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Hospitalist Appointed HHS’ Director of Provider Outreach
Matthew Heinz, MD, a hospitalist from Tucson, Ariz., has been appointed director of provider outreach at the U.S. Department of Health and Human Services (HHS), a position the agency created specifically to educate the public on health-care policies.
A practicing hospitalist at Tucson Medical Center and a former Arizona state legislator, Dr. Heinz travels to Washington a couple of weekends a month to work directly with healthcare providers, community leaders, and LGBT groups to provide information about implementation of the Affordable Care Act (ACA), including its coverage options and the enrollment period that started Oct. 1. He then brings questions and concerns back to HHS Secretary Kathleen Sebelius directly.
"Serving as a resource for providers and the community is a great honor," Dr. Heinz says. "It is an exciting time to be part of the Department of Health and Human Services; so much is happening with healthcare due to the ACA."
As a hospitalist for seven years, he says he understands what it means to be uninsured in America and what it can do to families economically. "I see firsthand how profoundly the lack of health insurance affects my patients," he says. "We have to make implementing the Affordable Care Act a priority, as providers, to help these families and individuals get the medical care that they need.
"This kind of change [in policies] hasn't been attempted since Medicare in the 1970s," Dr. Heinz says of the ACA. "It is a unique time and place. I'm pleased and honored that I am able to serve in this way."
Visit our website for more information on how the Affordable Care Act will affect hospitalists.
Matthew Heinz, MD, a hospitalist from Tucson, Ariz., has been appointed director of provider outreach at the U.S. Department of Health and Human Services (HHS), a position the agency created specifically to educate the public on health-care policies.
A practicing hospitalist at Tucson Medical Center and a former Arizona state legislator, Dr. Heinz travels to Washington a couple of weekends a month to work directly with healthcare providers, community leaders, and LGBT groups to provide information about implementation of the Affordable Care Act (ACA), including its coverage options and the enrollment period that started Oct. 1. He then brings questions and concerns back to HHS Secretary Kathleen Sebelius directly.
"Serving as a resource for providers and the community is a great honor," Dr. Heinz says. "It is an exciting time to be part of the Department of Health and Human Services; so much is happening with healthcare due to the ACA."
As a hospitalist for seven years, he says he understands what it means to be uninsured in America and what it can do to families economically. "I see firsthand how profoundly the lack of health insurance affects my patients," he says. "We have to make implementing the Affordable Care Act a priority, as providers, to help these families and individuals get the medical care that they need.
"This kind of change [in policies] hasn't been attempted since Medicare in the 1970s," Dr. Heinz says of the ACA. "It is a unique time and place. I'm pleased and honored that I am able to serve in this way."
Visit our website for more information on how the Affordable Care Act will affect hospitalists.
Matthew Heinz, MD, a hospitalist from Tucson, Ariz., has been appointed director of provider outreach at the U.S. Department of Health and Human Services (HHS), a position the agency created specifically to educate the public on health-care policies.
A practicing hospitalist at Tucson Medical Center and a former Arizona state legislator, Dr. Heinz travels to Washington a couple of weekends a month to work directly with healthcare providers, community leaders, and LGBT groups to provide information about implementation of the Affordable Care Act (ACA), including its coverage options and the enrollment period that started Oct. 1. He then brings questions and concerns back to HHS Secretary Kathleen Sebelius directly.
"Serving as a resource for providers and the community is a great honor," Dr. Heinz says. "It is an exciting time to be part of the Department of Health and Human Services; so much is happening with healthcare due to the ACA."
As a hospitalist for seven years, he says he understands what it means to be uninsured in America and what it can do to families economically. "I see firsthand how profoundly the lack of health insurance affects my patients," he says. "We have to make implementing the Affordable Care Act a priority, as providers, to help these families and individuals get the medical care that they need.
"This kind of change [in policies] hasn't been attempted since Medicare in the 1970s," Dr. Heinz says of the ACA. "It is a unique time and place. I'm pleased and honored that I am able to serve in this way."
Visit our website for more information on how the Affordable Care Act will affect hospitalists.
Hospitalist Appointed HHS’ Director of Provider Outreach
Matthew Heinz, MD, a hospitalist from Tucson, Ariz., has been appointed director of provider outreach at the U.S. Department of Health and Human Services (HHS), a position the agency created specifically to educate the public on health-care policies.
A practicing hospitalist at Tucson Medical Center and a former Arizona state legislator, Dr. Heinz travels to Washington a couple of weekends a month to work directly with healthcare providers, community leaders, and LGBT groups to provide information about implementation of the Affordable Care Act (ACA), including its coverage options and the enrollment period that started Oct. 1. He then brings questions and concerns back to HHS Secretary Kathleen Sebelius directly.
"Serving as a resource for providers and the community is a great honor," Dr. Heinz says. "It is an exciting time to be part of the Department of Health and Human Services; so much is happening with healthcare due to the ACA."
As a hospitalist for seven years, he says he understands what it means to be uninsured in America and what it can do to families economically. "I see firsthand how profoundly the lack of health insurance affects my patients," he says. "We have to make implementing the Affordable Care Act a priority, as providers, to help these families and individuals get the medical care that they need.
"This kind of change [in policies] hasn't been attempted since Medicare in the 1970s," Dr. Heinz says of the ACA. "It is a unique time and place. I'm pleased and honored that I am able to serve in this way."
Visit our website for more information on how the Affordable Care Act will affect hospitalists.
Matthew Heinz, MD, a hospitalist from Tucson, Ariz., has been appointed director of provider outreach at the U.S. Department of Health and Human Services (HHS), a position the agency created specifically to educate the public on health-care policies.
A practicing hospitalist at Tucson Medical Center and a former Arizona state legislator, Dr. Heinz travels to Washington a couple of weekends a month to work directly with healthcare providers, community leaders, and LGBT groups to provide information about implementation of the Affordable Care Act (ACA), including its coverage options and the enrollment period that started Oct. 1. He then brings questions and concerns back to HHS Secretary Kathleen Sebelius directly.
"Serving as a resource for providers and the community is a great honor," Dr. Heinz says. "It is an exciting time to be part of the Department of Health and Human Services; so much is happening with healthcare due to the ACA."
As a hospitalist for seven years, he says he understands what it means to be uninsured in America and what it can do to families economically. "I see firsthand how profoundly the lack of health insurance affects my patients," he says. "We have to make implementing the Affordable Care Act a priority, as providers, to help these families and individuals get the medical care that they need.
"This kind of change [in policies] hasn't been attempted since Medicare in the 1970s," Dr. Heinz says of the ACA. "It is a unique time and place. I'm pleased and honored that I am able to serve in this way."
Visit our website for more information on how the Affordable Care Act will affect hospitalists.
Matthew Heinz, MD, a hospitalist from Tucson, Ariz., has been appointed director of provider outreach at the U.S. Department of Health and Human Services (HHS), a position the agency created specifically to educate the public on health-care policies.
A practicing hospitalist at Tucson Medical Center and a former Arizona state legislator, Dr. Heinz travels to Washington a couple of weekends a month to work directly with healthcare providers, community leaders, and LGBT groups to provide information about implementation of the Affordable Care Act (ACA), including its coverage options and the enrollment period that started Oct. 1. He then brings questions and concerns back to HHS Secretary Kathleen Sebelius directly.
"Serving as a resource for providers and the community is a great honor," Dr. Heinz says. "It is an exciting time to be part of the Department of Health and Human Services; so much is happening with healthcare due to the ACA."
As a hospitalist for seven years, he says he understands what it means to be uninsured in America and what it can do to families economically. "I see firsthand how profoundly the lack of health insurance affects my patients," he says. "We have to make implementing the Affordable Care Act a priority, as providers, to help these families and individuals get the medical care that they need.
"This kind of change [in policies] hasn't been attempted since Medicare in the 1970s," Dr. Heinz says of the ACA. "It is a unique time and place. I'm pleased and honored that I am able to serve in this way."
Visit our website for more information on how the Affordable Care Act will affect hospitalists.
MARQUIS Highlights Need for Improved Medication Reconciliation
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.1
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website. TH
Larry Beresford is a freelance writer in San Francisco.
Reference
1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.1
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website. TH
Larry Beresford is a freelance writer in San Francisco.
Reference
1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.1
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website. TH
Larry Beresford is a freelance writer in San Francisco.
Reference
1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.
Hospitalists Should Take Wait-and-See Approach to Newly Approved Medications
Wait-and-See Approach Best for Newly Approved Meds
I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?
–David Ray, MD
Dr. Hospitalist responds:
I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.
I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.
Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.
This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.
In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.
In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.
In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
Wait-and-See Approach Best for Newly Approved Meds
I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?
–David Ray, MD
Dr. Hospitalist responds:
I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.
I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.
Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.
This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.
In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.
In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.
In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
Wait-and-See Approach Best for Newly Approved Meds
I am a new hospitalist, out of residency for two years, and feel very uncertain about using new or recently approved medications on my patients. Do you have any suggestions about how or when new medications should be used in practice?
–David Ray, MD
Dr. Hospitalist responds:
I certainly can understand your trepidation about using newly approved medications. Although our system of evaluating and approving medications for clinical use is considered the most rigorous in the world, 16 so-called novel medications were pulled from the shelves from 2000 to 2010, which equates to 6% of the total approved during that period. All in all, not a bad ratio, but the number of poor outcomes associated with a high-profile dud can be astronomical.
I think there are several major reasons why we have adverse issues with medications that have survived the rigors of the initial FDA approval process. First, many human drug trials are conducted in developing countries, where the human genome is much more homogenous and the liabilities for injuries are way less than in the U.S. Many researchers have acknowledged the significant role of pharmacogenomics, and how each physiology and pathology is unique. Couple these with the tendency to test drugs one at a time in younger cohorts—very few medications are administered in this manner in the U.S.—and one can quickly see how complex the equation becomes.
Another reason is the influence relegated to clinical trials. All clinicians should be familiar with the stages (0 to 4) and processes of how the FDA analyzes human drug trials. The FDA usually requires that two “adequate and well-controlled” trials confirm that a drug is safe and effective before it approves it for sale to the public. Once a drug completes Stage 3, an extensive statistical analysis is conducted to assure a drug’s demonstrated benefit is real and not the result of chance. But as it turns out, because the measured effects in most clinical trials are so small, chance is very hard to prove or disprove.
This was astutely demonstrated in a 2005 article published in the Journal of the American Medical Association (2005;294(2):218-228). John P. Ioannidis, MD, examined the results of 49 high-profile clinical-research studies in which 45 found that proposed intervention was effective. Of the 45 claiming effectiveness, seven (16%) were contradicted by subsequent studies, and seven others had found effects that were stronger than those of subsequent studies. Of the 26 randomly controlled trials that were followed up by larger trials, the initial finding was entirely contradicted in three cases (12%); another six cases (23%) found the benefit to be less than half of what had been initially reported.
In most instances, it wasn’t the therapy that changed but the sample size. In fact, many clinicians and biostatisticians believe many more so-called “evidence-based” practices or medicinals would be legitimately challenged if subjected to rigorous follow-up studies.
In my own personal experience as a hospitalist, I can think of two areas where the general medical community accepted initial studies only to refute them later: perioperative use of beta-blockers and inpatient glycemic control.
In light of the many high-profile medications that have been pulled from the market, I don’t like being in the first group to jump on the bandwagon. My general rule is to wait three to five years after a drug has been released before prescribing for patients. As always, there are exceptions. In instances where new medications have profound or life-altering potential (i.e. the new anticoagulants or gene-targeting meds for certain cancers) and the risks are substantiated, I’m all in!
Do you have a problem or concern that you’d like Dr. Hospitalist to address? Email your questions to [email protected].
MGMA Surveys Make Hospitalists' Productivity Hard to Assess
The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).
For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.
In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.
More Details on FTE Definition
MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.
For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.
I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.
As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).
Data Application
My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.
Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.
It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.
Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.
Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.
Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.
Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.
Does It Really Matter?
The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).
For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.
In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.
More Details on FTE Definition
MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.
For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.
I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.
As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).
Data Application
My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.
Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.
It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.
Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.
Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.
Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.
Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.
Does It Really Matter?
The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
The Medical Group Management Association (MGMA) surveys regard both a doctor who works the standard number of annual shifts their practice defines as full time, and a doctor who works many extra shifts, as one full-time equivalent (FTE). This can cause confusion when assessing productivity per FTE (see “SHM and MGMA Survey History,” right).
For example, consider a hospitalist who generated 4,000 wRVUs while working 182 shifts—the standard number of shifts to be full time in that doctor’s practice—during the survey year. In the same practice, another hospitalist worked 39 extra shifts over the same year for a total of 220 shifts, generating 4,860 wRVUs. If the survey contained only these two doctors, it would show them both as full time, with an average productivity per FTE of 4,430 wRVUs. But that would be misleading because 1.0 FTE worth of work as defined by their practice for both doctors would have come to 4,000 wRVUs generated while working 182 shifts.
In prior columns, I’ve highlighted some other numbers in hospitalist productivity and compensation surveys that can lead to confusion. But the MGMA survey methodology, which assigns a particular FTE to a single doctor, may be the most confusing issue, potentially leading to meaningful misunderstandings.
More Details on FTE Definition
MGMA has been conducting physician compensation and productivity surveys across essentially all medical specialties for decades. Competing organizations conduct similar surveys, but most regard the MGMA survey as the most relevant and valuable.
For a long time, MGMA has regarded as “full time” any doctor working 0.75 FTE or greater, using the respondent practice’s definition of an FTE. No single doctor can ever be counted as more than 1.0 FTE, regardless of how much extra the doctor may have worked. Any doctor working 0.35-0.75 FTE is regarded as part time, and those working less than 0.35 FTE are excluded from the survey report. The fact that each practice might have a different definition of what constitutes an FTE is addressed by having a large number of respondents in most medical specialties.
I’m uncertain how MGMA ended up not counting any single doctor as more than 1.0 FTE, even when they work a lot of extra shifts. But my guess is that for the first years, or even decades, that MGMA conducted its survey, few, if any, medical practices even had a strict definition of what constituted 1.0 FTE and simply didn’t keep track of which doctors worked extra shifts or days. So even if MGMA had wanted to know, for example, when a doctor worked extra shifts and should be counted as more than 1.0 FTE, few if any practices even thought about the precise number of shifts or days worked constituting full time versus what was an “extra” shift. So it probably made sense to simply have two categories: full time and part time.
As more practices began assigning FTE with greater precision, like nearly all hospitalist practices do, then using 0.75 FTE to separate full time and part time seemed practical, though imprecise. But keep in mind it also means that all of the doctors who work from 0.75 to 0.99 FTE (that is, something less than 1.0) offset, at least partially, those who work lots of extra shifts (i.e., above 1.0 FTE).
Data Application
My anecdotal experience is that a large portion of hospitalists, probably around half, work more shifts than what their practice regards as full time. I don’t know of any survey database that quantifies this, but my guess is that 25% to 35% of full-time hospitalists work extra shifts at their own practice, and maybe another 15% to 20% moonlight at a different practice. Let’s consider only those in the first category.
Chronic staffing shortages is one of the reasons hospitalists so commonly work extra shifts at their own practice. Extra shifts are sometimes even required by the practice to make up for open positions. And in some places, the hospitalists choose not to fill positions to preserve their ability to continue working more than the number of shifts required to be full time.
It would be great if we had a precise way to adjust the MGMA survey data for hospitalists who work above 1.0 FTE. For example, let’s make three assumptions so that we can then adjust the reported compensation and productivity data to remove the effect of the many doctors working extra shifts, thereby more clearly matching 1.0 FTE. These numbers are my guesses based on lots of anecdotal experience. But they are only guesses. Don’t make too much of them.
Assume 25% of hospitalists nationally work an average of 20% more than the full-time number of shifts for their practice. That is my best guess and intentionally leaves out those who moonlight for a practice other than their own.
Some portion of those working extra shifts (above 1.0 FTE) is offset by survey respondents working between 0.75 and 1.0 FTE, resulting in a wild guess of a net 20% of hospitalists working extra shifts.
Last, let’s assume that their productivity and compensation on extra shifts is identical to their “normal” shifts. This is not true for many practices, but when aggregating the data, it is probably reasonably close.
Using these assumptions (guesses, really), we can decrease both the reported survey mean and median productivity and compensation by about 5% to more accurately reflect results for hospitalists doing only the number of shifts required by the practice to be full time—no extra shifts. I’ll spare you the simple math showing how I arrived at the approximately 5%, but basically it is removing the 20% additional compensation and productivity generated by the net 20% of hospitalists who work extra shifts above 1.0 FTE.
Does It Really Matter?
The whole issue of hospitalists working many extra shifts yet only counting as 1.0 FTE in the MGMA survey might matter a lot for some, and others might see it as useless hand-wringing. As long as a meaningful number of hospitalists work extra shifts, then survey values for productivity and compensation will always be a little higher than the “average” 1.0 FTE hospitalists working no extra shifts. But it may still be well within the range of error of the survey anyway. And the compensation per unit of work (wRVUs or encounters) probably isn’t much affected by this FTE issue.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course. Write to him at [email protected].
Hospitalists as Industrial Engineers
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Wikipedia defines “industrial engineering” as a branch of engineering that deals with the optimization of complex processes or systems. It goes on to link industrial engineering to “operations” and use of quantitative methods to “specify, predict, and evaluate” results. Any hospitalist that’s been tapped to reduce length of stay, help manage readmissions, implement an electronic health record, or increase the quality of care likely can relate to that definition. It seems to me that hospitalists often are the de facto industrial engineers in many of our hospitals.
The hospitalist as an industrial engineer makes perfect sense. What other group of physicians, nurse practitioners, and physician assistants provide services in virtually any clinical venue, from ED to DC, from (occasionally) PACU to ICU, the wards, and even post-discharge? Hospitalists see it all, from the first few hours of life (pediatrics) to life’s last stages (palliative care) and all stages in between. As a parody to “there’s an app for that,” Dr. Mindy Kantsiper, a hospitalist in Columbia, Md., says if there’s something that needs to be fixed, “there’s a hospitalist for that.” We are the Swiss Army knives of the medical world.
Looking through the HMX “Practice Management” discussions on the SHM website (www.hospitalmedicine.com/xchange) confirms my belief. Topics are as varied as using RNs in hospitalist practices, medication reconciliation, billing, outpatient orders (!!) after discharge, and patient-centered care/patient satisfaction. And that was just the last two weeks!
Type “hospitalist” into PubMed, and the words that auto-populate are: model, care, quality, discharge, communication, program, and handoff—all words I think of as system-related issues. Oh, sure, there are clinical-related topics, too, of course, just like for the “organ-based” specialties. However, none of the common organ-based specialties had any words auto-populate in PubMed that could be deemed related to “industrial engineering.”
Engineer Training
Like all engineers, we de facto industrial engineers need tools and skills to be effective at in our new engineering role. While we may not need slide rules and calculus like a more traditional engineer, many of the new skills we will need as industrial engineers were not taught in medical school, and the tools were not readily available for us to use in our training.
Fortunately, there are a plethora of options for us budding, de facto industrial engineers. Here are the ones I believe you will need and where to get them:
Skill No. 1: Negotiation.
HM is a team sport, and teams bring interpersonal dynamics and tension and conflict. Effective negotiation skills can help hospitalists use conflict to spur team growth and development rather than team dysfunction.
Tools: SHM’s Leadership Academies have effective negotiation modules in each of the leveled courses. If you can’t spare the time, then books to read include “Getting to Yes” by Fisher and Ury, or “Renegotiating Health Care” by Leonard Marcus (he lectures at SHM’s leadership academies).
Skill No. 2: Data analytics.
All engineers, including industrial engineers, need to be able to evaluate. Whether it’s quality and safety, clinical operations, or financial improvement, if you don’t measure it, you can’t change it. Some of the data will be handed to you, and you need to know the strengths and weaknesses to best interpret it. Some data you will need to define and develop measurement systems for on your own, and even basic dashboard development requires understanding data.
Tools: Wow. There are a lot here, so I am only going to mention the highlights. You could get your MBA, or MPH, or even a PhD! You certainly could train to become a “true” diploma-carrying industrial engineer. And I know of a few insightful hospitals that employ them. A less in-depth, but cheaper and faster, option is to take specific courses related to your area of interest.
The SHM-AAIM Quality and Safety Educators Academy and SHM’s Leadership Academies are two great examples. Participating in a mentored project (i.e., Project BOOST) provides structure and an experienced mentor with a cadre of experts to back them up. Many institutions have courses on data analytics, basic finance, and quality improvement. The easiest, cheapest, and probably the most common is to find a mentor at your own institution. CFOs, CNOs, CQOs, and CMOs often are eager to partner with clinicians—and frequently are delighted to talk about their areas of expertise.
Skill No. 3: Leadership.
I don’t know many leaders who were born that way. Most learned through experience and continuous self-improvement. Understanding your personality traits, the traits of others (as an introvert, I still am trying to understand how extroverts work, especially my wife), and how to get all of those different personalities to work together as a team is an important component of any team-based engineering success.
Tools: I have found the books “From Good to Great” by Jim Collins and “Switch” by Chip and Dan Heath to be invaluable. I think another one of my recent reads, “Drive” by Daniel Pink, had important lessons, too. Formal courses, such as SHM’s Leadership Academies, QSEA, and those offered by the American Hospital Association, are designed to provide hospitalists with the leadership skills they need in a variety of hospital environments.
Skill No. 4: Thinking “system” instead of “individual.”
So many of us were trained that to make improvements, we just need to “be better,” to know more, try harder, and to work longer. Good industrial engineers design systems that make it easier for our doctors, healthcare providers, and patients to succeed. Of course, we need to be accountable, too, but supportive systems are a key component to successful individuals. The airline industry learned this long ago.
Tools: I really think “Switch” is an excellent read for those of us trying to help re-engineer our complex systems. It discusses how humans are both rational and emotional, and how our environment can help both sides succeed. Another helpful tool for me is asking “why” whenever someone says “if only they would do something differently for a better outcome…”
For example, “if only the hospitalists would discharge before 2 p.m.,” or “if only the ED didn’t clump their admissions,” or “if only the nurse didn’t call during rounds”—these are all classic systems problems, not people problems, and the solution isn’t to mandate 2 p.m. discharges, or stand up in a meeting finger pointing at the ED, or admonish a nurse for calling during rounds. The solution is to find out why these behaviors occur, then eliminate, change, or minimize the reasons.
Hospitalists don’t discharge by 2 p.m. often because they are waiting on tests; ED docs work in an environment that has highly variable workloads, coupled with dysfunctional systems that promote “batching” work patterns; and nurses may not be included in rounds but still need to be able to manage minute-to-minute patient-care needs. Sure, there are a few bad apples that need to be scolded, but I bet most of the issues at your hospital aren’t related to evildoers but good people who are often trapped in dysfunctional, antiquated systems and are just trying to do the best they can for their patients.
In Closing
I’d like to say thank you to all of the “de facto” industrial engineers out there. Keep up the critically important work of that most complex system—the hospital.
Dr. Howell is president of SHM, chief of the division of hospital medicine at Johns Hopkins Bayview in Baltimore, and spends a significant part of his time and research on hospital operations. Email questions or comments to [email protected].
Hospitalist James O’Callaghan Finds Career Satisfaction in Pediatric Medicine
It took a while for James J. O’Callaghan, MD, FAAP, FHM, to settle on a career path. First, he pursued the life of a chemical engineer. Then, in his third year at Rensselaer Polytechnic Institute in Troy, N.Y., he realized the kind of job he would be getting into was not quite for him. His then-girlfriend was a pre-med student, and it wasn’t long until he switched majors.
Hospital medicine drew his interest during residency, when he spent a monthlong rotation with a small group of physicians at a community hospital in Cleveland.
“Their days consisted of rounding on pediatric inpatients, examining normal newborns, completing pediatric consults in the ED, and performing minor procedures on the floor,” he says. “To me, it seemed the perfect job.”
Dr. O’Callaghan married an adult-medicine hospitalist and moved to Seattle, but he could not find a good fit in a hospitalist practice. He did private practice for two years, and in 2004, he landed a position in pediatric hospital medicine.
“I quickly changed career paths,” he says.
Dr. O’Callaghan is now a regional pediatric hospitalist at Evergreen Hospital in Kirkland, Wash., and a medical hospitalist at Seattle Children’s Hospital. He is a clinical assistant professor at the University of Washington and one of nine new Team Hospitalist members, The Hospitalist’s volunteer editorial advisory group.
As the section head for pediatrics at Evergreen, Dr. O’Callaghan spends most of his time seeing patients. However, he has in recent years developed a keen interest in quality improvement (QI). He’s the lead pediatric hospitalist on two clinical pathways at Seattle Children’s and has been an active member of SHM’s Hospital Quality and Patient Safety Committee since 2012.
“I want to continue to expand on this QI work,” he says, “with the goal of developing into a formal QI role at either, or both, hospitals.”
Question: What do you like most about working as a hospitalist?
Answer: I like the fact that the work I am doing as a hospitalist can have both an immediate impact on a single patient and a prolonged impact on multiple patients. I can admit a child with community-acquired pneumonia and, through my treatment, prevent serious sequelae from developing. However, I can also develop an evidenced-based, community-acquired pneumonia pathway and, potentially, affect the care of hundreds of children. There is immediate gratification in treating today’s patient and delayed gratification knowing that you are helping many of tomorrow’s patients.
Q: What do you dislike?
A: One of the hardest parts of a career in HM is trying to effect culture change. Hospital systems are typically large, complex organizations with their own culture. In order to successfully produce sustainable, long-term improvement, you must change this culture. You can perform a robust search of the literature to produce a brilliant clinical-care path, but unless you can affect behavior, your work and effort may not last. It can be frustrating to think you have the answer to a clinical problem only to see your effort fail because you could not change culture.
Q: What’s the biggest change you’ve seen in HM in your career?
A: In the early years, much of the conversation in HM was centered on the viability of a career in HM. Could one make a sustainable career in HM? Would hospitals and health systems continue to support physicians in HM? The biggest change I have seen is that we are no longer having those conversations. Now, the conversations are focused on determining which areas of medicine will be owned by HM: First it was QI work, then patient safety, and now resource utilization and cost containment. We are no longer spending time and energy worrying about the future of HM, but rather now our efforts are focused on the present work of HM. As a sustainable career, HM is here to stay.
Q: For group leaders, why is it important for you to continue seeing patients?
A: In my QI work, I have studied Lean thinking and methodology. Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work. Effective solutions must come from those actually doing the work, rather than from those managing the work from above.
Q: What does it mean to you to be elected a Fellow in Hospital Medicine?
A: It meant that I had committed fully to a career in hospital medicine. I use the FHM designation proudly in all my communications, as a signal to others of my commitment and dedication to hospital medicine. Someday, I hope to earn the designation of SFHM, as a validation and recognition of my contributions to the field of pediatric hospital medicine.
Q: When you aren’t working, what is important to you?
A: After family, it is important for me to maintain a healthy lifestyle and stay in shape. I am able to commute to Seattle Children’s Hospital by bicycle and I try to run two to three times a week. I squeeze in half-marathons and marathons, along with century [100 miles] and double-century bicycle rides each year.
Q: If you weren’t a doctor, what would you be doing right now?
A: I would love to be a stay-at-home father for my boys and also devote the time and energy into pursuing a career in trail running.
Q: What’s the best book you’ve read recently?
A: I recently read Jim Collins’ “Good to Great” as part of a management training course at Seattle Children’s Hospital. This easy-to-read, highly entertaining book clearly demonstrates the culture changes that need to occur for companies to move from good to great. As a field, hospital medicine, with its focus on QI work and patient safety, is now in the midst of trying to become “great.”
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: As many as possible. My wife and I own two iPhones, two iPads, and a MacBook Air, which she thinks we share but, in actuality, is mine. We are hoping to purchase a Mac desktop, and then we will have fully given over to the dark side.
Richard Quinn is a freelance writer in New Jersey.
It took a while for James J. O’Callaghan, MD, FAAP, FHM, to settle on a career path. First, he pursued the life of a chemical engineer. Then, in his third year at Rensselaer Polytechnic Institute in Troy, N.Y., he realized the kind of job he would be getting into was not quite for him. His then-girlfriend was a pre-med student, and it wasn’t long until he switched majors.
Hospital medicine drew his interest during residency, when he spent a monthlong rotation with a small group of physicians at a community hospital in Cleveland.
“Their days consisted of rounding on pediatric inpatients, examining normal newborns, completing pediatric consults in the ED, and performing minor procedures on the floor,” he says. “To me, it seemed the perfect job.”
Dr. O’Callaghan married an adult-medicine hospitalist and moved to Seattle, but he could not find a good fit in a hospitalist practice. He did private practice for two years, and in 2004, he landed a position in pediatric hospital medicine.
“I quickly changed career paths,” he says.
Dr. O’Callaghan is now a regional pediatric hospitalist at Evergreen Hospital in Kirkland, Wash., and a medical hospitalist at Seattle Children’s Hospital. He is a clinical assistant professor at the University of Washington and one of nine new Team Hospitalist members, The Hospitalist’s volunteer editorial advisory group.
As the section head for pediatrics at Evergreen, Dr. O’Callaghan spends most of his time seeing patients. However, he has in recent years developed a keen interest in quality improvement (QI). He’s the lead pediatric hospitalist on two clinical pathways at Seattle Children’s and has been an active member of SHM’s Hospital Quality and Patient Safety Committee since 2012.
“I want to continue to expand on this QI work,” he says, “with the goal of developing into a formal QI role at either, or both, hospitals.”
Question: What do you like most about working as a hospitalist?
Answer: I like the fact that the work I am doing as a hospitalist can have both an immediate impact on a single patient and a prolonged impact on multiple patients. I can admit a child with community-acquired pneumonia and, through my treatment, prevent serious sequelae from developing. However, I can also develop an evidenced-based, community-acquired pneumonia pathway and, potentially, affect the care of hundreds of children. There is immediate gratification in treating today’s patient and delayed gratification knowing that you are helping many of tomorrow’s patients.
Q: What do you dislike?
A: One of the hardest parts of a career in HM is trying to effect culture change. Hospital systems are typically large, complex organizations with their own culture. In order to successfully produce sustainable, long-term improvement, you must change this culture. You can perform a robust search of the literature to produce a brilliant clinical-care path, but unless you can affect behavior, your work and effort may not last. It can be frustrating to think you have the answer to a clinical problem only to see your effort fail because you could not change culture.
Q: What’s the biggest change you’ve seen in HM in your career?
A: In the early years, much of the conversation in HM was centered on the viability of a career in HM. Could one make a sustainable career in HM? Would hospitals and health systems continue to support physicians in HM? The biggest change I have seen is that we are no longer having those conversations. Now, the conversations are focused on determining which areas of medicine will be owned by HM: First it was QI work, then patient safety, and now resource utilization and cost containment. We are no longer spending time and energy worrying about the future of HM, but rather now our efforts are focused on the present work of HM. As a sustainable career, HM is here to stay.
Q: For group leaders, why is it important for you to continue seeing patients?
A: In my QI work, I have studied Lean thinking and methodology. Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work. Effective solutions must come from those actually doing the work, rather than from those managing the work from above.
Q: What does it mean to you to be elected a Fellow in Hospital Medicine?
A: It meant that I had committed fully to a career in hospital medicine. I use the FHM designation proudly in all my communications, as a signal to others of my commitment and dedication to hospital medicine. Someday, I hope to earn the designation of SFHM, as a validation and recognition of my contributions to the field of pediatric hospital medicine.
Q: When you aren’t working, what is important to you?
A: After family, it is important for me to maintain a healthy lifestyle and stay in shape. I am able to commute to Seattle Children’s Hospital by bicycle and I try to run two to three times a week. I squeeze in half-marathons and marathons, along with century [100 miles] and double-century bicycle rides each year.
Q: If you weren’t a doctor, what would you be doing right now?
A: I would love to be a stay-at-home father for my boys and also devote the time and energy into pursuing a career in trail running.
Q: What’s the best book you’ve read recently?
A: I recently read Jim Collins’ “Good to Great” as part of a management training course at Seattle Children’s Hospital. This easy-to-read, highly entertaining book clearly demonstrates the culture changes that need to occur for companies to move from good to great. As a field, hospital medicine, with its focus on QI work and patient safety, is now in the midst of trying to become “great.”
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: As many as possible. My wife and I own two iPhones, two iPads, and a MacBook Air, which she thinks we share but, in actuality, is mine. We are hoping to purchase a Mac desktop, and then we will have fully given over to the dark side.
Richard Quinn is a freelance writer in New Jersey.
It took a while for James J. O’Callaghan, MD, FAAP, FHM, to settle on a career path. First, he pursued the life of a chemical engineer. Then, in his third year at Rensselaer Polytechnic Institute in Troy, N.Y., he realized the kind of job he would be getting into was not quite for him. His then-girlfriend was a pre-med student, and it wasn’t long until he switched majors.
Hospital medicine drew his interest during residency, when he spent a monthlong rotation with a small group of physicians at a community hospital in Cleveland.
“Their days consisted of rounding on pediatric inpatients, examining normal newborns, completing pediatric consults in the ED, and performing minor procedures on the floor,” he says. “To me, it seemed the perfect job.”
Dr. O’Callaghan married an adult-medicine hospitalist and moved to Seattle, but he could not find a good fit in a hospitalist practice. He did private practice for two years, and in 2004, he landed a position in pediatric hospital medicine.
“I quickly changed career paths,” he says.
Dr. O’Callaghan is now a regional pediatric hospitalist at Evergreen Hospital in Kirkland, Wash., and a medical hospitalist at Seattle Children’s Hospital. He is a clinical assistant professor at the University of Washington and one of nine new Team Hospitalist members, The Hospitalist’s volunteer editorial advisory group.
As the section head for pediatrics at Evergreen, Dr. O’Callaghan spends most of his time seeing patients. However, he has in recent years developed a keen interest in quality improvement (QI). He’s the lead pediatric hospitalist on two clinical pathways at Seattle Children’s and has been an active member of SHM’s Hospital Quality and Patient Safety Committee since 2012.
“I want to continue to expand on this QI work,” he says, “with the goal of developing into a formal QI role at either, or both, hospitals.”
Question: What do you like most about working as a hospitalist?
Answer: I like the fact that the work I am doing as a hospitalist can have both an immediate impact on a single patient and a prolonged impact on multiple patients. I can admit a child with community-acquired pneumonia and, through my treatment, prevent serious sequelae from developing. However, I can also develop an evidenced-based, community-acquired pneumonia pathway and, potentially, affect the care of hundreds of children. There is immediate gratification in treating today’s patient and delayed gratification knowing that you are helping many of tomorrow’s patients.
Q: What do you dislike?
A: One of the hardest parts of a career in HM is trying to effect culture change. Hospital systems are typically large, complex organizations with their own culture. In order to successfully produce sustainable, long-term improvement, you must change this culture. You can perform a robust search of the literature to produce a brilliant clinical-care path, but unless you can affect behavior, your work and effort may not last. It can be frustrating to think you have the answer to a clinical problem only to see your effort fail because you could not change culture.
Q: What’s the biggest change you’ve seen in HM in your career?
A: In the early years, much of the conversation in HM was centered on the viability of a career in HM. Could one make a sustainable career in HM? Would hospitals and health systems continue to support physicians in HM? The biggest change I have seen is that we are no longer having those conversations. Now, the conversations are focused on determining which areas of medicine will be owned by HM: First it was QI work, then patient safety, and now resource utilization and cost containment. We are no longer spending time and energy worrying about the future of HM, but rather now our efforts are focused on the present work of HM. As a sustainable career, HM is here to stay.
Q: For group leaders, why is it important for you to continue seeing patients?
A: In my QI work, I have studied Lean thinking and methodology. Lean thinking teaches you that change and improvement do not come down from leadership, but rather develop up from front-line workers. Group leaders need to continue seeing patients to truly understand the processes and problems inherent in clinical work. Effective solutions must come from those actually doing the work, rather than from those managing the work from above.
Q: What does it mean to you to be elected a Fellow in Hospital Medicine?
A: It meant that I had committed fully to a career in hospital medicine. I use the FHM designation proudly in all my communications, as a signal to others of my commitment and dedication to hospital medicine. Someday, I hope to earn the designation of SFHM, as a validation and recognition of my contributions to the field of pediatric hospital medicine.
Q: When you aren’t working, what is important to you?
A: After family, it is important for me to maintain a healthy lifestyle and stay in shape. I am able to commute to Seattle Children’s Hospital by bicycle and I try to run two to three times a week. I squeeze in half-marathons and marathons, along with century [100 miles] and double-century bicycle rides each year.
Q: If you weren’t a doctor, what would you be doing right now?
A: I would love to be a stay-at-home father for my boys and also devote the time and energy into pursuing a career in trail running.
Q: What’s the best book you’ve read recently?
A: I recently read Jim Collins’ “Good to Great” as part of a management training course at Seattle Children’s Hospital. This easy-to-read, highly entertaining book clearly demonstrates the culture changes that need to occur for companies to move from good to great. As a field, hospital medicine, with its focus on QI work and patient safety, is now in the midst of trying to become “great.”
Q: How many Apple products (phones, iPods, tablets, iTunes, etc.) do you interface with in a given week?
A: As many as possible. My wife and I own two iPhones, two iPads, and a MacBook Air, which she thinks we share but, in actuality, is mine. We are hoping to purchase a Mac desktop, and then we will have fully given over to the dark side.
Richard Quinn is a freelance writer in New Jersey.
Society of Hospital Medicine’s MARQUIS Initiative Highlights Need For Improved Medication Reconciliation
–Jeffrey Schnipper, MD, MPH, FHM
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.
Larry Beresford is a freelance writer in San Francisco.
–Jeffrey Schnipper, MD, MPH, FHM
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.
Larry Beresford is a freelance writer in San Francisco.
–Jeffrey Schnipper, MD, MPH, FHM
What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?
Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.
“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.
The concept of the “best possible medication history” (BPMH) originated with patient-safety expert Edward Etchells, MD, MSc, at Sunnybrook Health Sciences Centre in Toronto. The concept is outlined on a pocket reminder card for MARQUIS participants, explained co-presenter and principal investigator Jeffrey Schnipper MD, MPH, FHM, a hospitalist at Brigham & Women’s Hospital in Boston.
“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.
Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.
An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.
“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.
The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.
Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.
Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.
The MARQUIS toolkit is available on the SHM website at www.hospitalmedicine.org/marquis.
Larry Beresford is a freelance writer in San Francisco.
Boston Hospital Earns Quality Award
In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.2 Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.
The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.
Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.
Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).
“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”
Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.
Larry Beresford is a freelance writer in San Francisco.
References
- Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
- Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
- Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
- Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
- Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
- Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.
In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.2 Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.
The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.
Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.
Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).
“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”
Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.
Larry Beresford is a freelance writer in San Francisco.
References
- Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
- Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
- Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
- Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
- Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
- Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.
In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.2 Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.
The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.
Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.
Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).
“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”
Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.
Larry Beresford is a freelance writer in San Francisco.
References
- Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
- Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
- Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
- Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
- Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
- Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.
Post-Discharge Phone Calls Prevent Hospital Readmissions
Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.
UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”1
Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.
“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”
However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.
Larry Beresford is a freelance writer in San Francisco.
References
- Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
- Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
- Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
- Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
- Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
- Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.
Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.
UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”1
Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.
“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”
However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.
Larry Beresford is a freelance writer in San Francisco.
References
- Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
- Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
- Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
- Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
- Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
- Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.
Two RIV posters presented at HM13 from University of California at San Francisco (UCSF) hospitalists analyzed outcomes from post-discharge phone calls to patients and found that those who were reached and interviewed by a call nurse had a 33% lower all-cause readmission rate.
UCSF joined SHM’s Project BOOST quality initiative in 2009 and adopted its recommendation to call patients within 72 hours of their hospital discharge, according to co-author Michelle Mourad, MD, assistant professor of clinical medicine and a UCSF hospitalist. “We reached out to about 60% to 70% of our patients with a standard script to address issues associated with readmissions,” Dr. Mourad explains. “We were also lucky enough to build a computer program with quantifiable outcomes in the database.”1
Researchers broke the data down into three categories: those called and interviewed by the nurse; those called who didn’t answer the phone or had a wrong number; and those who were never called due to errors in the administrative list of discharged patients. Interpreting the results is complicated, Dr. Mourad says, because of the challenges of separating factors leading to patients answering the survey from those that affect their readmission risk.
“These phone calls weren’t done in isolation and were part of our overall bridging interventions for patients going home from the hospital,” she says. “We designed the intervention to help people, and we found that 43% of those reached had at least one issue identified in the call for which the nurse tried to help.”
However, whether patients reported post-discharge issues and their responses to specific questions within the interview were not associated with readmission rates. “Does that mean the nurses’ calls are not helping? It either means the nurses are effectively managing these issues to prevent readmissions or that the factors affecting readmissions are more complicated than we currently understand,” Dr. Mourad says.
Larry Beresford is a freelance writer in San Francisco.
References
- Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
- Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
- Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
- Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
- Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
- Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
- Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.