially fraught with conflict if the data are focused on judgment of character traits (I believe this hospitalist has a good bedside manner) rather than on observable behaviors (This hospitalist always/sometimes/never comes to meetings on time). Measures are best when they are objective, relevant to the position, and interpretable. Remember: All measures are flawed; some are useful.

Aligning Compensation With Expectations

Conventional wisdom states that people will do more of what they are incentivized to do. The corollary to this is to be sure what you incentivize is actually what you want. For the group that is trying to improve individual productivity and reduce length of stay, providing financial rewards for work RVU’s alone may result in less assertiveness in managing timely discharges and bickering over who picks up the 11 p.m. vs. 2 a.m. overnight admission the following morning. Ultimately, compensation must be intimately linked with the mission of the group, and tremendous care must be taken in determining the construct of any system. Although it is well beyond the scope of this article to detail the many considerations of designing a compensation system, one must understand that it is only one component―and not the most important component―of a performance management program.

Here are a few points to consider as you integrate your compensation system into the rest of the steps in the pyramid:

1. A straight salary with or without a “guaranteed” bonus is unlikely to reward or motivate any new behaviors.
2. For a performance-based compensation plan to have sufficient impact, at least 20%–30% of compensation must be tied to performance.
3. Consider having both group and individual measures as part of your plan to engender a sense of teamwork and collective effort in performing well.
4. Limit the number of variables in the plan to 3–5; otherwise, measures are too diluted to carry meaningful weight.
5. Perform a local market comparison for benchmarking your goal median compensation; often administrative staff are more willing to share this information with other administrative staff if the understanding is that all market results will be shared.
6. The process of constructing or evolving your plan, being inclusive of members of your group as well as any group sponsors, ends up being far more valuable than the final plan itself.

Providing Regular Feedback

Have you ever had a complaint that sounded like “I get way too much feedback around here?” Probably not. More likely is the case that your hospitalists wonder how they stand in terms of being compared to others and to themselves over time. The creed “no news must be good news” is hardly supportive of promoting top performance. Feedback itself can be highly influential and reflects the expectations explained by the group leader. Expectations not measured or fed back to the individual hospitalists will be expectations soon forgotten or ignored, because they may be felt not to matter.

Effective feedback is both formal and informal. The annual performance review is a common example of the former, but it is in no way meant to be the only feedback a hospitalist should receive, nor is it the most powerful. The annual review should be well structured, can outline longer term goals and ideas for self-improvement, and may serve in some key administrative functions like compensation and promotion. Informal, regular feedback, however, may serve you much better in driving performance, because it is timelier, more relevant to daily work, and more specific to the individual. Individuals also respond much more constructively to positive feedback, and some experts believe the ratio of positive to negative feedback should be on the order of 9 to 1. Be sure that feedback is done in a coaching manner and focuses on the behavior (You may try sitting down when you talk with patients as a way of making them feel more at ease) rather than on the person themselves (You’re really not a good communicator).

Managing Marginal Performance

Marginal performance can be defined as a physician whose observed behaviors or measured outcomes are at significant variance from what is expected. This pattern takes place over time and happens in spite of having in place all the other elements of a performance management system. Consider the “clock puncher” who rarely helps out the rest of the team on busy days and never shows up to group meetings or committees. Or the “tortoise” that has wonderful staff relations but chronically arrives at work late and repeatedly forgets to submit inpatient charges. Then there’s the “hothead” who is clinically adept and has high patient satisfaction but loses his or her temper with nursing and is pervasively confrontational with consultants. The steps to be taken in these and other cases like them include ensuring adequate documentation, reaching an agreement with the individual in recognizing that there is a problem, generating options for causality, negotiating a contract for improvement, and then letting future behavior determine the consequences.

Taking Corrective Action

Sometimes you simply cannot fix everything, and you need to be easy on yourself for having reached the point where the situation is no longer remediable in spite of your best efforts. In the end, everyone will be better off. When physician conduct becomes detrimental to patient safety, staff safety or quality patient care; is disruptive to the organization; or is otherwise chronically aberrant, then it is time to take adverse action. Since there are many pitfalls that have HR and legal implications, it is advisable to consult with relevant personnel to avoid problems with inadequate documentation and the potential need to report actions to state agencies and the National Practitioner Data Bank (per the Healthcare Quality Improvement Act of 1986).

Resources

1. Ury W, Fisher R. Getting to Yes: Negotiating Agreement Without Giving In. 2nd ed. New York: Penguin Books; 1991.
2. Reinertsen J. Physicians as leaders in the improvement of health care systems. Ann Intern Med. 1998;128:833-8.
3. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
4. American College of Physician Executives. Managing Physician Performance in Organizations. Ongoing courses available at www.acpe.org.

SHM presented its 2005 national awards of excellence to four hospitalists whose work and research have contributed significantly to hospital medicine and to the betterment of hospital care across America. The award winners, who were recognized at the SHM annual meeting in Chicago, included:

• Sunil Kripalani, MD, MSc, assistant professor, Division of General Medicine, Emory University School of Medicine, and attending physician and assistant director for research, Hospitalist Program, Grady Memorial Hospital, both in Atlanta, GA– recipient of Young Investigator Award.
• Shaun Frost, MD, FACP, assistant professor of Medicine, University of Minnesota Medical School, and hospitalist, HealthPartners Medical Group and Clinics, Regions Hospital, St Paul, MN– recipient of Clinical Excellence Award.
• Joseph Ming Wah Li, MD, hospitalist and director of the Hospital Medicine section, Beth Israel Deaconess Medical Center, Boston, MA– recipient of Outstanding Service in Hospital Medicine Award.
• Jeff Wiese, MD, associate professor of medicine, associate chairman of medicine, director of the Internal Medicine Residency Program, Tulane University Health Sciences Center, and chief of medicine, Medical Center of Louisiana at New Orleans and Charity Hospital, New Orleans, LA– recipient of Excellence in Teaching Award.

Sunil Kripalani with SHM President Steve Pantilat.

Dr. Kripalani has established himself as one of the leading investigators in the field of patient literacy and its impact on health outcomes. He has been the recipient of more than $1 million in grant funding, including a prestigious K23 Patient Oriented Research Career Development Award from the National Institutes of Health (NIH) to examine the relationship between health literacy and medication adherence after hospital discharge. He is currently the principal investigator on a randomized trial of two low literacy interventions designed to improve medication adherence among patients with coronary heart disease, funded by the American Heart Association. In addition, through a Pfizer Health Literacy Scholar Award, he has established a training program to improve physician communication with low literacy patients.

Dr. Kripalani has authored over 20 scientific and educational publications, including articles in the Journal of the American Medical Association, Journal of General Internal Medicine, and American Journal of Preventive Medicine. He serves as a reviewer for several prominent medical journals and has reviewed grants for the NIH. Dr. Kripalani has lectured at the Centers for Disease Control and Prevention, Georgia Hospital Association, SHM, and Society of General Internal Medicine (SGIM), where he coordinates the health literacy interest group. He is also serving as an associate editor of the upcoming book, Hospital Medicine Secrets, and coeditor of an upcoming special issue on health literacy for the Journal of General Internal Medicine.

In addition to these activities, Dr. Kripalani has proven himself a dedicated champion of SHM, contributing substantial time to research efforts at SHM, including the SHM Research Committee, Continuity of Care Task Force, Abstract Committee, Advisory Board Young Hospitalists Section, and the research section of SHM’s The Hospitalist publication.

After graduating summa cum laude from Rice University in 1993 with a BA in Psychology, Dr. Kripalani received an MD with honors from Baylor College of Medicine in 1997. He completed his residency in Internal Medicine at Emory University in Atlanta in 2000, where he also completed one of the nation’s first Hospital Medicine Fellowships, including a Master of Science in Clinical Research.

Shaun Frost with SHM President Steve Pantilat.

Dr. Frost has dedicated himself to the advancement of clinical knowledge through clinical teaching and scientific publication. He is a member of the Regions Hospital Palliative Care Service and Patient Safety Committee, was a lead participant in a “Lean” implementation team on inpatient testing results, and was selected as the leafter of Regions Hospital “Best Care, Best Experience” work team on provider support. He is also currently participating in the development and implementation of inpatient “Prepared Practice Teams,” a model of multidisciplinary rounding to enhance communication among physicians, nurses, case managers, social workers, and pharmacists.

A teaching faculty member of the University of Minnesota Medical School, he is highly regarded by residents and medical students, and has been instrumental in developing curricula in perioperative medicine for residents to improve the systems of surgical care through education.

Dr. Frost is a frequent lecturer on topics ranging from perioperative medicine to venous thromboembolism and has been published in: Annals of Internal Medicine, JAMA, Medical Clinics of North America, Mayo Clinic Proceedings, Cleveland Clinic Journal of Medicine, and The Hospitalist. He currently is lead investigator for a trial on preoperative medication administration.

Dr. Frost has demonstrated consistent leadership within SHM. He is regarded as the definitive resource in local chapter development due to his work in the SHM Lake Erie Chapter, where he was founder and president. He also is credited with establishing the very first formal chapter of SHM. His vision for the future of chapter activities – including community service and a national recognition program – resulted in a Membership Committee task force on chapter development. As a leader in the Midwest SHM region, Dr. Frost was named a Councilor to the SHM Midwest Council. His outstanding performance led to his assuming the chair of the Council in 2004. Dr. Frost is also recognized as a subject matter expert in biomedical ethics, serving consecutive terms on the Ethics Committee as well.

Dr. Frost earned his MD at the University of Texas Southwestern Medical School in Dallas as an AOA graduate, and completed his residency in Internal Medicine there. From 1998 through 2004, as a hospitalist at Cleveland Clinic Foundation, he was a contributor to the development, maturation, and operation of its hospital medicine model of care.

Joseph Ming Wah Li with SHM President Steve Pantilat.

Dr. Li was the first hospitalist at the Beth Israel Deaconess Hospital Medicine Program in 1998. There he helped define the role of an academic hospitalist through clinical work, teaching, and service on countless committees and hospital initiatives. He quickly distinguished himself and was made associate chief of the HCA/ACOVE medical teaching

firm and, more recently, director of the BIDMC Hospital Medicine Program. A key focus for Dr. Li was broadening the Hospital Medicine Program at BIDMC. Under his guidance, the program grew to eleven hospitalists that account for over 50% of all general medicine admissions and over 50% of teaching attending months on the medical service. He also developed a system that allowed staff to provide 24/7 seamless coverage and created a website of referring physicians. He initiated new clinical programs and working arrangements for the hospitalist team, and helped institute a program to staff a local hospital with Beth Israel Deaconess hospitalists.

Dr. Li’s advocacy for Hospital Medicine did not stop at the doors of BIDMC, however. He was a co-developer of the first Harvard Medical School CME course on the emerging role of hospital medicine, and was the cofounder of the Boston Area Hospitalists and the SHM Northeast Regional Chapter of hospitalists. A charter member of SHM, he co-directed the first SHM annual northeastern regional meeting in 2001. He currently is a member of the SHM Education Committee, Annual Meeting Committee, and Membership Committee Task Force.

A nationally recognized expert in hospital medicine, Dr. Li lectures extensively and has testified on hearings dealing with mandatory hospitalist programs. He has published numerous articles in Critical Pathways in Cardiology, WebMD, Infectious Diseases in Clinical Practice, Current Opinion in Pulmonary Medicine, and Medscape.com, to name a few.

After earning his MD from the University of Oklahoma in Oklahoma City in 1994, Dr. Li did his residency at New England Deaconess Hospital before becoming chief medical resident at Beth Israel Deaconess Medical Center.

Jeff Wiese with SHM President Steve Pantilat.

Dr. Wiese has received 21 awards for teaching over the last five years, including six from the University of California at San Francisco, where he started his career in 1998 as a clinical instructor. Since joining Tulane University in 2000, he has earned 16 teaching awards, including the prestigious all Tulane Faculty of the Year Award (twice) and the Virginia Furrow Award for Innovation in Medical Education. On the clinical wards, he has twice won Attending of the Year honors, and his Professor Rounds are routinely rated among the best.

Dr. Wiese designed numerous innovative curriculums. As a result of his clinical diagnosis innovations, the Clinical Diagnosis scores at Tulane increased from the 46th percentile to the 80th and 82nd percentile, with 10% of the 2004 class scoring in the top percentile in the nation. As a result of his restructuring of core curriculum to emphasize rational, evidenced based medical decision making, Tulane’s internal medicine program recently went the highest on its match list in the past 20 years. And through Dr. Wiese’s pyramid mentor system, Tulane Internal Medicine presented more regional and national presentations than any residency program in the country.

Dr. Wiese has written over 50 articles, books, or book chapters, is assistant editor for two educational textbooks and a reviewer for six national journals, has authored two textbooks, and is on the editorial board for a monthly publication. As an active SHM member, he has served on the Education Committee, Southern SHM Committee, and was program director for SHM’s Intensive Care Pre-course.

Dr. Wiese received his MD from Johns Hopkins School of Medicine in 1995. He completed his residency and chief residency training in Internal Medicine at the University of California at San Francisco, where he also completed a fellowship in General Internal Medicine with a focus on Hospitalist Medicine. He joined Tulane in 2000, after being recruited to start a hospitalist system at the Medical Center of Louisiana at New Orleans (Charity Hospital). His hospitalist proposal was accepted by the state and hospital administration, helping to provide funding to hospitalists at Charity.

Please join us in congratulating all of this year’s outstanding award winners.

SHM presented its 2005 national awards of excellence to four hospitalists whose work and research have contributed significantly to hospital medicine and to the betterment of hospital care across America. The award winners, who were recognized at the SHM annual meeting in Chicago, included:

• Sunil Kripalani, MD, MSc, assistant professor, Division of General Medicine, Emory University School of Medicine, and attending physician and assistant director for research, Hospitalist Program, Grady Memorial Hospital, both in Atlanta, GA– recipient of Young Investigator Award.
• Shaun Frost, MD, FACP, assistant professor of Medicine, University of Minnesota Medical School, and hospitalist, HealthPartners Medical Group and Clinics, Regions Hospital, St Paul, MN– recipient of Clinical Excellence Award.
• Joseph Ming Wah Li, MD, hospitalist and director of the Hospital Medicine section, Beth Israel Deaconess Medical Center, Boston, MA– recipient of Outstanding Service in Hospital Medicine Award.
• Jeff Wiese, MD, associate professor of medicine, associate chairman of medicine, director of the Internal Medicine Residency Program, Tulane University Health Sciences Center, and chief of medicine, Medical Center of Louisiana at New Orleans and Charity Hospital, New Orleans, LA– recipient of Excellence in Teaching Award.

Sunil Kripalani with SHM President Steve Pantilat.

Dr. Kripalani has established himself as one of the leading investigators in the field of patient literacy and its impact on health outcomes. He has been the recipient of more than $1 million in grant funding, including a prestigious K23 Patient Oriented Research Career Development Award from the National Institutes of Health (NIH) to examine the relationship between health literacy and medication adherence after hospital discharge. He is currently the principal investigator on a randomized trial of two low literacy interventions designed to improve medication adherence among patients with coronary heart disease, funded by the American Heart Association. In addition, through a Pfizer Health Literacy Scholar Award, he has established a training program to improve physician communication with low literacy patients.

Dr. Kripalani has authored over 20 scientific and educational publications, including articles in the Journal of the American Medical Association, Journal of General Internal Medicine, and American Journal of Preventive Medicine. He serves as a reviewer for several prominent medical journals and has reviewed grants for the NIH. Dr. Kripalani has lectured at the Centers for Disease Control and Prevention, Georgia Hospital Association, SHM, and Society of General Internal Medicine (SGIM), where he coordinates the health literacy interest group. He is also serving as an associate editor of the upcoming book, Hospital Medicine Secrets, and coeditor of an upcoming special issue on health literacy for the Journal of General Internal Medicine.

In addition to these activities, Dr. Kripalani has proven himself a dedicated champion of SHM, contributing substantial time to research efforts at SHM, including the SHM Research Committee, Continuity of Care Task Force, Abstract Committee, Advisory Board Young Hospitalists Section, and the research section of SHM’s The Hospitalist publication.

After graduating summa cum laude from Rice University in 1993 with a BA in Psychology, Dr. Kripalani received an MD with honors from Baylor College of Medicine in 1997. He completed his residency in Internal Medicine at Emory University in Atlanta in 2000, where he also completed one of the nation’s first Hospital Medicine Fellowships, including a Master of Science in Clinical Research.

Shaun Frost with SHM President Steve Pantilat.

Dr. Frost has dedicated himself to the advancement of clinical knowledge through clinical teaching and scientific publication. He is a member of the Regions Hospital Palliative Care Service and Patient Safety Committee, was a lead participant in a “Lean” implementation team on inpatient testing results, and was selected as the leafter of Regions Hospital “Best Care, Best Experience” work team on provider support. He is also currently participating in the development and implementation of inpatient “Prepared Practice Teams,” a model of multidisciplinary rounding to enhance communication among physicians, nurses, case managers, social workers, and pharmacists.

A teaching faculty member of the University of Minnesota Medical School, he is highly regarded by residents and medical students, and has been instrumental in developing curricula in perioperative medicine for residents to improve the systems of surgical care through education.

Dr. Frost is a frequent lecturer on topics ranging from perioperative medicine to venous thromboembolism and has been published in: Annals of Internal Medicine, JAMA, Medical Clinics of North America, Mayo Clinic Proceedings, Cleveland Clinic Journal of Medicine, and The Hospitalist. He currently is lead investigator for a trial on preoperative medication administration.

Dr. Frost has demonstrated consistent leadership within SHM. He is regarded as the definitive resource in local chapter development due to his work in the SHM Lake Erie Chapter, where he was founder and president. He also is credited with establishing the very first formal chapter of SHM. His vision for the future of chapter activities – including community service and a national recognition program – resulted in a Membership Committee task force on chapter development. As a leader in the Midwest SHM region, Dr. Frost was named a Councilor to the SHM Midwest Council. His outstanding performance led to his assuming the chair of the Council in 2004. Dr. Frost is also recognized as a subject matter expert in biomedical ethics, serving consecutive terms on the Ethics Committee as well.

Dr. Frost earned his MD at the University of Texas Southwestern Medical School in Dallas as an AOA graduate, and completed his residency in Internal Medicine there. From 1998 through 2004, as a hospitalist at Cleveland Clinic Foundation, he was a contributor to the development, maturation, and operation of its hospital medicine model of care.

Joseph Ming Wah Li with SHM President Steve Pantilat.

Dr. Li was the first hospitalist at the Beth Israel Deaconess Hospital Medicine Program in 1998. There he helped define the role of an academic hospitalist through clinical work, teaching, and service on countless committees and hospital initiatives. He quickly distinguished himself and was made associate chief of the HCA/ACOVE medical teaching

firm and, more recently, director of the BIDMC Hospital Medicine Program. A key focus for Dr. Li was broadening the Hospital Medicine Program at BIDMC. Under his guidance, the program grew to eleven hospitalists that account for over 50% of all general medicine admissions and over 50% of teaching attending months on the medical service. He also developed a system that allowed staff to provide 24/7 seamless coverage and created a website of referring physicians. He initiated new clinical programs and working arrangements for the hospitalist team, and helped institute a program to staff a local hospital with Beth Israel Deaconess hospitalists.

Dr. Li’s advocacy for Hospital Medicine did not stop at the doors of BIDMC, however. He was a co-developer of the first Harvard Medical School CME course on the emerging role of hospital medicine, and was the cofounder of the Boston Area Hospitalists and the SHM Northeast Regional Chapter of hospitalists. A charter member of SHM, he co-directed the first SHM annual northeastern regional meeting in 2001. He currently is a member of the SHM Education Committee, Annual Meeting Committee, and Membership Committee Task Force.

A nationally recognized expert in hospital medicine, Dr. Li lectures extensively and has testified on hearings dealing with mandatory hospitalist programs. He has published numerous articles in Critical Pathways in Cardiology, WebMD, Infectious Diseases in Clinical Practice, Current Opinion in Pulmonary Medicine, and Medscape.com, to name a few.

After earning his MD from the University of Oklahoma in Oklahoma City in 1994, Dr. Li did his residency at New England Deaconess Hospital before becoming chief medical resident at Beth Israel Deaconess Medical Center.

Jeff Wiese with SHM President Steve Pantilat.

Dr. Wiese has received 21 awards for teaching over the last five years, including six from the University of California at San Francisco, where he started his career in 1998 as a clinical instructor. Since joining Tulane University in 2000, he has earned 16 teaching awards, including the prestigious all Tulane Faculty of the Year Award (twice) and the Virginia Furrow Award for Innovation in Medical Education. On the clinical wards, he has twice won Attending of the Year honors, and his Professor Rounds are routinely rated among the best.

Dr. Wiese designed numerous innovative curriculums. As a result of his clinical diagnosis innovations, the Clinical Diagnosis scores at Tulane increased from the 46th percentile to the 80th and 82nd percentile, with 10% of the 2004 class scoring in the top percentile in the nation. As a result of his restructuring of core curriculum to emphasize rational, evidenced based medical decision making, Tulane’s internal medicine program recently went the highest on its match list in the past 20 years. And through Dr. Wiese’s pyramid mentor system, Tulane Internal Medicine presented more regional and national presentations than any residency program in the country.

Dr. Wiese has written over 50 articles, books, or book chapters, is assistant editor for two educational textbooks and a reviewer for six national journals, has authored two textbooks, and is on the editorial board for a monthly publication. As an active SHM member, he has served on the Education Committee, Southern SHM Committee, and was program director for SHM’s Intensive Care Pre-course.

Dr. Wiese received his MD from Johns Hopkins School of Medicine in 1995. He completed his residency and chief residency training in Internal Medicine at the University of California at San Francisco, where he also completed a fellowship in General Internal Medicine with a focus on Hospitalist Medicine. He joined Tulane in 2000, after being recruited to start a hospitalist system at the Medical Center of Louisiana at New Orleans (Charity Hospital). His hospitalist proposal was accepted by the state and hospital administration, helping to provide funding to hospitalists at Charity.

Please join us in congratulating all of this year’s outstanding award winners.

SHM presented its 2005 national awards of excellence to four hospitalists whose work and research have contributed significantly to hospital medicine and to the betterment of hospital care across America. The award winners, who were recognized at the SHM annual meeting in Chicago, included:

• Sunil Kripalani, MD, MSc, assistant professor, Division of General Medicine, Emory University School of Medicine, and attending physician and assistant director for research, Hospitalist Program, Grady Memorial Hospital, both in Atlanta, GA– recipient of Young Investigator Award.
• Shaun Frost, MD, FACP, assistant professor of Medicine, University of Minnesota Medical School, and hospitalist, HealthPartners Medical Group and Clinics, Regions Hospital, St Paul, MN– recipient of Clinical Excellence Award.
• Joseph Ming Wah Li, MD, hospitalist and director of the Hospital Medicine section, Beth Israel Deaconess Medical Center, Boston, MA– recipient of Outstanding Service in Hospital Medicine Award.
• Jeff Wiese, MD, associate professor of medicine, associate chairman of medicine, director of the Internal Medicine Residency Program, Tulane University Health Sciences Center, and chief of medicine, Medical Center of Louisiana at New Orleans and Charity Hospital, New Orleans, LA– recipient of Excellence in Teaching Award.

Sunil Kripalani with SHM President Steve Pantilat.

Dr. Kripalani has established himself as one of the leading investigators in the field of patient literacy and its impact on health outcomes. He has been the recipient of more than $1 million in grant funding, including a prestigious K23 Patient Oriented Research Career Development Award from the National Institutes of Health (NIH) to examine the relationship between health literacy and medication adherence after hospital discharge. He is currently the principal investigator on a randomized trial of two low literacy interventions designed to improve medication adherence among patients with coronary heart disease, funded by the American Heart Association. In addition, through a Pfizer Health Literacy Scholar Award, he has established a training program to improve physician communication with low literacy patients.

Dr. Kripalani has authored over 20 scientific and educational publications, including articles in the Journal of the American Medical Association, Journal of General Internal Medicine, and American Journal of Preventive Medicine. He serves as a reviewer for several prominent medical journals and has reviewed grants for the NIH. Dr. Kripalani has lectured at the Centers for Disease Control and Prevention, Georgia Hospital Association, SHM, and Society of General Internal Medicine (SGIM), where he coordinates the health literacy interest group. He is also serving as an associate editor of the upcoming book, Hospital Medicine Secrets, and coeditor of an upcoming special issue on health literacy for the Journal of General Internal Medicine.

In addition to these activities, Dr. Kripalani has proven himself a dedicated champion of SHM, contributing substantial time to research efforts at SHM, including the SHM Research Committee, Continuity of Care Task Force, Abstract Committee, Advisory Board Young Hospitalists Section, and the research section of SHM’s The Hospitalist publication.

After graduating summa cum laude from Rice University in 1993 with a BA in Psychology, Dr. Kripalani received an MD with honors from Baylor College of Medicine in 1997. He completed his residency in Internal Medicine at Emory University in Atlanta in 2000, where he also completed one of the nation’s first Hospital Medicine Fellowships, including a Master of Science in Clinical Research.

Shaun Frost with SHM President Steve Pantilat.

Dr. Frost has dedicated himself to the advancement of clinical knowledge through clinical teaching and scientific publication. He is a member of the Regions Hospital Palliative Care Service and Patient Safety Committee, was a lead participant in a “Lean” implementation team on inpatient testing results, and was selected as the leafter of Regions Hospital “Best Care, Best Experience” work team on provider support. He is also currently participating in the development and implementation of inpatient “Prepared Practice Teams,” a model of multidisciplinary rounding to enhance communication among physicians, nurses, case managers, social workers, and pharmacists.

A teaching faculty member of the University of Minnesota Medical School, he is highly regarded by residents and medical students, and has been instrumental in developing curricula in perioperative medicine for residents to improve the systems of surgical care through education.

Dr. Frost is a frequent lecturer on topics ranging from perioperative medicine to venous thromboembolism and has been published in: Annals of Internal Medicine, JAMA, Medical Clinics of North America, Mayo Clinic Proceedings, Cleveland Clinic Journal of Medicine, and The Hospitalist. He currently is lead investigator for a trial on preoperative medication administration.

Dr. Frost has demonstrated consistent leadership within SHM. He is regarded as the definitive resource in local chapter development due to his work in the SHM Lake Erie Chapter, where he was founder and president. He also is credited with establishing the very first formal chapter of SHM. His vision for the future of chapter activities – including community service and a national recognition program – resulted in a Membership Committee task force on chapter development. As a leader in the Midwest SHM region, Dr. Frost was named a Councilor to the SHM Midwest Council. His outstanding performance led to his assuming the chair of the Council in 2004. Dr. Frost is also recognized as a subject matter expert in biomedical ethics, serving consecutive terms on the Ethics Committee as well.

Dr. Frost earned his MD at the University of Texas Southwestern Medical School in Dallas as an AOA graduate, and completed his residency in Internal Medicine there. From 1998 through 2004, as a hospitalist at Cleveland Clinic Foundation, he was a contributor to the development, maturation, and operation of its hospital medicine model of care.

Joseph Ming Wah Li with SHM President Steve Pantilat.

Dr. Li was the first hospitalist at the Beth Israel Deaconess Hospital Medicine Program in 1998. There he helped define the role of an academic hospitalist through clinical work, teaching, and service on countless committees and hospital initiatives. He quickly distinguished himself and was made associate chief of the HCA/ACOVE medical teaching

firm and, more recently, director of the BIDMC Hospital Medicine Program. A key focus for Dr. Li was broadening the Hospital Medicine Program at BIDMC. Under his guidance, the program grew to eleven hospitalists that account for over 50% of all general medicine admissions and over 50% of teaching attending months on the medical service. He also developed a system that allowed staff to provide 24/7 seamless coverage and created a website of referring physicians. He initiated new clinical programs and working arrangements for the hospitalist team, and helped institute a program to staff a local hospital with Beth Israel Deaconess hospitalists.

Dr. Li’s advocacy for Hospital Medicine did not stop at the doors of BIDMC, however. He was a co-developer of the first Harvard Medical School CME course on the emerging role of hospital medicine, and was the cofounder of the Boston Area Hospitalists and the SHM Northeast Regional Chapter of hospitalists. A charter member of SHM, he co-directed the first SHM annual northeastern regional meeting in 2001. He currently is a member of the SHM Education Committee, Annual Meeting Committee, and Membership Committee Task Force.

A nationally recognized expert in hospital medicine, Dr. Li lectures extensively and has testified on hearings dealing with mandatory hospitalist programs. He has published numerous articles in Critical Pathways in Cardiology, WebMD, Infectious Diseases in Clinical Practice, Current Opinion in Pulmonary Medicine, and Medscape.com, to name a few.

After earning his MD from the University of Oklahoma in Oklahoma City in 1994, Dr. Li did his residency at New England Deaconess Hospital before becoming chief medical resident at Beth Israel Deaconess Medical Center.

Jeff Wiese with SHM President Steve Pantilat.

Dr. Wiese has received 21 awards for teaching over the last five years, including six from the University of California at San Francisco, where he started his career in 1998 as a clinical instructor. Since joining Tulane University in 2000, he has earned 16 teaching awards, including the prestigious all Tulane Faculty of the Year Award (twice) and the Virginia Furrow Award for Innovation in Medical Education. On the clinical wards, he has twice won Attending of the Year honors, and his Professor Rounds are routinely rated among the best.

Dr. Wiese designed numerous innovative curriculums. As a result of his clinical diagnosis innovations, the Clinical Diagnosis scores at Tulane increased from the 46th percentile to the 80th and 82nd percentile, with 10% of the 2004 class scoring in the top percentile in the nation. As a result of his restructuring of core curriculum to emphasize rational, evidenced based medical decision making, Tulane’s internal medicine program recently went the highest on its match list in the past 20 years. And through Dr. Wiese’s pyramid mentor system, Tulane Internal Medicine presented more regional and national presentations than any residency program in the country.

Dr. Wiese has written over 50 articles, books, or book chapters, is assistant editor for two educational textbooks and a reviewer for six national journals, has authored two textbooks, and is on the editorial board for a monthly publication. As an active SHM member, he has served on the Education Committee, Southern SHM Committee, and was program director for SHM’s Intensive Care Pre-course.

Dr. Wiese received his MD from Johns Hopkins School of Medicine in 1995. He completed his residency and chief residency training in Internal Medicine at the University of California at San Francisco, where he also completed a fellowship in General Internal Medicine with a focus on Hospitalist Medicine. He joined Tulane in 2000, after being recruited to start a hospitalist system at the Medical Center of Louisiana at New Orleans (Charity Hospital). His hospitalist proposal was accepted by the state and hospital administration, helping to provide funding to hospitalists at Charity.

Please join us in congratulating all of this year’s outstanding award winners.

Steven Pantilat, MD, assumed the role of SHM’s new president at the 2005 Annual Meeting, along with a slate of other newly elected officers, including: Mary Jo Gorman, MD, MBA, president elect, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary. “These are exciting times of growth for SHM and hospital medicine,” said Jeanne Huddleston, MD, SHM’s immediate past president. “So we’re thrilled to bring on a team of extraordinary leaders who have long demonstrated their commitment to our organization’s goals and to the hospital medicine movement.”

Steven Pantilat, MD

“I’m extremely pleased to have this opportunity to lead SHM at this critical juncture,” said new President Dr. Pantilat. “Hospitalists are leading breakthrough initiatives around the country in areas such as patient safety, hospital leadership, and quality of care. But there are other important areas where we can make a difference. My goals for SHM this year are twofold. First, I plan to promote research in hospital medicine to discover how best to improve the quality of care for hospitalized patients. Second, I have appointed a Palliative Care Task force to examine how hospitalists can improve the care of patients with serious and life threatening illnesses.”

Dr. Pantilat is an associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco. He also is a hospitalist attending on the medical service and is the founding director of both the Palliative Care Consult Service and the Comfort Care Suites, a 2-bed inpatient palliative care unit at UCSF. Dr. Pantilat is a full-time faculty member in the Program in Medical Ethics at UCSF, a faculty scholar of the Soros Foundation Project on Death in America and a recipient of a research career development award from the National Institute on Aging. Dr. Pantilat is also the director of the UCSF Palliative Care leadership Center, which trains teams from hospitals across the country to develop and implement palliative care services in their own institutions.

In addition to his research on improving palliative care, Dr. Pantilat teaches palliative care at UCSF and is coeditor of an end of life care series in the Journal of the American Medical Association (JAMA) titled “Perspectives on Care at the Close of Life.”

A charter member of SHM, Dr. Pantilat has served in numerous leadership positions through the years, including as first chair of the SHM Ethics Committee, member of the Board of Directors and treasurer.

Mary Jo Gorman, MD

SHM President-elect Mary Jo Gorman, MD, MBA, is chief medical officer for IPC The Hospitalist Company, a private practice hospital medicine company. There she works with more than 300 physicians in developing programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and

clinical studies.

Dr. Gorman has been a practicing hospitalist since 1997, when she founded the first hospital medicine practice in St. Louis, MO. Her original group merged into IPC in January 1999 and since that time has grown to become the dominant hospital medicine group in the city. Dr. Gorman is a charter member of SHM and has served on multiple committees, including chairman of the Public Policy Committee.

William Atchley, MD

New Treasurer William Atchley, MD is the director of the hospital medicine service at Sentara Careplex Hospital in Hampton, VA. He has been a practicing hospitalist since 1995, when he founded the hospital medicine practice for Sentara Medical Group in Norfolk, VA. The program grew to provide coverage to three local hospitals. He also helped to create the Division of Hospital Medicine in Sentara Medical Group. In 2002 he led Sentara Medical Group to start the hospital medicine service at Sentara Careplex Hospital. At that time he founded Peninsula Inpatient Medicine Specialists, which now has eight hospitalists.

Dr. Atchley is a charter member of SHM and had previously served as secretary since 2003. He also serves the organization as chair of the Awards Committee and a member of the Finance Committee and the Southern Regional Council. He previously served on the Benchmarks and Compensation Task Force, Membership Committee and the Annual Session Planning Committee.

Lisa Kettering, MD

Secretary Lisa Kettering, MD, FACP, is associate director of Inpatient Services for the Department of Graduate Medical Education, Internal Medicine, at Exempla Saint Joseph Hospital in Denver. She also serves as director of the Evidence Based Medicine Curriculum for the Exempla Saint Joseph Hospital Internal Medicine residency program and is an assistant clinical professor in the Department of Internal Medicine at the University of Colorado School of Medicine.

Dr. Kettering is a charter member of SHM and was elected to the board in 2003. She has also served as chair of the Membership Committee from 20032005, and course director for the 6th Annual Meeting. She has served on the Awards Committee, Nominations Committee, Annual Meeting Planning Committee, and the Education Committee. She currently is a member of the Western Regional Council and is president of the Rocky Mountain Chapter of SHM.

Please join us in congratulating all the new officers.

Steven Pantilat, MD, assumed the role of SHM’s new president at the 2005 Annual Meeting, along with a slate of other newly elected officers, including: Mary Jo Gorman, MD, MBA, president elect, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary. “These are exciting times of growth for SHM and hospital medicine,” said Jeanne Huddleston, MD, SHM’s immediate past president. “So we’re thrilled to bring on a team of extraordinary leaders who have long demonstrated their commitment to our organization’s goals and to the hospital medicine movement.”

Steven Pantilat, MD

“I’m extremely pleased to have this opportunity to lead SHM at this critical juncture,” said new President Dr. Pantilat. “Hospitalists are leading breakthrough initiatives around the country in areas such as patient safety, hospital leadership, and quality of care. But there are other important areas where we can make a difference. My goals for SHM this year are twofold. First, I plan to promote research in hospital medicine to discover how best to improve the quality of care for hospitalized patients. Second, I have appointed a Palliative Care Task force to examine how hospitalists can improve the care of patients with serious and life threatening illnesses.”

Dr. Pantilat is an associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco. He also is a hospitalist attending on the medical service and is the founding director of both the Palliative Care Consult Service and the Comfort Care Suites, a 2-bed inpatient palliative care unit at UCSF. Dr. Pantilat is a full-time faculty member in the Program in Medical Ethics at UCSF, a faculty scholar of the Soros Foundation Project on Death in America and a recipient of a research career development award from the National Institute on Aging. Dr. Pantilat is also the director of the UCSF Palliative Care leadership Center, which trains teams from hospitals across the country to develop and implement palliative care services in their own institutions.

In addition to his research on improving palliative care, Dr. Pantilat teaches palliative care at UCSF and is coeditor of an end of life care series in the Journal of the American Medical Association (JAMA) titled “Perspectives on Care at the Close of Life.”

A charter member of SHM, Dr. Pantilat has served in numerous leadership positions through the years, including as first chair of the SHM Ethics Committee, member of the Board of Directors and treasurer.

Mary Jo Gorman, MD

SHM President-elect Mary Jo Gorman, MD, MBA, is chief medical officer for IPC The Hospitalist Company, a private practice hospital medicine company. There she works with more than 300 physicians in developing programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and

clinical studies.

Dr. Gorman has been a practicing hospitalist since 1997, when she founded the first hospital medicine practice in St. Louis, MO. Her original group merged into IPC in January 1999 and since that time has grown to become the dominant hospital medicine group in the city. Dr. Gorman is a charter member of SHM and has served on multiple committees, including chairman of the Public Policy Committee.

William Atchley, MD

New Treasurer William Atchley, MD is the director of the hospital medicine service at Sentara Careplex Hospital in Hampton, VA. He has been a practicing hospitalist since 1995, when he founded the hospital medicine practice for Sentara Medical Group in Norfolk, VA. The program grew to provide coverage to three local hospitals. He also helped to create the Division of Hospital Medicine in Sentara Medical Group. In 2002 he led Sentara Medical Group to start the hospital medicine service at Sentara Careplex Hospital. At that time he founded Peninsula Inpatient Medicine Specialists, which now has eight hospitalists.

Dr. Atchley is a charter member of SHM and had previously served as secretary since 2003. He also serves the organization as chair of the Awards Committee and a member of the Finance Committee and the Southern Regional Council. He previously served on the Benchmarks and Compensation Task Force, Membership Committee and the Annual Session Planning Committee.

Lisa Kettering, MD

Secretary Lisa Kettering, MD, FACP, is associate director of Inpatient Services for the Department of Graduate Medical Education, Internal Medicine, at Exempla Saint Joseph Hospital in Denver. She also serves as director of the Evidence Based Medicine Curriculum for the Exempla Saint Joseph Hospital Internal Medicine residency program and is an assistant clinical professor in the Department of Internal Medicine at the University of Colorado School of Medicine.

Dr. Kettering is a charter member of SHM and was elected to the board in 2003. She has also served as chair of the Membership Committee from 20032005, and course director for the 6th Annual Meeting. She has served on the Awards Committee, Nominations Committee, Annual Meeting Planning Committee, and the Education Committee. She currently is a member of the Western Regional Council and is president of the Rocky Mountain Chapter of SHM.

Please join us in congratulating all the new officers.

Steven Pantilat, MD, assumed the role of SHM’s new president at the 2005 Annual Meeting, along with a slate of other newly elected officers, including: Mary Jo Gorman, MD, MBA, president elect, William Atchley, MD, FACP, treasurer, and Lisa Kettering, MD, FACP, secretary. “These are exciting times of growth for SHM and hospital medicine,” said Jeanne Huddleston, MD, SHM’s immediate past president. “So we’re thrilled to bring on a team of extraordinary leaders who have long demonstrated their commitment to our organization’s goals and to the hospital medicine movement.”

Steven Pantilat, MD

“I’m extremely pleased to have this opportunity to lead SHM at this critical juncture,” said new President Dr. Pantilat. “Hospitalists are leading breakthrough initiatives around the country in areas such as patient safety, hospital leadership, and quality of care. But there are other important areas where we can make a difference. My goals for SHM this year are twofold. First, I plan to promote research in hospital medicine to discover how best to improve the quality of care for hospitalized patients. Second, I have appointed a Palliative Care Task force to examine how hospitalists can improve the care of patients with serious and life threatening illnesses.”

Dr. Pantilat is an associate professor of clinical medicine in the Department of Medicine at the University of California, San Francisco. He also is a hospitalist attending on the medical service and is the founding director of both the Palliative Care Consult Service and the Comfort Care Suites, a 2-bed inpatient palliative care unit at UCSF. Dr. Pantilat is a full-time faculty member in the Program in Medical Ethics at UCSF, a faculty scholar of the Soros Foundation Project on Death in America and a recipient of a research career development award from the National Institute on Aging. Dr. Pantilat is also the director of the UCSF Palliative Care leadership Center, which trains teams from hospitals across the country to develop and implement palliative care services in their own institutions.

In addition to his research on improving palliative care, Dr. Pantilat teaches palliative care at UCSF and is coeditor of an end of life care series in the Journal of the American Medical Association (JAMA) titled “Perspectives on Care at the Close of Life.”

A charter member of SHM, Dr. Pantilat has served in numerous leadership positions through the years, including as first chair of the SHM Ethics Committee, member of the Board of Directors and treasurer.

Mary Jo Gorman, MD

SHM President-elect Mary Jo Gorman, MD, MBA, is chief medical officer for IPC The Hospitalist Company, a private practice hospital medicine company. There she works with more than 300 physicians in developing programs and strategies that enhance clinical performance and drive the delivery system towards more efficient care and greater patient satisfaction. She also oversees IPC’s physician training, mentoring and retention programs, as well as IPC’s call center nurses, healthcare services and

clinical studies.

Dr. Gorman has been a practicing hospitalist since 1997, when she founded the first hospital medicine practice in St. Louis, MO. Her original group merged into IPC in January 1999 and since that time has grown to become the dominant hospital medicine group in the city. Dr. Gorman is a charter member of SHM and has served on multiple committees, including chairman of the Public Policy Committee.

William Atchley, MD

New Treasurer William Atchley, MD is the director of the hospital medicine service at Sentara Careplex Hospital in Hampton, VA. He has been a practicing hospitalist since 1995, when he founded the hospital medicine practice for Sentara Medical Group in Norfolk, VA. The program grew to provide coverage to three local hospitals. He also helped to create the Division of Hospital Medicine in Sentara Medical Group. In 2002 he led Sentara Medical Group to start the hospital medicine service at Sentara Careplex Hospital. At that time he founded Peninsula Inpatient Medicine Specialists, which now has eight hospitalists.

Dr. Atchley is a charter member of SHM and had previously served as secretary since 2003. He also serves the organization as chair of the Awards Committee and a member of the Finance Committee and the Southern Regional Council. He previously served on the Benchmarks and Compensation Task Force, Membership Committee and the Annual Session Planning Committee.

Lisa Kettering, MD

Secretary Lisa Kettering, MD, FACP, is associate director of Inpatient Services for the Department of Graduate Medical Education, Internal Medicine, at Exempla Saint Joseph Hospital in Denver. She also serves as director of the Evidence Based Medicine Curriculum for the Exempla Saint Joseph Hospital Internal Medicine residency program and is an assistant clinical professor in the Department of Internal Medicine at the University of Colorado School of Medicine.

Dr. Kettering is a charter member of SHM and was elected to the board in 2003. She has also served as chair of the Membership Committee from 20032005, and course director for the 6th Annual Meeting. She has served on the Awards Committee, Nominations Committee, Annual Meeting Planning Committee, and the Education Committee. She currently is a member of the Western Regional Council and is president of the Rocky Mountain Chapter of SHM.

Please join us in congratulating all the new officers.