Editorial

It seemed like years had passed since he was told he had cancer. While he basked in the cool white ambiance of the examination room, Jim mentally traced his many steps up and down the nearby hospital hallways. From this room to that, he had shuffled through most of the rooms on this hospital ward. Jim had read every outdated Time and National Geographic magazine, and all of the kids' books. From sitting in waiting rooms, he had even developed a deep appreciation for Thomas the Tank Engine. As he sat there, he realized that he had only spent 8 days in this hospital ward. But in here, 8 days might as well be 11 years. Time doesn't so much pass in hospital wards as it stands perfectly still on your chest. The total isolation for those who must stay is startling. Jim had begun judging time by the movements of those lucky enough to go home. Instead of Mondays, Tuesdays, and Wednesdays, he was also measuring time by food. Days of the week had become known as Styrofoam meatloaf, highly suspect lasagna, and inedible beef Wellington; all had become units of time measurement.

When he was told about his cancerthe doctor told him it was a type of hematological neo‐something‐or‐otherJim felt strangely aroused by the news. He felt energy racing through his body as he geared for battle. His immediate response was to think about how he would volunteer for the harshest, meanest, nastiest treatment he could get the doctor to agree with. Poke him full of holes, pour poison straight in his veins, run him on treadmills while doing all of thatit didn't matter. There was nothing he would not do to beat this thing. The doctor had finished telling Jim about all those options at the very minute Jim was ready to hear them. Whatever, whatever, Doc, let's get going with this, was his response.

Then, he had gradually noticed that the pace of medicine was something a little less urgent than he had thought. On TV the doctors run everywhere, but here they walked with a brisk but awkward gait, as if afraid of falling on the floor by going too fast. While waiting for his appointments, Jim noticed that everything was about waitingwaiting for everything. Nothing happens in the hospital. There are people walking everywhere with some projected sense of purpose but it all seems so meaningless when there's a hundred people in hospital uniforms walking past a whole room of patients.

Finally, the door to the examination room burst open and in walked Dr. Day. Standing slightly less than 6 feet tall, Docas Jim called himwas one of those well‐preserved 50‐year‐olds who could be found wind‐surfing his way back to his convertible sports car during his off‐hours. Jim imagined that Doc had been the star student, the handsome rover, the jock. Age had started to claw at his youthful looks, but vanity had led the charge against age for Doc. His behavior and choices worked against his clock, and he was not going quietly into that dark night. Doc's athletic stride made it seem like his feet never touched the floor, and he wafted deep into the room before the doors had even fully opened. Doc never looked forward, but always studied the charts in front of him. He was intense; it was as if he had to truly concentrate sometimes to keep pace with his own mind. Doc was talking, but it was unclear to whom. Finally, he looked up with an expectant pause, and Jim, battered with indifference, nodded in affirmationto what, he didn't care. Doc then gave Jim the thumbs‐up, turned on his heel and headed toward the door; he spun around on the spot and looked back, Yeah, you'll need to change into a robe with nothing on underneath it. He gestured to the one wall where a shelf held neatly folded paper‐thin gowns. Jim put one on and could barely believe how sheer it was. It had the density of a paper napkin, he thought. Then again, this was hardly a cause for modesty. The cancer, he had learned, was actually lymphoma, and it had settled in his groin. At first, Jim was ashamed to have doctors and nurses poke and prod his nether regions, but after a while he became quite causal about it with the usual array of doctors and nurses who populated his monotonous life in this shiny new white palace. After the requisite 15 minutes of unexplained absence, Dr. Day returned through the doors. There was something different about him now, and in a world so dominated by sameness, predictability, and routine, change was a dark storm cloud and sudden wind in Jim's mind.

Lie down on that table please, Doc said in his usual my hand may be making a tactile map of your groin, but my mind is in Bermuda manner. As Jim hopped up on the table and shifted his diseased area closer to the end, the Doc seemed to brighten up, Stay right there, he said as he moved quickly from the room once again. Jim pondered the instruction. As opposed to going where? Jim groaned. He would go somewhere, but his treatment, eventually, would happen here. If he left, he didn't know if would ever come back.

In through the door, one more time, came Dr. Day, but this time he seemed to be leading some kind of tour. Trailing behind him in different states of interest and alertness was a team of young people, all in the little training smocks they give them that look just like the big‐boy coat that Dr. Day wore. Their smocks were more wrinkled and more ivory colored, but they still looked official. Dr. Day hardly looked toward the patient as he smoothly rolled into the side of the table nearest Jim's now‐exposed groin.

Jim looked up between his upstretched knees to see them, all of them, standing around trying to decide if they should be looking at the Doc or looking at the affected area. Jim was embarrassed. Jim was mad. Jim was embarrassed again. He tried to make eye contact with every single visitor in the room, and all he could see were eyes looking straight down under the flap of his hospital gown. Doc had broken into his whole song and dance when he stopped short and looked to Jim, almost apologetically, You're alright with this, right? These are first‐year residents and I wanted them to see this kind of tumor up close. Doc hardly took a full breath and he had turned and was back into his blather about mito, crypto, this, that, and some other bullshit. Jim felt like if he rested his head back maybe no one would ever know that he was the real fleshy cadaver that they stared at that day. He might never see any of these students again, and even if he did, none of them could bring themselves to look him anywhere near the eye anyway. Not much danger that any of them could pick him out of a police lineup, even if he did it without any pants on.

It's important to palpate the region, each of you need to feel what this is like, starting with you. Jim heard this particular instruction and snapped his head up to see exactly where the students were now headed to see and feel the thing they just had to touch. Imagine his dismay when he saw that all of them were still there, still transfixed on whatever they had found to look at studiously during this whole period of time. Doc had motioned to the smallest, frailest, most out‐of‐her‐element young woman he had ever seen. She visibly swallowed hard at the news that she would be first. Her eyes, previously fixed without distraction on some point on Jim's leg, now began to frantically search the eyes of others, possibly looking for some permission to run away. Her eyes met Jim's quite by accident, and she shared with him a look of total and complete shame. He took out his annoyance on her by fixing her with a murderous stare, while he watched as her hand inched ever closer to his leg. In a continuous, but painfully slow motion, she reached under the robe and Jim felt the slightest touch of what he assumed was her finger come to rest on the lowest part of his abdomen. She held her finger there, motionless, and then drew it away quickly while nodding to the Doc. No, no, no, you have to really feel it! Doc chided. He reached down and poked the area firmly, but with a certainty and comfort that comes only from unspoken familiarity. Doc then grabbed the poor girl's hand and guided it and proceeded, with his hand holding her wrist, to make the poking motion with her hand. She was clearly horrified and would have rather been poking through the exposed abdomen of a cadaver at that point. Jim's mood became even more annoyed at her response. It was okay to be embarrassed, but she was now acting like his groin was Elephant‐Man‐esque in its hideousness. He wondered if Doc would set up a barker stand and call to the passers‐by to see the bulbous freak, 50 cents for a viewing! Don't forget about our snack tents! Nobody should go home without candy, everybody loves candy!

After the young resident had endured all that the Doc thought she should, he motioned to the next one and repeated the same process; one after another, after another. The students instinctively formed a line that snaked around the table and spilled out through the room. Jim became callous at this point and began chatting up the students while they stood, quietly waiting their turn for the guided poking, to make them feel even more uncomfortable and intimidated. Jim spied one extremely uncomfortable‐looking male student. You know, if you like this, it doesn't make you gay, Jim shared in an almost caring tone. As the target of his comments shuffled forward, eyes never leaving the floor, Jim targeted another victim with his comments, and then another, and then another. Jim became a sniper of sarcasm, picking off helpless young residents as they stood helplessly in his aim. Doc finally reacted to Jim and shot him a scolding look. Doc leaned into Jim's ear, Fun is fun, but let's just take it easy now, ok? Jim grunted in disagreement, but complied. There was no anger left to vent, and really no need to vent it. Residents weren't the problem, but it was easy to treat them that way. Besides, Jim figured there was many more days for him to make it up to them by being a nicer patient. Today was today, but there were probably 20 more tomorrows for him here.

Finally, the last student had his moment. Jim noticed that the region was now sore from the guiding probing, and Doc had his back to him while addressing the students about what they had seen there today. Jim hopped off the table and proceeded to change back into his clothes while Doc carried on talking. Then, Doc was gone; he sped from the room with his entourage in close pursuit. Jim finished dressing and shuffled down the hallway to his room. Jim sighed under the weight of monotony. Every day was the same, and only the torturous delight he enjoyed at the expense of those residents made the day unique. It was, for the most part, emotion that broke the routine. Emotion was the only thing that Jim controlled at this point, and occasionally, selfishly, he would let it loose on the unsuspecting, simply to bookmark his day. Cancer was not killing Jim, but boredom quite possibly could. As Jim passed the drink machine around the corner from his ward, he saw nurse Janet coming in to work with her neon pink lunch kit slung over her shoulder. She smiled at Jim and asked him how he was feeling. Jim smiled, told her all was getting better, and then made his way back to his room. Janet's arrival meant it was almost supper time, and today was lasagna.

It seemed like years had passed since he was told he had cancer. While he basked in the cool white ambiance of the examination room, Jim mentally traced his many steps up and down the nearby hospital hallways. From this room to that, he had shuffled through most of the rooms on this hospital ward. Jim had read every outdated Time and National Geographic magazine, and all of the kids' books. From sitting in waiting rooms, he had even developed a deep appreciation for Thomas the Tank Engine. As he sat there, he realized that he had only spent 8 days in this hospital ward. But in here, 8 days might as well be 11 years. Time doesn't so much pass in hospital wards as it stands perfectly still on your chest. The total isolation for those who must stay is startling. Jim had begun judging time by the movements of those lucky enough to go home. Instead of Mondays, Tuesdays, and Wednesdays, he was also measuring time by food. Days of the week had become known as Styrofoam meatloaf, highly suspect lasagna, and inedible beef Wellington; all had become units of time measurement.

When he was told about his cancerthe doctor told him it was a type of hematological neo‐something‐or‐otherJim felt strangely aroused by the news. He felt energy racing through his body as he geared for battle. His immediate response was to think about how he would volunteer for the harshest, meanest, nastiest treatment he could get the doctor to agree with. Poke him full of holes, pour poison straight in his veins, run him on treadmills while doing all of thatit didn't matter. There was nothing he would not do to beat this thing. The doctor had finished telling Jim about all those options at the very minute Jim was ready to hear them. Whatever, whatever, Doc, let's get going with this, was his response.

Then, he had gradually noticed that the pace of medicine was something a little less urgent than he had thought. On TV the doctors run everywhere, but here they walked with a brisk but awkward gait, as if afraid of falling on the floor by going too fast. While waiting for his appointments, Jim noticed that everything was about waitingwaiting for everything. Nothing happens in the hospital. There are people walking everywhere with some projected sense of purpose but it all seems so meaningless when there's a hundred people in hospital uniforms walking past a whole room of patients.

Finally, the door to the examination room burst open and in walked Dr. Day. Standing slightly less than 6 feet tall, Docas Jim called himwas one of those well‐preserved 50‐year‐olds who could be found wind‐surfing his way back to his convertible sports car during his off‐hours. Jim imagined that Doc had been the star student, the handsome rover, the jock. Age had started to claw at his youthful looks, but vanity had led the charge against age for Doc. His behavior and choices worked against his clock, and he was not going quietly into that dark night. Doc's athletic stride made it seem like his feet never touched the floor, and he wafted deep into the room before the doors had even fully opened. Doc never looked forward, but always studied the charts in front of him. He was intense; it was as if he had to truly concentrate sometimes to keep pace with his own mind. Doc was talking, but it was unclear to whom. Finally, he looked up with an expectant pause, and Jim, battered with indifference, nodded in affirmationto what, he didn't care. Doc then gave Jim the thumbs‐up, turned on his heel and headed toward the door; he spun around on the spot and looked back, Yeah, you'll need to change into a robe with nothing on underneath it. He gestured to the one wall where a shelf held neatly folded paper‐thin gowns. Jim put one on and could barely believe how sheer it was. It had the density of a paper napkin, he thought. Then again, this was hardly a cause for modesty. The cancer, he had learned, was actually lymphoma, and it had settled in his groin. At first, Jim was ashamed to have doctors and nurses poke and prod his nether regions, but after a while he became quite causal about it with the usual array of doctors and nurses who populated his monotonous life in this shiny new white palace. After the requisite 15 minutes of unexplained absence, Dr. Day returned through the doors. There was something different about him now, and in a world so dominated by sameness, predictability, and routine, change was a dark storm cloud and sudden wind in Jim's mind.

Lie down on that table please, Doc said in his usual my hand may be making a tactile map of your groin, but my mind is in Bermuda manner. As Jim hopped up on the table and shifted his diseased area closer to the end, the Doc seemed to brighten up, Stay right there, he said as he moved quickly from the room once again. Jim pondered the instruction. As opposed to going where? Jim groaned. He would go somewhere, but his treatment, eventually, would happen here. If he left, he didn't know if would ever come back.

In through the door, one more time, came Dr. Day, but this time he seemed to be leading some kind of tour. Trailing behind him in different states of interest and alertness was a team of young people, all in the little training smocks they give them that look just like the big‐boy coat that Dr. Day wore. Their smocks were more wrinkled and more ivory colored, but they still looked official. Dr. Day hardly looked toward the patient as he smoothly rolled into the side of the table nearest Jim's now‐exposed groin.

Jim looked up between his upstretched knees to see them, all of them, standing around trying to decide if they should be looking at the Doc or looking at the affected area. Jim was embarrassed. Jim was mad. Jim was embarrassed again. He tried to make eye contact with every single visitor in the room, and all he could see were eyes looking straight down under the flap of his hospital gown. Doc had broken into his whole song and dance when he stopped short and looked to Jim, almost apologetically, You're alright with this, right? These are first‐year residents and I wanted them to see this kind of tumor up close. Doc hardly took a full breath and he had turned and was back into his blather about mito, crypto, this, that, and some other bullshit. Jim felt like if he rested his head back maybe no one would ever know that he was the real fleshy cadaver that they stared at that day. He might never see any of these students again, and even if he did, none of them could bring themselves to look him anywhere near the eye anyway. Not much danger that any of them could pick him out of a police lineup, even if he did it without any pants on.

It's important to palpate the region, each of you need to feel what this is like, starting with you. Jim heard this particular instruction and snapped his head up to see exactly where the students were now headed to see and feel the thing they just had to touch. Imagine his dismay when he saw that all of them were still there, still transfixed on whatever they had found to look at studiously during this whole period of time. Doc had motioned to the smallest, frailest, most out‐of‐her‐element young woman he had ever seen. She visibly swallowed hard at the news that she would be first. Her eyes, previously fixed without distraction on some point on Jim's leg, now began to frantically search the eyes of others, possibly looking for some permission to run away. Her eyes met Jim's quite by accident, and she shared with him a look of total and complete shame. He took out his annoyance on her by fixing her with a murderous stare, while he watched as her hand inched ever closer to his leg. In a continuous, but painfully slow motion, she reached under the robe and Jim felt the slightest touch of what he assumed was her finger come to rest on the lowest part of his abdomen. She held her finger there, motionless, and then drew it away quickly while nodding to the Doc. No, no, no, you have to really feel it! Doc chided. He reached down and poked the area firmly, but with a certainty and comfort that comes only from unspoken familiarity. Doc then grabbed the poor girl's hand and guided it and proceeded, with his hand holding her wrist, to make the poking motion with her hand. She was clearly horrified and would have rather been poking through the exposed abdomen of a cadaver at that point. Jim's mood became even more annoyed at her response. It was okay to be embarrassed, but she was now acting like his groin was Elephant‐Man‐esque in its hideousness. He wondered if Doc would set up a barker stand and call to the passers‐by to see the bulbous freak, 50 cents for a viewing! Don't forget about our snack tents! Nobody should go home without candy, everybody loves candy!

After the young resident had endured all that the Doc thought she should, he motioned to the next one and repeated the same process; one after another, after another. The students instinctively formed a line that snaked around the table and spilled out through the room. Jim became callous at this point and began chatting up the students while they stood, quietly waiting their turn for the guided poking, to make them feel even more uncomfortable and intimidated. Jim spied one extremely uncomfortable‐looking male student. You know, if you like this, it doesn't make you gay, Jim shared in an almost caring tone. As the target of his comments shuffled forward, eyes never leaving the floor, Jim targeted another victim with his comments, and then another, and then another. Jim became a sniper of sarcasm, picking off helpless young residents as they stood helplessly in his aim. Doc finally reacted to Jim and shot him a scolding look. Doc leaned into Jim's ear, Fun is fun, but let's just take it easy now, ok? Jim grunted in disagreement, but complied. There was no anger left to vent, and really no need to vent it. Residents weren't the problem, but it was easy to treat them that way. Besides, Jim figured there was many more days for him to make it up to them by being a nicer patient. Today was today, but there were probably 20 more tomorrows for him here.

Finally, the last student had his moment. Jim noticed that the region was now sore from the guiding probing, and Doc had his back to him while addressing the students about what they had seen there today. Jim hopped off the table and proceeded to change back into his clothes while Doc carried on talking. Then, Doc was gone; he sped from the room with his entourage in close pursuit. Jim finished dressing and shuffled down the hallway to his room. Jim sighed under the weight of monotony. Every day was the same, and only the torturous delight he enjoyed at the expense of those residents made the day unique. It was, for the most part, emotion that broke the routine. Emotion was the only thing that Jim controlled at this point, and occasionally, selfishly, he would let it loose on the unsuspecting, simply to bookmark his day. Cancer was not killing Jim, but boredom quite possibly could. As Jim passed the drink machine around the corner from his ward, he saw nurse Janet coming in to work with her neon pink lunch kit slung over her shoulder. She smiled at Jim and asked him how he was feeling. Jim smiled, told her all was getting better, and then made his way back to his room. Janet's arrival meant it was almost supper time, and today was lasagna.

It seemed like years had passed since he was told he had cancer. While he basked in the cool white ambiance of the examination room, Jim mentally traced his many steps up and down the nearby hospital hallways. From this room to that, he had shuffled through most of the rooms on this hospital ward. Jim had read every outdated Time and National Geographic magazine, and all of the kids' books. From sitting in waiting rooms, he had even developed a deep appreciation for Thomas the Tank Engine. As he sat there, he realized that he had only spent 8 days in this hospital ward. But in here, 8 days might as well be 11 years. Time doesn't so much pass in hospital wards as it stands perfectly still on your chest. The total isolation for those who must stay is startling. Jim had begun judging time by the movements of those lucky enough to go home. Instead of Mondays, Tuesdays, and Wednesdays, he was also measuring time by food. Days of the week had become known as Styrofoam meatloaf, highly suspect lasagna, and inedible beef Wellington; all had become units of time measurement.

When he was told about his cancerthe doctor told him it was a type of hematological neo‐something‐or‐otherJim felt strangely aroused by the news. He felt energy racing through his body as he geared for battle. His immediate response was to think about how he would volunteer for the harshest, meanest, nastiest treatment he could get the doctor to agree with. Poke him full of holes, pour poison straight in his veins, run him on treadmills while doing all of thatit didn't matter. There was nothing he would not do to beat this thing. The doctor had finished telling Jim about all those options at the very minute Jim was ready to hear them. Whatever, whatever, Doc, let's get going with this, was his response.

Then, he had gradually noticed that the pace of medicine was something a little less urgent than he had thought. On TV the doctors run everywhere, but here they walked with a brisk but awkward gait, as if afraid of falling on the floor by going too fast. While waiting for his appointments, Jim noticed that everything was about waitingwaiting for everything. Nothing happens in the hospital. There are people walking everywhere with some projected sense of purpose but it all seems so meaningless when there's a hundred people in hospital uniforms walking past a whole room of patients.

Finally, the door to the examination room burst open and in walked Dr. Day. Standing slightly less than 6 feet tall, Docas Jim called himwas one of those well‐preserved 50‐year‐olds who could be found wind‐surfing his way back to his convertible sports car during his off‐hours. Jim imagined that Doc had been the star student, the handsome rover, the jock. Age had started to claw at his youthful looks, but vanity had led the charge against age for Doc. His behavior and choices worked against his clock, and he was not going quietly into that dark night. Doc's athletic stride made it seem like his feet never touched the floor, and he wafted deep into the room before the doors had even fully opened. Doc never looked forward, but always studied the charts in front of him. He was intense; it was as if he had to truly concentrate sometimes to keep pace with his own mind. Doc was talking, but it was unclear to whom. Finally, he looked up with an expectant pause, and Jim, battered with indifference, nodded in affirmationto what, he didn't care. Doc then gave Jim the thumbs‐up, turned on his heel and headed toward the door; he spun around on the spot and looked back, Yeah, you'll need to change into a robe with nothing on underneath it. He gestured to the one wall where a shelf held neatly folded paper‐thin gowns. Jim put one on and could barely believe how sheer it was. It had the density of a paper napkin, he thought. Then again, this was hardly a cause for modesty. The cancer, he had learned, was actually lymphoma, and it had settled in his groin. At first, Jim was ashamed to have doctors and nurses poke and prod his nether regions, but after a while he became quite causal about it with the usual array of doctors and nurses who populated his monotonous life in this shiny new white palace. After the requisite 15 minutes of unexplained absence, Dr. Day returned through the doors. There was something different about him now, and in a world so dominated by sameness, predictability, and routine, change was a dark storm cloud and sudden wind in Jim's mind.

Lie down on that table please, Doc said in his usual my hand may be making a tactile map of your groin, but my mind is in Bermuda manner. As Jim hopped up on the table and shifted his diseased area closer to the end, the Doc seemed to brighten up, Stay right there, he said as he moved quickly from the room once again. Jim pondered the instruction. As opposed to going where? Jim groaned. He would go somewhere, but his treatment, eventually, would happen here. If he left, he didn't know if would ever come back.

In through the door, one more time, came Dr. Day, but this time he seemed to be leading some kind of tour. Trailing behind him in different states of interest and alertness was a team of young people, all in the little training smocks they give them that look just like the big‐boy coat that Dr. Day wore. Their smocks were more wrinkled and more ivory colored, but they still looked official. Dr. Day hardly looked toward the patient as he smoothly rolled into the side of the table nearest Jim's now‐exposed groin.

Jim looked up between his upstretched knees to see them, all of them, standing around trying to decide if they should be looking at the Doc or looking at the affected area. Jim was embarrassed. Jim was mad. Jim was embarrassed again. He tried to make eye contact with every single visitor in the room, and all he could see were eyes looking straight down under the flap of his hospital gown. Doc had broken into his whole song and dance when he stopped short and looked to Jim, almost apologetically, You're alright with this, right? These are first‐year residents and I wanted them to see this kind of tumor up close. Doc hardly took a full breath and he had turned and was back into his blather about mito, crypto, this, that, and some other bullshit. Jim felt like if he rested his head back maybe no one would ever know that he was the real fleshy cadaver that they stared at that day. He might never see any of these students again, and even if he did, none of them could bring themselves to look him anywhere near the eye anyway. Not much danger that any of them could pick him out of a police lineup, even if he did it without any pants on.

It's important to palpate the region, each of you need to feel what this is like, starting with you. Jim heard this particular instruction and snapped his head up to see exactly where the students were now headed to see and feel the thing they just had to touch. Imagine his dismay when he saw that all of them were still there, still transfixed on whatever they had found to look at studiously during this whole period of time. Doc had motioned to the smallest, frailest, most out‐of‐her‐element young woman he had ever seen. She visibly swallowed hard at the news that she would be first. Her eyes, previously fixed without distraction on some point on Jim's leg, now began to frantically search the eyes of others, possibly looking for some permission to run away. Her eyes met Jim's quite by accident, and she shared with him a look of total and complete shame. He took out his annoyance on her by fixing her with a murderous stare, while he watched as her hand inched ever closer to his leg. In a continuous, but painfully slow motion, she reached under the robe and Jim felt the slightest touch of what he assumed was her finger come to rest on the lowest part of his abdomen. She held her finger there, motionless, and then drew it away quickly while nodding to the Doc. No, no, no, you have to really feel it! Doc chided. He reached down and poked the area firmly, but with a certainty and comfort that comes only from unspoken familiarity. Doc then grabbed the poor girl's hand and guided it and proceeded, with his hand holding her wrist, to make the poking motion with her hand. She was clearly horrified and would have rather been poking through the exposed abdomen of a cadaver at that point. Jim's mood became even more annoyed at her response. It was okay to be embarrassed, but she was now acting like his groin was Elephant‐Man‐esque in its hideousness. He wondered if Doc would set up a barker stand and call to the passers‐by to see the bulbous freak, 50 cents for a viewing! Don't forget about our snack tents! Nobody should go home without candy, everybody loves candy!

After the young resident had endured all that the Doc thought she should, he motioned to the next one and repeated the same process; one after another, after another. The students instinctively formed a line that snaked around the table and spilled out through the room. Jim became callous at this point and began chatting up the students while they stood, quietly waiting their turn for the guided poking, to make them feel even more uncomfortable and intimidated. Jim spied one extremely uncomfortable‐looking male student. You know, if you like this, it doesn't make you gay, Jim shared in an almost caring tone. As the target of his comments shuffled forward, eyes never leaving the floor, Jim targeted another victim with his comments, and then another, and then another. Jim became a sniper of sarcasm, picking off helpless young residents as they stood helplessly in his aim. Doc finally reacted to Jim and shot him a scolding look. Doc leaned into Jim's ear, Fun is fun, but let's just take it easy now, ok? Jim grunted in disagreement, but complied. There was no anger left to vent, and really no need to vent it. Residents weren't the problem, but it was easy to treat them that way. Besides, Jim figured there was many more days for him to make it up to them by being a nicer patient. Today was today, but there were probably 20 more tomorrows for him here.

Finally, the last student had his moment. Jim noticed that the region was now sore from the guiding probing, and Doc had his back to him while addressing the students about what they had seen there today. Jim hopped off the table and proceeded to change back into his clothes while Doc carried on talking. Then, Doc was gone; he sped from the room with his entourage in close pursuit. Jim finished dressing and shuffled down the hallway to his room. Jim sighed under the weight of monotony. Every day was the same, and only the torturous delight he enjoyed at the expense of those residents made the day unique. It was, for the most part, emotion that broke the routine. Emotion was the only thing that Jim controlled at this point, and occasionally, selfishly, he would let it loose on the unsuspecting, simply to bookmark his day. Cancer was not killing Jim, but boredom quite possibly could. As Jim passed the drink machine around the corner from his ward, he saw nurse Janet coming in to work with her neon pink lunch kit slung over her shoulder. She smiled at Jim and asked him how he was feeling. Jim smiled, told her all was getting better, and then made his way back to his room. Janet's arrival meant it was almost supper time, and today was lasagna.

Studies of the transition of care between inpatient and outpatient settings have shown that there are significant patient safety and quality deficiencies in our current system. The transition from the hospital setting to the outpatient setting has been more extensively studied than the transition from the outpatient setting to the inpatient setting. One prospective cohort study of 400 patients found that 1 in 5 patients discharged from the hospital to home experienced an adverse event, which was defined as an injury resulting from medical management rather than the underlying disease, within 3 weeks of discharge.1 This study also concluded that 66% of these were drug‐related adverse events, many of which could have been avoided or mitigated. Another prospective cross‐sectional study of 2644 patient discharges found that approximately 40% of the patients had pending test results at the time of discharge and that 10% of these required some action, yet the outpatient physicians and patients were unaware of these results.2 Medication discrepancies have also been shown to be prevalent, with 1 prospective observational study of 375 patients showing that 14% of elderly patients had 1 or more medication discrepancies and 14% of those patients with medication discrepancies were rehospitalized within 30 days versus 6% of the patients who did not experience a medication discrepancy.3 A recent review of the literature cited improving transitional care as a key area of opportunity for improving postdischarge care4

Lack of communication has clearly been shown to adversely affect postdischarge care transitions.5 A recent summary of the literature by a Society of Hospital Medicine (SHM)/Society of General Internal Medicine (SGIM) task force found that direct communication between hospital physicians and primary care physicians occurs infrequently (in 3%‐20% of cases studied), and the availability of a discharge summary at the first postdischarge visit is low (12%‐34%) and does not improve greatly even after 4 weeks (51%‐77%); this affects the quality of care in approximately 25% of follow‐up visits.5 This systematic review of the literature also found that discharge summaries often lack important information such as diagnostic test results, the treatment or hospital course, discharge medications, test results pending at discharge, patient or family counseling, and follow‐up plans.

However, the lack of studies of the communication between ambulatory physicians and hospital physicians prior to admission or during emergency department (ED) visits does not imply that this communication is not equally important and essential to high‐quality care. According to the Centers for Disease Control, the greatest source of hospital admissions in many institutions is the ED. Over 115,000,000 visits were made to the nation's approximately 4828 EDs in 2005, and about 85.2% of ED visits end in discharge.6 The ED is also the point of re‐entry into the system for individuals who may have had an adverse outcome linked to a prior hospitalization.6 Communication between hospital physicians and primary care physicians must be established to create a loop of continuous care and diminish morbidity and mortality at this critical transition point.

While transitions can be a risky period for patient safety, observational studies suggest there are benefits to transitions. A new physician may notice something overlooked by the current caregivers.712 Another factor contributing to the challenges of care transitions is the lack of a single clinician or clinical entity taking responsibility for coordination across the continuum of the patient's overall healthcare, regardless of setting.13 Studies indicate that a relationship with a medical home is associated with better health on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations.14 Several medical societies have addressed this issue, including the American College of Physicians (ACP), SGIM, American Academy of Family Physicians, and American Academy of Pediatrics, and they have proposed the concept of the medical home or patient‐centered medical home, which calls for clinicians to assume this responsibility for coordinating their patients' care across settings and for the healthcare system to value and reimburse clinicians for this patient‐centered and comprehensive method of practice.1517

Finally, patients and their families or caregivers have an important role to play in transitions of care. Several observational and cross‐sectional studies have shown that patients and their caregivers and families express significant feelings of anxiety during care transitions. This anxiety can be caused by a lack of understanding and preparation for their self‐care role in the next care setting, confusion due to conflicting advice from different practitioners, and a sense of abandonment attributable to the inability to contact an appropriate healthcare practitioner for guidance, and they report an overall disregard for their preferences and input into the design of the care plan.1820 Clearly, there is room for improvement in all these areas of the inpatient and outpatient care transition, and the Transitions of Care Consensus Conference (TOCCC) attempted to address these areas by developing standards for the transition of care that also harmonize with the work of the Stepping up to the Plate (SUTTP) Alliance of the American Board of Internal Medicine (ABIM) Foundation.21 In addition, other important stakeholders are addressing this topic and actively working to improve communication and continuity in care, including the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF). CMS recently developed the Continuity Assessment Record & Evaluation (CARE) tool, a data collection instrument designed to be a standardized, interoperable, common assessment tool to capture key patient characteristics that will provide information related to resource utilization, clinical outcomes, and postdischarge disposition. NQF held a national forum on care coordination in the spring of 2008.

In summary, it is clear that there are qualitative and quantitative deficiencies in transitions of care between the inpatient and outpatient setting that are affecting patient safety and experience with care. The transition from the inpatient setting to the outpatient setting has been more extensively studied, and this body of literature has underscored for the TOCCC several important areas in need of guidance and improvement. Because of this, the scope of application of this document should initially emphasize inpatient‐to‐outpatient transitions as a first step in learning how to improve these processes. However, the transition from the outpatient setting to the inpatient setting also is a clear priority. Because the needs for transfer of information, authority, and responsibility may be different in these situations, a second phase of additional work to develop principles to guide these transitions should be undertaken as quickly as possible. Experience gained in applying these principles to inpatient‐to‐outpatient transitions might usefully inform such work.

Communication among providers and with the patients and their families arose as a clear priority. Medication discrepancies, pending tests, and unknown diagnostic or treatment plans have an immediate impact on patients' health and outcomes. The TOCCC discussed what elements should be among the standard pieces of information exchanged among providers during these transition points. The dire need for coordination of care or a coordinating clinician/medical home became a clear theme in the deliberations of the TOCCC. Most importantly, the role of the patients and their families/caregivers in their continuing care is apparent, and the TOCCC felt this must be an integral part of any principles or standards for transitions of care.

Methods

In the fall/winter of 2006, the executive committees of ACP, SGIM, and SHM agreed to jointly develop a policy statement on transitions of care. Transitions of care specifically between the inpatient and outpatient settings were selected as an ideal topic for collaboration for the 3 societies as they represent the continuum of care for internal medicine within these settings. To accomplish this, the 3 organizations decided to convene a consensus conference to develop consensus guidelines and standards concerning transitions between inpatient and outpatient settings through a multi‐stakeholder process. A steering committee was convened with representatives from ACP, SGIM, SHM, the Agency for Healthcare Research and Quality (AHRQ), ABIM, and the American Geriatric Society (AGS). The steering committee developed the agenda and invitee list for the consensus conference. After the conference was held, the steering committee was expanded to include representation from the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM).

During the planning stages of the TOCCC, the steering committee became aware of the SUTTP Alliance of the ABIM Foundation. The SUTTP Alliance has representation from medical specialties such as internal medicine and its subspecialties, family medicine, and surgery. The alliance was formed in 2006 and has been working on care coordination across multiple settings and specialties. The SUTTP Alliance had developed a set of principles and standards for care transitions and agreed to provide the draft document to the TOCCC for review, input, and further development and refinement.

Recommendations on Principles and Standards for Managing Transitions in Care Between the Inpatient and Outpatient Settings from ACP, SGIM, SHM, AGS, ACEP, and SAEM

The SUTTP Alliance presented a draft document entitled Principles and Standards for Managing Transitions in Care. In this document, the SUTTP Alliance proposes 5 principles and 8 standards for effective care transitions. A key element of the conference was a presentation by NQF on how to move from principles to standards and eventually to measures. This presentation provided the TOCCC with the theoretical underpinnings for the discussion of these principles and standards and how the TOCCC would provide input on them. The presentation provided an outline for the flow from principles to measures. First, there needs to be a framework that provides guiding principles for what we would like to measure and eventually report. From those principles, a set of preferred practices or standards are developed; the standards are more granular and allow for more specificity in describing the desired practice or outcome and its elements. Standards then provide a roadmap for identification and development of performance measures. With this framework in mind, the TOCCC then discussed in detail the SUTTP principles and standards.

The 5 principles for effective care transitions developed by the SUTTP Alliance are as follows:

• Accountability.

• Communication: clear and direct communication of treatment plans and follow‐up expectations.

• Timely feedback and feed‐forward of information.

• Involvement of the patient and family member, unless inappropriate, in all steps.

• Respect of the hub of coordination of care.

The TOCCC re‐affirmed these principles and added 4 additional principles to this list. Three of the new principles were statements within the 8 standards developed by the SUTTP, but when taking into consideration the framework for the development of principles into standards, the TOCCC felt that the statements were better represented as principles. They are as follows:

• All patients and their families/caregivers should have and should be able to identify their medical home or coordinating clinician (ie, practice or practitioner). (This was originally part of the coordinating clinicians standard, and the TOCCC voted to elevate this to a principle).

• At every point along the transition, the patients and/or their families/caregivers need to know who is responsible for care at that point and who to contact and how.

• National standards should be established for transitions in care and should be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, medical institutions, and so forth in order to improve patient outcomes and patient safety. (This was originally part of the SUTTP community standards standard, and the TOCCC moved to elevate this to a principle).

• For monitoring and improving transitions, standardized metrics related to these standards should be used in order to lead to continuous quality improvement and accountability. (This was originally part of the measurement standard, and the TOCCC voted to elevate this to a principle).

The SUTTP Alliance proposed the following 8 standards for care transitions:

• Coordinating clinicians.

• Care plans.

• Communication infrastructure.

• Standard communication formats.

• Transition responsibility.

• Timeliness.

• Community standards.

• Measurement.

The TOCCC affirmed these standards and through a consensus process added more specificity to most of them and elevated components of some of them to principles, as discussed previously. The TOCCC proposes that the following be merged with the SUTTP standards:

• Coordinating clinicians. Communication and information exchange between the medical home and the receiving provider should occur in an amount of time that will allow the receiving provider to effectively treat the patient. This communication and information exchange should ideally occur whenever patients are at a transition of care (eg, at discharge from the inpatient setting). The timeliness of this communication should be consistent with the patient's clinical presentation and, in the case of a patient being discharged, the urgency of the follow‐up required. Guidelines will need to be developed that address both the timeliness and means of communication between the discharging physician and the medical home. Communication and information exchange between the medical home and other physicians may be in the form of a call, voice mail, fax, or other secure, private, and accessible means including mutual access to an electronic health record.

  The ED represents a unique subset of transitions of care. The potential transition can generally be described as outpatient to outpatient or outpatient to inpatient, depending on whether or not the patient is admitted to the hospital. The outpatient‐to‐outpatient transition can also encompass a number of potential variations. Patients with a medical home may be referred to the ED by the medical home, or they may self‐refer. A significant number of patients do not have a physician and self‐refer to the ED. The disposition from the ED, either outpatient to outpatient or outpatient to inpatient, is similarly represented by a number of variables. Discharged patients may or may not have a medical home, may or may not need a specialist, and may or may not require urgent (<24 hours) follow‐up. Admitted patients may or may not have a medical home and may or may not require specialty care. This variety of variables precludes a single approach to ED transition of care coordination. The determination of which scenarios will be appropriate for the development of standards (coordinating clinicians and transition responsibility) will require further contributions from ACEP and SAEM and review by the steering committee.

• Care plans/transition record. The TOCCC also agreed that there is a minimal set of data elements that should always be part of the transition record. The TOCCC suggested that this minimal data set be part of an initial implementation of this standard. That list includes the following:

  The TOCCC discussed what components should be included in an ideal transition record and agreed on the following elements:

  The TOCCC also added a new standard under this heading: Patients and/or their families/caregivers must receive, understand, and be encouraged to participate in the development of the transition record, which should take into consideration patients' health literacy and insurance status and be culturally sensitive.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Clear identification of the medical home/transferring coordinating physician/emnstitution and the contact information.

• Patient's cognitive status.

• Test results/pending results.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Emergency plan and contact number and person.

• Treatment and diagnostic plan.

• Prognosis and goals of care.

• Test results/pending results.

• Clear identification of the medical home and/or transferring coordinating physician/emnstitution.

• Patient's cognitive status.

• Advance directives, power of attorney, and consent.

• Planned interventions, durable medical equipment, wound care, and so forth.

• Assessment of caregiver status.

• Communication infrastructure. All communications between providers and between providers and patients and families/caregivers need to be secure, private, Health Insurance Portability and Accountability Actcompliant, and accessible to patients and those practitioners who care for them. Communication needs to be 2‐way with an opportunity for clarification and feedback. Each sending provider needs to provide a contact name and the number of an individual who can respond to questions or concerns. The content of transferred information needs to include a core standardized data set. This information needs to be transferred as a living database; that is, it is created only once, and then each subsequent provider only needs to update, validate, or modify the information. Patient information should be available to the provider prior to the patient's arrival. Information transfer needs to adhere to national data standards. Patients should be provided with a medication list that is accessible (paper or electronic), clear, and dated.

• Standard communication formats. Communities need to develop standard data transfer forms (templates and transmission protocols). Access to a patient's medical history needs to be on a current and ongoing basis with the ability to modify information as a patient's condition changes. Patients, families, and caregivers should have access to their information (nothing about me without me). A section on the transfer record should be devoted to communicating a patient's preferences, priorities, goals, and values (eg, the patient does not want intubation).

• Transition responsibility. The sending provider/emnstitution/team at the clinical organization maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete (within a reasonable timeframe for the receiving clinician to receive the information; ie, transfers that occur in the middle of the night can be communicated during standard working hours). The sending provider should be available for clarification with issues of care within a reasonable timeframe after the transfer has been completed, and this timeframe should be based on the conditions of the transfer settings. The patient should be able to identify the responsible provider. In the case of patients who do not have an ongoing ambulatory care provider or whose ambulatory care provider has not assumed responsibility, the hospital‐based clinicians will not be required to assume responsibility for the care of these patients once they are discharged.

• Timeliness. Timeliness of feedback and feed‐forward of information from a sending provider to a receiving provider should be contingent on 4 factors:

  This information should be available at the time of the patient encounter.

• Transition settings.

• Patient circumstances.

• Level of acuity.

• Clear transition responsibility.

• Community standards. Medical communities/emnstitutions must demonstrate accountability for transitions of care by adopting national standards, and processes should be established to promote effective transitions of care.

• Measurement. For monitoring and improving transitions, standardized metrics related to these standards should be used. These metrics/measures should be evidence‐based, address documented gaps, and have a demonstrated impact on improving care (complying with performance measure standards) whenever feasible. Results from measurements using standardized metrics must lead to continuous improvement of the transition process. The validity, reliability, cost, and impact, including unintended consequences, of these measures should be assessed and re‐evaluated.

All these standards should be applied with special attention to the various transition settings and should be appropriate to each transition setting. Measure developers will need to take this into account when developing measures based on these proposed standards.

The TOCCC also went through a consensus prioritization exercise to rank‐order the consensus standards. All meeting participants were asked to rank their top 3 priorities of the 7 standards, giving a numeric score of 1 for their highest priority, a score of 2 for their second highest priority, and a score of 3 for their third highest priority. Summary scores were calculated, and the standards were rank‐ordered from the lowest summary score to the highest. The TOCCC recognizes that full implementation of all of these standards may not be feasible and that these standards may be implemented on a stepped or incremental basis. This prioritization can assist in deciding which of these to implement. The results of the prioritization exercise are as follows:

• 1

  All transitions must include a transition record

• 2

  Transition responsibility

• 3

  Coordinating clinicians

• 4

  Patient and family involvement and ownership of the transition record

• 5

  Communication infrastructure

• 6

  Timeliness

• 7

  Community standards

Future Challenges

In addition to the work on the principles and standards, the TOCCC uncovered six further challenges which are described below.

Next Steps for the TOCCC

The TOCCC focuses only on the transitions between the inpatient and outpatient settings and does not address the equally important transitions between many other different care settings, such as the transition from a hospital to a nursing home or rehabilitation facility. The intent of the TOCCC is to provide this document to national measure developers such as the Physician Consortium for Performance Improvement and others in order to guide measure development and ultimately lead to improvements in quality and safety in care transitions.

Studies of the transition of care between inpatient and outpatient settings have shown that there are significant patient safety and quality deficiencies in our current system. The transition from the hospital setting to the outpatient setting has been more extensively studied than the transition from the outpatient setting to the inpatient setting. One prospective cohort study of 400 patients found that 1 in 5 patients discharged from the hospital to home experienced an adverse event, which was defined as an injury resulting from medical management rather than the underlying disease, within 3 weeks of discharge.1 This study also concluded that 66% of these were drug‐related adverse events, many of which could have been avoided or mitigated. Another prospective cross‐sectional study of 2644 patient discharges found that approximately 40% of the patients had pending test results at the time of discharge and that 10% of these required some action, yet the outpatient physicians and patients were unaware of these results.2 Medication discrepancies have also been shown to be prevalent, with 1 prospective observational study of 375 patients showing that 14% of elderly patients had 1 or more medication discrepancies and 14% of those patients with medication discrepancies were rehospitalized within 30 days versus 6% of the patients who did not experience a medication discrepancy.3 A recent review of the literature cited improving transitional care as a key area of opportunity for improving postdischarge care4

Lack of communication has clearly been shown to adversely affect postdischarge care transitions.5 A recent summary of the literature by a Society of Hospital Medicine (SHM)/Society of General Internal Medicine (SGIM) task force found that direct communication between hospital physicians and primary care physicians occurs infrequently (in 3%‐20% of cases studied), and the availability of a discharge summary at the first postdischarge visit is low (12%‐34%) and does not improve greatly even after 4 weeks (51%‐77%); this affects the quality of care in approximately 25% of follow‐up visits.5 This systematic review of the literature also found that discharge summaries often lack important information such as diagnostic test results, the treatment or hospital course, discharge medications, test results pending at discharge, patient or family counseling, and follow‐up plans.

However, the lack of studies of the communication between ambulatory physicians and hospital physicians prior to admission or during emergency department (ED) visits does not imply that this communication is not equally important and essential to high‐quality care. According to the Centers for Disease Control, the greatest source of hospital admissions in many institutions is the ED. Over 115,000,000 visits were made to the nation's approximately 4828 EDs in 2005, and about 85.2% of ED visits end in discharge.6 The ED is also the point of re‐entry into the system for individuals who may have had an adverse outcome linked to a prior hospitalization.6 Communication between hospital physicians and primary care physicians must be established to create a loop of continuous care and diminish morbidity and mortality at this critical transition point.

While transitions can be a risky period for patient safety, observational studies suggest there are benefits to transitions. A new physician may notice something overlooked by the current caregivers.712 Another factor contributing to the challenges of care transitions is the lack of a single clinician or clinical entity taking responsibility for coordination across the continuum of the patient's overall healthcare, regardless of setting.13 Studies indicate that a relationship with a medical home is associated with better health on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations.14 Several medical societies have addressed this issue, including the American College of Physicians (ACP), SGIM, American Academy of Family Physicians, and American Academy of Pediatrics, and they have proposed the concept of the medical home or patient‐centered medical home, which calls for clinicians to assume this responsibility for coordinating their patients' care across settings and for the healthcare system to value and reimburse clinicians for this patient‐centered and comprehensive method of practice.1517

Finally, patients and their families or caregivers have an important role to play in transitions of care. Several observational and cross‐sectional studies have shown that patients and their caregivers and families express significant feelings of anxiety during care transitions. This anxiety can be caused by a lack of understanding and preparation for their self‐care role in the next care setting, confusion due to conflicting advice from different practitioners, and a sense of abandonment attributable to the inability to contact an appropriate healthcare practitioner for guidance, and they report an overall disregard for their preferences and input into the design of the care plan.1820 Clearly, there is room for improvement in all these areas of the inpatient and outpatient care transition, and the Transitions of Care Consensus Conference (TOCCC) attempted to address these areas by developing standards for the transition of care that also harmonize with the work of the Stepping up to the Plate (SUTTP) Alliance of the American Board of Internal Medicine (ABIM) Foundation.21 In addition, other important stakeholders are addressing this topic and actively working to improve communication and continuity in care, including the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF). CMS recently developed the Continuity Assessment Record & Evaluation (CARE) tool, a data collection instrument designed to be a standardized, interoperable, common assessment tool to capture key patient characteristics that will provide information related to resource utilization, clinical outcomes, and postdischarge disposition. NQF held a national forum on care coordination in the spring of 2008.

In summary, it is clear that there are qualitative and quantitative deficiencies in transitions of care between the inpatient and outpatient setting that are affecting patient safety and experience with care. The transition from the inpatient setting to the outpatient setting has been more extensively studied, and this body of literature has underscored for the TOCCC several important areas in need of guidance and improvement. Because of this, the scope of application of this document should initially emphasize inpatient‐to‐outpatient transitions as a first step in learning how to improve these processes. However, the transition from the outpatient setting to the inpatient setting also is a clear priority. Because the needs for transfer of information, authority, and responsibility may be different in these situations, a second phase of additional work to develop principles to guide these transitions should be undertaken as quickly as possible. Experience gained in applying these principles to inpatient‐to‐outpatient transitions might usefully inform such work.

Communication among providers and with the patients and their families arose as a clear priority. Medication discrepancies, pending tests, and unknown diagnostic or treatment plans have an immediate impact on patients' health and outcomes. The TOCCC discussed what elements should be among the standard pieces of information exchanged among providers during these transition points. The dire need for coordination of care or a coordinating clinician/medical home became a clear theme in the deliberations of the TOCCC. Most importantly, the role of the patients and their families/caregivers in their continuing care is apparent, and the TOCCC felt this must be an integral part of any principles or standards for transitions of care.

Methods

In the fall/winter of 2006, the executive committees of ACP, SGIM, and SHM agreed to jointly develop a policy statement on transitions of care. Transitions of care specifically between the inpatient and outpatient settings were selected as an ideal topic for collaboration for the 3 societies as they represent the continuum of care for internal medicine within these settings. To accomplish this, the 3 organizations decided to convene a consensus conference to develop consensus guidelines and standards concerning transitions between inpatient and outpatient settings through a multi‐stakeholder process. A steering committee was convened with representatives from ACP, SGIM, SHM, the Agency for Healthcare Research and Quality (AHRQ), ABIM, and the American Geriatric Society (AGS). The steering committee developed the agenda and invitee list for the consensus conference. After the conference was held, the steering committee was expanded to include representation from the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM).

During the planning stages of the TOCCC, the steering committee became aware of the SUTTP Alliance of the ABIM Foundation. The SUTTP Alliance has representation from medical specialties such as internal medicine and its subspecialties, family medicine, and surgery. The alliance was formed in 2006 and has been working on care coordination across multiple settings and specialties. The SUTTP Alliance had developed a set of principles and standards for care transitions and agreed to provide the draft document to the TOCCC for review, input, and further development and refinement.

Recommendations on Principles and Standards for Managing Transitions in Care Between the Inpatient and Outpatient Settings from ACP, SGIM, SHM, AGS, ACEP, and SAEM

The SUTTP Alliance presented a draft document entitled Principles and Standards for Managing Transitions in Care. In this document, the SUTTP Alliance proposes 5 principles and 8 standards for effective care transitions. A key element of the conference was a presentation by NQF on how to move from principles to standards and eventually to measures. This presentation provided the TOCCC with the theoretical underpinnings for the discussion of these principles and standards and how the TOCCC would provide input on them. The presentation provided an outline for the flow from principles to measures. First, there needs to be a framework that provides guiding principles for what we would like to measure and eventually report. From those principles, a set of preferred practices or standards are developed; the standards are more granular and allow for more specificity in describing the desired practice or outcome and its elements. Standards then provide a roadmap for identification and development of performance measures. With this framework in mind, the TOCCC then discussed in detail the SUTTP principles and standards.

The 5 principles for effective care transitions developed by the SUTTP Alliance are as follows:

• Accountability.

• Communication: clear and direct communication of treatment plans and follow‐up expectations.

• Timely feedback and feed‐forward of information.

• Involvement of the patient and family member, unless inappropriate, in all steps.

• Respect of the hub of coordination of care.

The TOCCC re‐affirmed these principles and added 4 additional principles to this list. Three of the new principles were statements within the 8 standards developed by the SUTTP, but when taking into consideration the framework for the development of principles into standards, the TOCCC felt that the statements were better represented as principles. They are as follows:

• All patients and their families/caregivers should have and should be able to identify their medical home or coordinating clinician (ie, practice or practitioner). (This was originally part of the coordinating clinicians standard, and the TOCCC voted to elevate this to a principle).

• At every point along the transition, the patients and/or their families/caregivers need to know who is responsible for care at that point and who to contact and how.

• National standards should be established for transitions in care and should be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, medical institutions, and so forth in order to improve patient outcomes and patient safety. (This was originally part of the SUTTP community standards standard, and the TOCCC moved to elevate this to a principle).

• For monitoring and improving transitions, standardized metrics related to these standards should be used in order to lead to continuous quality improvement and accountability. (This was originally part of the measurement standard, and the TOCCC voted to elevate this to a principle).

The SUTTP Alliance proposed the following 8 standards for care transitions:

• Coordinating clinicians.

• Care plans.

• Communication infrastructure.

• Standard communication formats.

• Transition responsibility.

• Timeliness.

• Community standards.

• Measurement.

The TOCCC affirmed these standards and through a consensus process added more specificity to most of them and elevated components of some of them to principles, as discussed previously. The TOCCC proposes that the following be merged with the SUTTP standards:

• Coordinating clinicians. Communication and information exchange between the medical home and the receiving provider should occur in an amount of time that will allow the receiving provider to effectively treat the patient. This communication and information exchange should ideally occur whenever patients are at a transition of care (eg, at discharge from the inpatient setting). The timeliness of this communication should be consistent with the patient's clinical presentation and, in the case of a patient being discharged, the urgency of the follow‐up required. Guidelines will need to be developed that address both the timeliness and means of communication between the discharging physician and the medical home. Communication and information exchange between the medical home and other physicians may be in the form of a call, voice mail, fax, or other secure, private, and accessible means including mutual access to an electronic health record.

  The ED represents a unique subset of transitions of care. The potential transition can generally be described as outpatient to outpatient or outpatient to inpatient, depending on whether or not the patient is admitted to the hospital. The outpatient‐to‐outpatient transition can also encompass a number of potential variations. Patients with a medical home may be referred to the ED by the medical home, or they may self‐refer. A significant number of patients do not have a physician and self‐refer to the ED. The disposition from the ED, either outpatient to outpatient or outpatient to inpatient, is similarly represented by a number of variables. Discharged patients may or may not have a medical home, may or may not need a specialist, and may or may not require urgent (<24 hours) follow‐up. Admitted patients may or may not have a medical home and may or may not require specialty care. This variety of variables precludes a single approach to ED transition of care coordination. The determination of which scenarios will be appropriate for the development of standards (coordinating clinicians and transition responsibility) will require further contributions from ACEP and SAEM and review by the steering committee.

• Care plans/transition record. The TOCCC also agreed that there is a minimal set of data elements that should always be part of the transition record. The TOCCC suggested that this minimal data set be part of an initial implementation of this standard. That list includes the following:

  The TOCCC discussed what components should be included in an ideal transition record and agreed on the following elements:

  The TOCCC also added a new standard under this heading: Patients and/or their families/caregivers must receive, understand, and be encouraged to participate in the development of the transition record, which should take into consideration patients' health literacy and insurance status and be culturally sensitive.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Clear identification of the medical home/transferring coordinating physician/emnstitution and the contact information.

• Patient's cognitive status.

• Test results/pending results.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Emergency plan and contact number and person.

• Treatment and diagnostic plan.

• Prognosis and goals of care.

• Test results/pending results.

• Clear identification of the medical home and/or transferring coordinating physician/emnstitution.

• Patient's cognitive status.

• Advance directives, power of attorney, and consent.

• Planned interventions, durable medical equipment, wound care, and so forth.

• Assessment of caregiver status.

• Communication infrastructure. All communications between providers and between providers and patients and families/caregivers need to be secure, private, Health Insurance Portability and Accountability Actcompliant, and accessible to patients and those practitioners who care for them. Communication needs to be 2‐way with an opportunity for clarification and feedback. Each sending provider needs to provide a contact name and the number of an individual who can respond to questions or concerns. The content of transferred information needs to include a core standardized data set. This information needs to be transferred as a living database; that is, it is created only once, and then each subsequent provider only needs to update, validate, or modify the information. Patient information should be available to the provider prior to the patient's arrival. Information transfer needs to adhere to national data standards. Patients should be provided with a medication list that is accessible (paper or electronic), clear, and dated.

• Standard communication formats. Communities need to develop standard data transfer forms (templates and transmission protocols). Access to a patient's medical history needs to be on a current and ongoing basis with the ability to modify information as a patient's condition changes. Patients, families, and caregivers should have access to their information (nothing about me without me). A section on the transfer record should be devoted to communicating a patient's preferences, priorities, goals, and values (eg, the patient does not want intubation).

• Transition responsibility. The sending provider/emnstitution/team at the clinical organization maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete (within a reasonable timeframe for the receiving clinician to receive the information; ie, transfers that occur in the middle of the night can be communicated during standard working hours). The sending provider should be available for clarification with issues of care within a reasonable timeframe after the transfer has been completed, and this timeframe should be based on the conditions of the transfer settings. The patient should be able to identify the responsible provider. In the case of patients who do not have an ongoing ambulatory care provider or whose ambulatory care provider has not assumed responsibility, the hospital‐based clinicians will not be required to assume responsibility for the care of these patients once they are discharged.

• Timeliness. Timeliness of feedback and feed‐forward of information from a sending provider to a receiving provider should be contingent on 4 factors:

  This information should be available at the time of the patient encounter.

• Transition settings.

• Patient circumstances.

• Level of acuity.

• Clear transition responsibility.

• Community standards. Medical communities/emnstitutions must demonstrate accountability for transitions of care by adopting national standards, and processes should be established to promote effective transitions of care.

• Measurement. For monitoring and improving transitions, standardized metrics related to these standards should be used. These metrics/measures should be evidence‐based, address documented gaps, and have a demonstrated impact on improving care (complying with performance measure standards) whenever feasible. Results from measurements using standardized metrics must lead to continuous improvement of the transition process. The validity, reliability, cost, and impact, including unintended consequences, of these measures should be assessed and re‐evaluated.

All these standards should be applied with special attention to the various transition settings and should be appropriate to each transition setting. Measure developers will need to take this into account when developing measures based on these proposed standards.

The TOCCC also went through a consensus prioritization exercise to rank‐order the consensus standards. All meeting participants were asked to rank their top 3 priorities of the 7 standards, giving a numeric score of 1 for their highest priority, a score of 2 for their second highest priority, and a score of 3 for their third highest priority. Summary scores were calculated, and the standards were rank‐ordered from the lowest summary score to the highest. The TOCCC recognizes that full implementation of all of these standards may not be feasible and that these standards may be implemented on a stepped or incremental basis. This prioritization can assist in deciding which of these to implement. The results of the prioritization exercise are as follows:

• 1

  All transitions must include a transition record

• 2

  Transition responsibility

• 3

  Coordinating clinicians

• 4

  Patient and family involvement and ownership of the transition record

• 5

  Communication infrastructure

• 6

  Timeliness

• 7

  Community standards

Future Challenges

In addition to the work on the principles and standards, the TOCCC uncovered six further challenges which are described below.

Next Steps for the TOCCC

The TOCCC focuses only on the transitions between the inpatient and outpatient settings and does not address the equally important transitions between many other different care settings, such as the transition from a hospital to a nursing home or rehabilitation facility. The intent of the TOCCC is to provide this document to national measure developers such as the Physician Consortium for Performance Improvement and others in order to guide measure development and ultimately lead to improvements in quality and safety in care transitions.

Studies of the transition of care between inpatient and outpatient settings have shown that there are significant patient safety and quality deficiencies in our current system. The transition from the hospital setting to the outpatient setting has been more extensively studied than the transition from the outpatient setting to the inpatient setting. One prospective cohort study of 400 patients found that 1 in 5 patients discharged from the hospital to home experienced an adverse event, which was defined as an injury resulting from medical management rather than the underlying disease, within 3 weeks of discharge.1 This study also concluded that 66% of these were drug‐related adverse events, many of which could have been avoided or mitigated. Another prospective cross‐sectional study of 2644 patient discharges found that approximately 40% of the patients had pending test results at the time of discharge and that 10% of these required some action, yet the outpatient physicians and patients were unaware of these results.2 Medication discrepancies have also been shown to be prevalent, with 1 prospective observational study of 375 patients showing that 14% of elderly patients had 1 or more medication discrepancies and 14% of those patients with medication discrepancies were rehospitalized within 30 days versus 6% of the patients who did not experience a medication discrepancy.3 A recent review of the literature cited improving transitional care as a key area of opportunity for improving postdischarge care4

Lack of communication has clearly been shown to adversely affect postdischarge care transitions.5 A recent summary of the literature by a Society of Hospital Medicine (SHM)/Society of General Internal Medicine (SGIM) task force found that direct communication between hospital physicians and primary care physicians occurs infrequently (in 3%‐20% of cases studied), and the availability of a discharge summary at the first postdischarge visit is low (12%‐34%) and does not improve greatly even after 4 weeks (51%‐77%); this affects the quality of care in approximately 25% of follow‐up visits.5 This systematic review of the literature also found that discharge summaries often lack important information such as diagnostic test results, the treatment or hospital course, discharge medications, test results pending at discharge, patient or family counseling, and follow‐up plans.

However, the lack of studies of the communication between ambulatory physicians and hospital physicians prior to admission or during emergency department (ED) visits does not imply that this communication is not equally important and essential to high‐quality care. According to the Centers for Disease Control, the greatest source of hospital admissions in many institutions is the ED. Over 115,000,000 visits were made to the nation's approximately 4828 EDs in 2005, and about 85.2% of ED visits end in discharge.6 The ED is also the point of re‐entry into the system for individuals who may have had an adverse outcome linked to a prior hospitalization.6 Communication between hospital physicians and primary care physicians must be established to create a loop of continuous care and diminish morbidity and mortality at this critical transition point.

While transitions can be a risky period for patient safety, observational studies suggest there are benefits to transitions. A new physician may notice something overlooked by the current caregivers.712 Another factor contributing to the challenges of care transitions is the lack of a single clinician or clinical entity taking responsibility for coordination across the continuum of the patient's overall healthcare, regardless of setting.13 Studies indicate that a relationship with a medical home is associated with better health on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations.14 Several medical societies have addressed this issue, including the American College of Physicians (ACP), SGIM, American Academy of Family Physicians, and American Academy of Pediatrics, and they have proposed the concept of the medical home or patient‐centered medical home, which calls for clinicians to assume this responsibility for coordinating their patients' care across settings and for the healthcare system to value and reimburse clinicians for this patient‐centered and comprehensive method of practice.1517

Finally, patients and their families or caregivers have an important role to play in transitions of care. Several observational and cross‐sectional studies have shown that patients and their caregivers and families express significant feelings of anxiety during care transitions. This anxiety can be caused by a lack of understanding and preparation for their self‐care role in the next care setting, confusion due to conflicting advice from different practitioners, and a sense of abandonment attributable to the inability to contact an appropriate healthcare practitioner for guidance, and they report an overall disregard for their preferences and input into the design of the care plan.1820 Clearly, there is room for improvement in all these areas of the inpatient and outpatient care transition, and the Transitions of Care Consensus Conference (TOCCC) attempted to address these areas by developing standards for the transition of care that also harmonize with the work of the Stepping up to the Plate (SUTTP) Alliance of the American Board of Internal Medicine (ABIM) Foundation.21 In addition, other important stakeholders are addressing this topic and actively working to improve communication and continuity in care, including the Centers for Medicare and Medicaid Services (CMS) and the National Quality Forum (NQF). CMS recently developed the Continuity Assessment Record & Evaluation (CARE) tool, a data collection instrument designed to be a standardized, interoperable, common assessment tool to capture key patient characteristics that will provide information related to resource utilization, clinical outcomes, and postdischarge disposition. NQF held a national forum on care coordination in the spring of 2008.

In summary, it is clear that there are qualitative and quantitative deficiencies in transitions of care between the inpatient and outpatient setting that are affecting patient safety and experience with care. The transition from the inpatient setting to the outpatient setting has been more extensively studied, and this body of literature has underscored for the TOCCC several important areas in need of guidance and improvement. Because of this, the scope of application of this document should initially emphasize inpatient‐to‐outpatient transitions as a first step in learning how to improve these processes. However, the transition from the outpatient setting to the inpatient setting also is a clear priority. Because the needs for transfer of information, authority, and responsibility may be different in these situations, a second phase of additional work to develop principles to guide these transitions should be undertaken as quickly as possible. Experience gained in applying these principles to inpatient‐to‐outpatient transitions might usefully inform such work.

Communication among providers and with the patients and their families arose as a clear priority. Medication discrepancies, pending tests, and unknown diagnostic or treatment plans have an immediate impact on patients' health and outcomes. The TOCCC discussed what elements should be among the standard pieces of information exchanged among providers during these transition points. The dire need for coordination of care or a coordinating clinician/medical home became a clear theme in the deliberations of the TOCCC. Most importantly, the role of the patients and their families/caregivers in their continuing care is apparent, and the TOCCC felt this must be an integral part of any principles or standards for transitions of care.

Methods

In the fall/winter of 2006, the executive committees of ACP, SGIM, and SHM agreed to jointly develop a policy statement on transitions of care. Transitions of care specifically between the inpatient and outpatient settings were selected as an ideal topic for collaboration for the 3 societies as they represent the continuum of care for internal medicine within these settings. To accomplish this, the 3 organizations decided to convene a consensus conference to develop consensus guidelines and standards concerning transitions between inpatient and outpatient settings through a multi‐stakeholder process. A steering committee was convened with representatives from ACP, SGIM, SHM, the Agency for Healthcare Research and Quality (AHRQ), ABIM, and the American Geriatric Society (AGS). The steering committee developed the agenda and invitee list for the consensus conference. After the conference was held, the steering committee was expanded to include representation from the American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM).

During the planning stages of the TOCCC, the steering committee became aware of the SUTTP Alliance of the ABIM Foundation. The SUTTP Alliance has representation from medical specialties such as internal medicine and its subspecialties, family medicine, and surgery. The alliance was formed in 2006 and has been working on care coordination across multiple settings and specialties. The SUTTP Alliance had developed a set of principles and standards for care transitions and agreed to provide the draft document to the TOCCC for review, input, and further development and refinement.

Recommendations on Principles and Standards for Managing Transitions in Care Between the Inpatient and Outpatient Settings from ACP, SGIM, SHM, AGS, ACEP, and SAEM

The SUTTP Alliance presented a draft document entitled Principles and Standards for Managing Transitions in Care. In this document, the SUTTP Alliance proposes 5 principles and 8 standards for effective care transitions. A key element of the conference was a presentation by NQF on how to move from principles to standards and eventually to measures. This presentation provided the TOCCC with the theoretical underpinnings for the discussion of these principles and standards and how the TOCCC would provide input on them. The presentation provided an outline for the flow from principles to measures. First, there needs to be a framework that provides guiding principles for what we would like to measure and eventually report. From those principles, a set of preferred practices or standards are developed; the standards are more granular and allow for more specificity in describing the desired practice or outcome and its elements. Standards then provide a roadmap for identification and development of performance measures. With this framework in mind, the TOCCC then discussed in detail the SUTTP principles and standards.

The 5 principles for effective care transitions developed by the SUTTP Alliance are as follows:

• Accountability.

• Communication: clear and direct communication of treatment plans and follow‐up expectations.

• Timely feedback and feed‐forward of information.

• Involvement of the patient and family member, unless inappropriate, in all steps.

• Respect of the hub of coordination of care.

The TOCCC re‐affirmed these principles and added 4 additional principles to this list. Three of the new principles were statements within the 8 standards developed by the SUTTP, but when taking into consideration the framework for the development of principles into standards, the TOCCC felt that the statements were better represented as principles. They are as follows:

• All patients and their families/caregivers should have and should be able to identify their medical home or coordinating clinician (ie, practice or practitioner). (This was originally part of the coordinating clinicians standard, and the TOCCC voted to elevate this to a principle).

• At every point along the transition, the patients and/or their families/caregivers need to know who is responsible for care at that point and who to contact and how.

• National standards should be established for transitions in care and should be adopted and implemented at the national and community level through public health institutions, national accreditation bodies, medical societies, medical institutions, and so forth in order to improve patient outcomes and patient safety. (This was originally part of the SUTTP community standards standard, and the TOCCC moved to elevate this to a principle).

• For monitoring and improving transitions, standardized metrics related to these standards should be used in order to lead to continuous quality improvement and accountability. (This was originally part of the measurement standard, and the TOCCC voted to elevate this to a principle).

The SUTTP Alliance proposed the following 8 standards for care transitions:

• Coordinating clinicians.

• Care plans.

• Communication infrastructure.

• Standard communication formats.

• Transition responsibility.

• Timeliness.

• Community standards.

• Measurement.

The TOCCC affirmed these standards and through a consensus process added more specificity to most of them and elevated components of some of them to principles, as discussed previously. The TOCCC proposes that the following be merged with the SUTTP standards:

• Coordinating clinicians. Communication and information exchange between the medical home and the receiving provider should occur in an amount of time that will allow the receiving provider to effectively treat the patient. This communication and information exchange should ideally occur whenever patients are at a transition of care (eg, at discharge from the inpatient setting). The timeliness of this communication should be consistent with the patient's clinical presentation and, in the case of a patient being discharged, the urgency of the follow‐up required. Guidelines will need to be developed that address both the timeliness and means of communication between the discharging physician and the medical home. Communication and information exchange between the medical home and other physicians may be in the form of a call, voice mail, fax, or other secure, private, and accessible means including mutual access to an electronic health record.

  The ED represents a unique subset of transitions of care. The potential transition can generally be described as outpatient to outpatient or outpatient to inpatient, depending on whether or not the patient is admitted to the hospital. The outpatient‐to‐outpatient transition can also encompass a number of potential variations. Patients with a medical home may be referred to the ED by the medical home, or they may self‐refer. A significant number of patients do not have a physician and self‐refer to the ED. The disposition from the ED, either outpatient to outpatient or outpatient to inpatient, is similarly represented by a number of variables. Discharged patients may or may not have a medical home, may or may not need a specialist, and may or may not require urgent (<24 hours) follow‐up. Admitted patients may or may not have a medical home and may or may not require specialty care. This variety of variables precludes a single approach to ED transition of care coordination. The determination of which scenarios will be appropriate for the development of standards (coordinating clinicians and transition responsibility) will require further contributions from ACEP and SAEM and review by the steering committee.

• Care plans/transition record. The TOCCC also agreed that there is a minimal set of data elements that should always be part of the transition record. The TOCCC suggested that this minimal data set be part of an initial implementation of this standard. That list includes the following:

  The TOCCC discussed what components should be included in an ideal transition record and agreed on the following elements:

  The TOCCC also added a new standard under this heading: Patients and/or their families/caregivers must receive, understand, and be encouraged to participate in the development of the transition record, which should take into consideration patients' health literacy and insurance status and be culturally sensitive.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Clear identification of the medical home/transferring coordinating physician/emnstitution and the contact information.

• Patient's cognitive status.

• Test results/pending results.

• Principle diagnosis and problem list.

• Medication list (reconciliation) including over‐the‐counter medications/herbals, allergies, and drug interactions.

• Emergency plan and contact number and person.

• Treatment and diagnostic plan.

• Prognosis and goals of care.

• Test results/pending results.

• Clear identification of the medical home and/or transferring coordinating physician/emnstitution.

• Patient's cognitive status.

• Advance directives, power of attorney, and consent.

• Planned interventions, durable medical equipment, wound care, and so forth.

• Assessment of caregiver status.

• Communication infrastructure. All communications between providers and between providers and patients and families/caregivers need to be secure, private, Health Insurance Portability and Accountability Actcompliant, and accessible to patients and those practitioners who care for them. Communication needs to be 2‐way with an opportunity for clarification and feedback. Each sending provider needs to provide a contact name and the number of an individual who can respond to questions or concerns. The content of transferred information needs to include a core standardized data set. This information needs to be transferred as a living database; that is, it is created only once, and then each subsequent provider only needs to update, validate, or modify the information. Patient information should be available to the provider prior to the patient's arrival. Information transfer needs to adhere to national data standards. Patients should be provided with a medication list that is accessible (paper or electronic), clear, and dated.

• Standard communication formats. Communities need to develop standard data transfer forms (templates and transmission protocols). Access to a patient's medical history needs to be on a current and ongoing basis with the ability to modify information as a patient's condition changes. Patients, families, and caregivers should have access to their information (nothing about me without me). A section on the transfer record should be devoted to communicating a patient's preferences, priorities, goals, and values (eg, the patient does not want intubation).

• Transition responsibility. The sending provider/emnstitution/team at the clinical organization maintains responsibility for the care of the patient until the receiving clinician/location confirms that the transfer and assumption of responsibility is complete (within a reasonable timeframe for the receiving clinician to receive the information; ie, transfers that occur in the middle of the night can be communicated during standard working hours). The sending provider should be available for clarification with issues of care within a reasonable timeframe after the transfer has been completed, and this timeframe should be based on the conditions of the transfer settings. The patient should be able to identify the responsible provider. In the case of patients who do not have an ongoing ambulatory care provider or whose ambulatory care provider has not assumed responsibility, the hospital‐based clinicians will not be required to assume responsibility for the care of these patients once they are discharged.

• Timeliness. Timeliness of feedback and feed‐forward of information from a sending provider to a receiving provider should be contingent on 4 factors:

  This information should be available at the time of the patient encounter.

• Transition settings.

• Patient circumstances.

• Level of acuity.

• Clear transition responsibility.

• Community standards. Medical communities/emnstitutions must demonstrate accountability for transitions of care by adopting national standards, and processes should be established to promote effective transitions of care.

• Measurement. For monitoring and improving transitions, standardized metrics related to these standards should be used. These metrics/measures should be evidence‐based, address documented gaps, and have a demonstrated impact on improving care (complying with performance measure standards) whenever feasible. Results from measurements using standardized metrics must lead to continuous improvement of the transition process. The validity, reliability, cost, and impact, including unintended consequences, of these measures should be assessed and re‐evaluated.

All these standards should be applied with special attention to the various transition settings and should be appropriate to each transition setting. Measure developers will need to take this into account when developing measures based on these proposed standards.

The TOCCC also went through a consensus prioritization exercise to rank‐order the consensus standards. All meeting participants were asked to rank their top 3 priorities of the 7 standards, giving a numeric score of 1 for their highest priority, a score of 2 for their second highest priority, and a score of 3 for their third highest priority. Summary scores were calculated, and the standards were rank‐ordered from the lowest summary score to the highest. The TOCCC recognizes that full implementation of all of these standards may not be feasible and that these standards may be implemented on a stepped or incremental basis. This prioritization can assist in deciding which of these to implement. The results of the prioritization exercise are as follows:

• 1

  All transitions must include a transition record

• 2

  Transition responsibility

• 3

  Coordinating clinicians

• 4

  Patient and family involvement and ownership of the transition record

• 5

  Communication infrastructure

• 6

  Timeliness

• 7

  Community standards

Future Challenges

In addition to the work on the principles and standards, the TOCCC uncovered six further challenges which are described below.

Next Steps for the TOCCC

The TOCCC focuses only on the transitions between the inpatient and outpatient settings and does not address the equally important transitions between many other different care settings, such as the transition from a hospital to a nursing home or rehabilitation facility. The intent of the TOCCC is to provide this document to national measure developers such as the Physician Consortium for Performance Improvement and others in order to guide measure development and ultimately lead to improvements in quality and safety in care transitions.

I was 12 years old before I knew her actual name, Le Thi Canh, because we always called her Ba ngoai. She was my grandmother, and this is the story of how she died.

To see my grandmother for the warrior woman that she was to me, you have to know that her farmer father sent her to the city for schooling because he didn't know what else to do with a daughter who was so smart. In early 20th‐century Vietnam, this was an unusual thing to do with a girl. She met my grandfather there, when he was a campus activist, helping him hand out nationalist leaflets. He introduced her to his Communist friends. After the French jailed my grandfather, my grandmother courted him by sending him long letters and care packages while he was in prison. When he was finally released, they married and started a family while he struggled financially as a newspaper publisher and at other odd jobs. But in 1947 his own Communist comrades killed him as part of a party purge. He had been forewarned, and opted to go quietly rather than try to escape because he was promised that this would guarantee her safety. Before they killed him, somewhere in the mountains, my grandfather gave a soldier friend a poem he wrote for his wife. When she told me this story 8 years ago, more than half a century later, she recited his love missive from memory.

At the time of her husband's death, my grandmother had 6 children, the last born just a few weeks before. After a few years of scraping by (she ran her own one‐room school for a while), she decided to leave Hanoi, and migrated south to Saigon with her brood. She was a famously strict parent, to hear my aunts and uncles tell it. She watched them like a hawk, worked full‐time, put them all through school, and eventually rose to a leadership position in the Ministry of Social Work in South Vietnam. My memories of Saigon life are punctuated by scenes of siblings and cousins running around at her regal house, yellow stucco with porticos and black iron gates, at a corner turn in the road, past a cemetery.

On this side of the world, to see her, you would never have thought that my grandmother had led such an epic life. She never worked again after immigrating with us in 1975. She lived on Social Security checks, gardened, said Buddhist prayers, and was nanny to her grandchildren. She watched soap operas religiously, and could report their full plot lines while sitting and knitting. She bundled her many sadnesses in a contented, 4‐foot 9‐inch frame.

Having no home of her own, she would move from one child's house to another every few months so as not to wear out her welcome. But her children lived in Pennsylvania, New Jersey, Florida, Texas, and Maryland. And in most of these cities, she had a different primary care physician. She has 21 grandchildren; 8 of us are physicians. Yet the aunts and uncles told us very little about her medical care. She preferred older‐generation Vietnamese physicians and I'm not sure that they were all competent, but her children did not want to argue with an octogenarian war survivor, and we deferred to their judgment. So we would find out only incidentally, for example, that a doctor prescribed her tuberculosis drugs for a visit to Vietnam.

For many years, Ba ngoai had no major medical problems. She was hypothyroid and hypertensive but on medication and generally high functioning. She had a lumpectomy for early‐stage breast cancer. Then, a year or so after she told me the story of my grandfather's death, Alzheimer's set in. It became harder for her to report symptoms reliably, and she became mildly depressed. Her grandchildren were now birthing our own babies, and we offered these as a distraction, trying to surround her with celebrations of these new fruits of her life labors.

Ba ngoai's decline worsened 3 years ago. She became more easily fatigued, depressed, and confused. A few months before she died, she started to get dyspneic, and couldn't go for short walks any more. In retrospect, I think that her prescription for thyroid replacement somehow fell through the cracks, probably in the transfer of care from one city to another, although there remains a great deal of confusion in the family about exactly what happened. Her thyroxine levels dwindled. One evening in October of that year, at my uncle's house in Maryland, she became severely short of breath and nearly unconscious. They called her Maryland PCP, who sent her to an emergency room at a local hospital. She was admitted in severe congestive heart failure. When the hospitalist spoke with my mother and uncle, he explained that he could take some fluid off her lungs, but that she might need to be intubated and admitted to intensive care. Looking back, I guessed that she probably needed pressors and invasive monitoring. He asked them, Is this what you want? My uncle said, No, it's not. And the hospitalist and the huddle of relatives decided she should come home.

The question was, into whose care would she be discharged? My elders were wary of contacting her PCP, partly because some blamed him for not catching and addressing her symptoms sooner, partly because to even confront him with this perception would cause him, and hence them, to lose face. This seemed too excruciating a scenario to them.

So at last, my uncle called my brother, the oldest grandchild and a very talented clinician. My brother is a pulmonologist, the kind of physician who once did a history and physical on a patient complaining only of Really feeling bad, Doc, and confidently started a steroid infusion before returning the next day with test results confirming his suspicion of Wegener's granulomatosis. He took my grandmother's physical by phone, and told my uncle to increase her furosemide dose. Then he said, I'm on call, but I'll be down there tomorrow. Call everyone together. Most of my relatives were already in town; they had come at news of her decline. She became alert enough for a couple of days to see and recognize most of the faces around her, like so many markers on a long journey. And then she died, slipped away.

I find it hard to define good coordination of care. My instinct as a researcher is to list measurable elements, but the tools we currently have generate metrics that are either reductionistsuch as how rapidly a physician returns a patient's callor so global that they no longer seem actionablesuch as patient satisfaction. But if such metrics set the goal in the distance, it seems useful to also define its counterpartdiscoordinationas a marker of the reality we would like to leave behind us as far as possible. Discoordination includes elements of discontinuity (lost patient history), fragmentation (actions by multiple players), overuse and/or inappropriate use of services, and ultimately, ineffective care (that is, the patient's needs go unmet).

My experience of discoordination was that of a Rube Goldberg contraption. It's composed of innumerable subtasks, each cleverly designed as the easiest solution to a seemingly short‐term problem, as quick fixes, but that in aggregate generate such chaos that the ultimate purpose is lost. They include acts of denial, lies to avoid embarrassment or conflict, and choices of convenience. My mother and her siblings accommodated my grandmother's choice of physicians by (secretly) not always adhering to care recommendations they didn't agree with, instead of challenging her. They took her to different physicians in different cities rather than risk embarrassing (due to an exaggerated sense of the smallness of the Vietnamese community) any one physician by dropping him. Her grandchildren, despite our medical training, found it culturally easier to defer to our elders than to intervene in substandard care. And none of her physicians aggressively followed up to ensure that a frail Alzheimer's patient was getting the care she needed. This is not to suggest that coordination is a simple task because Rube Goldberg machines make simple tasks complicated. Rather, it is a depiction of how indirectly we tend to address the problem.

I imagine a different course of events for my grandmother in the absence of discoordination. What if her children and physicians had understood and acknowledged to one another that her care was fragmented and therefore suboptimal? What if we grandchildren had confronted both Ba Ngoai and our parents sooner about their choice of physicians and offered to take on more of the burden of helping with her care decisions? Would we, as physicians, have been better able to ensure that her providers made rational clinical decisions? And what if she and her family had consistently recognized a single physician as her medical home? Snowbirding is hardly a rare phenomenon among Medicare patients; we could have designated one physician as primarily responsible for coordinating her care even without limiting her travel.

Care coordination is an inherently human activity. Supportive elements such as efficient transfer of medical information, resources for patient education and self‐care, and adequate reimbursement can take us to the brink of, but not actually bridge, the chasm that we want to cross. Traversing that divide sometimes requires settling turf issues over undesirable responsibilities between different physicians and between physicians and other providers; clarifying who has primary responsibility for different types of decisions (I lead on cardiac issues and her son leads on health maintenance); and the violation of cultural norms of patients, families, and/or providers. These can be uncomfortable, unpleasant conversations that at times seem beside the point. But in aggregate, they are the work of coordination, because they force us to align our expectations of one another. No level of information technology could have dismantled the Rube Goldberg machine that trapped my grandmother. Her last of many lessons for me was that emotional courage, honesty, and perseverance offer a much more direct path through the muck.

I was 12 years old before I knew her actual name, Le Thi Canh, because we always called her Ba ngoai. She was my grandmother, and this is the story of how she died.

To see my grandmother for the warrior woman that she was to me, you have to know that her farmer father sent her to the city for schooling because he didn't know what else to do with a daughter who was so smart. In early 20th‐century Vietnam, this was an unusual thing to do with a girl. She met my grandfather there, when he was a campus activist, helping him hand out nationalist leaflets. He introduced her to his Communist friends. After the French jailed my grandfather, my grandmother courted him by sending him long letters and care packages while he was in prison. When he was finally released, they married and started a family while he struggled financially as a newspaper publisher and at other odd jobs. But in 1947 his own Communist comrades killed him as part of a party purge. He had been forewarned, and opted to go quietly rather than try to escape because he was promised that this would guarantee her safety. Before they killed him, somewhere in the mountains, my grandfather gave a soldier friend a poem he wrote for his wife. When she told me this story 8 years ago, more than half a century later, she recited his love missive from memory.

At the time of her husband's death, my grandmother had 6 children, the last born just a few weeks before. After a few years of scraping by (she ran her own one‐room school for a while), she decided to leave Hanoi, and migrated south to Saigon with her brood. She was a famously strict parent, to hear my aunts and uncles tell it. She watched them like a hawk, worked full‐time, put them all through school, and eventually rose to a leadership position in the Ministry of Social Work in South Vietnam. My memories of Saigon life are punctuated by scenes of siblings and cousins running around at her regal house, yellow stucco with porticos and black iron gates, at a corner turn in the road, past a cemetery.

On this side of the world, to see her, you would never have thought that my grandmother had led such an epic life. She never worked again after immigrating with us in 1975. She lived on Social Security checks, gardened, said Buddhist prayers, and was nanny to her grandchildren. She watched soap operas religiously, and could report their full plot lines while sitting and knitting. She bundled her many sadnesses in a contented, 4‐foot 9‐inch frame.

Having no home of her own, she would move from one child's house to another every few months so as not to wear out her welcome. But her children lived in Pennsylvania, New Jersey, Florida, Texas, and Maryland. And in most of these cities, she had a different primary care physician. She has 21 grandchildren; 8 of us are physicians. Yet the aunts and uncles told us very little about her medical care. She preferred older‐generation Vietnamese physicians and I'm not sure that they were all competent, but her children did not want to argue with an octogenarian war survivor, and we deferred to their judgment. So we would find out only incidentally, for example, that a doctor prescribed her tuberculosis drugs for a visit to Vietnam.

For many years, Ba ngoai had no major medical problems. She was hypothyroid and hypertensive but on medication and generally high functioning. She had a lumpectomy for early‐stage breast cancer. Then, a year or so after she told me the story of my grandfather's death, Alzheimer's set in. It became harder for her to report symptoms reliably, and she became mildly depressed. Her grandchildren were now birthing our own babies, and we offered these as a distraction, trying to surround her with celebrations of these new fruits of her life labors.

Ba ngoai's decline worsened 3 years ago. She became more easily fatigued, depressed, and confused. A few months before she died, she started to get dyspneic, and couldn't go for short walks any more. In retrospect, I think that her prescription for thyroid replacement somehow fell through the cracks, probably in the transfer of care from one city to another, although there remains a great deal of confusion in the family about exactly what happened. Her thyroxine levels dwindled. One evening in October of that year, at my uncle's house in Maryland, she became severely short of breath and nearly unconscious. They called her Maryland PCP, who sent her to an emergency room at a local hospital. She was admitted in severe congestive heart failure. When the hospitalist spoke with my mother and uncle, he explained that he could take some fluid off her lungs, but that she might need to be intubated and admitted to intensive care. Looking back, I guessed that she probably needed pressors and invasive monitoring. He asked them, Is this what you want? My uncle said, No, it's not. And the hospitalist and the huddle of relatives decided she should come home.

The question was, into whose care would she be discharged? My elders were wary of contacting her PCP, partly because some blamed him for not catching and addressing her symptoms sooner, partly because to even confront him with this perception would cause him, and hence them, to lose face. This seemed too excruciating a scenario to them.

So at last, my uncle called my brother, the oldest grandchild and a very talented clinician. My brother is a pulmonologist, the kind of physician who once did a history and physical on a patient complaining only of Really feeling bad, Doc, and confidently started a steroid infusion before returning the next day with test results confirming his suspicion of Wegener's granulomatosis. He took my grandmother's physical by phone, and told my uncle to increase her furosemide dose. Then he said, I'm on call, but I'll be down there tomorrow. Call everyone together. Most of my relatives were already in town; they had come at news of her decline. She became alert enough for a couple of days to see and recognize most of the faces around her, like so many markers on a long journey. And then she died, slipped away.

I find it hard to define good coordination of care. My instinct as a researcher is to list measurable elements, but the tools we currently have generate metrics that are either reductionistsuch as how rapidly a physician returns a patient's callor so global that they no longer seem actionablesuch as patient satisfaction. But if such metrics set the goal in the distance, it seems useful to also define its counterpartdiscoordinationas a marker of the reality we would like to leave behind us as far as possible. Discoordination includes elements of discontinuity (lost patient history), fragmentation (actions by multiple players), overuse and/or inappropriate use of services, and ultimately, ineffective care (that is, the patient's needs go unmet).

My experience of discoordination was that of a Rube Goldberg contraption. It's composed of innumerable subtasks, each cleverly designed as the easiest solution to a seemingly short‐term problem, as quick fixes, but that in aggregate generate such chaos that the ultimate purpose is lost. They include acts of denial, lies to avoid embarrassment or conflict, and choices of convenience. My mother and her siblings accommodated my grandmother's choice of physicians by (secretly) not always adhering to care recommendations they didn't agree with, instead of challenging her. They took her to different physicians in different cities rather than risk embarrassing (due to an exaggerated sense of the smallness of the Vietnamese community) any one physician by dropping him. Her grandchildren, despite our medical training, found it culturally easier to defer to our elders than to intervene in substandard care. And none of her physicians aggressively followed up to ensure that a frail Alzheimer's patient was getting the care she needed. This is not to suggest that coordination is a simple task because Rube Goldberg machines make simple tasks complicated. Rather, it is a depiction of how indirectly we tend to address the problem.

I imagine a different course of events for my grandmother in the absence of discoordination. What if her children and physicians had understood and acknowledged to one another that her care was fragmented and therefore suboptimal? What if we grandchildren had confronted both Ba Ngoai and our parents sooner about their choice of physicians and offered to take on more of the burden of helping with her care decisions? Would we, as physicians, have been better able to ensure that her providers made rational clinical decisions? And what if she and her family had consistently recognized a single physician as her medical home? Snowbirding is hardly a rare phenomenon among Medicare patients; we could have designated one physician as primarily responsible for coordinating her care even without limiting her travel.

Care coordination is an inherently human activity. Supportive elements such as efficient transfer of medical information, resources for patient education and self‐care, and adequate reimbursement can take us to the brink of, but not actually bridge, the chasm that we want to cross. Traversing that divide sometimes requires settling turf issues over undesirable responsibilities between different physicians and between physicians and other providers; clarifying who has primary responsibility for different types of decisions (I lead on cardiac issues and her son leads on health maintenance); and the violation of cultural norms of patients, families, and/or providers. These can be uncomfortable, unpleasant conversations that at times seem beside the point. But in aggregate, they are the work of coordination, because they force us to align our expectations of one another. No level of information technology could have dismantled the Rube Goldberg machine that trapped my grandmother. Her last of many lessons for me was that emotional courage, honesty, and perseverance offer a much more direct path through the muck.

I was 12 years old before I knew her actual name, Le Thi Canh, because we always called her Ba ngoai. She was my grandmother, and this is the story of how she died.

To see my grandmother for the warrior woman that she was to me, you have to know that her farmer father sent her to the city for schooling because he didn't know what else to do with a daughter who was so smart. In early 20th‐century Vietnam, this was an unusual thing to do with a girl. She met my grandfather there, when he was a campus activist, helping him hand out nationalist leaflets. He introduced her to his Communist friends. After the French jailed my grandfather, my grandmother courted him by sending him long letters and care packages while he was in prison. When he was finally released, they married and started a family while he struggled financially as a newspaper publisher and at other odd jobs. But in 1947 his own Communist comrades killed him as part of a party purge. He had been forewarned, and opted to go quietly rather than try to escape because he was promised that this would guarantee her safety. Before they killed him, somewhere in the mountains, my grandfather gave a soldier friend a poem he wrote for his wife. When she told me this story 8 years ago, more than half a century later, she recited his love missive from memory.

At the time of her husband's death, my grandmother had 6 children, the last born just a few weeks before. After a few years of scraping by (she ran her own one‐room school for a while), she decided to leave Hanoi, and migrated south to Saigon with her brood. She was a famously strict parent, to hear my aunts and uncles tell it. She watched them like a hawk, worked full‐time, put them all through school, and eventually rose to a leadership position in the Ministry of Social Work in South Vietnam. My memories of Saigon life are punctuated by scenes of siblings and cousins running around at her regal house, yellow stucco with porticos and black iron gates, at a corner turn in the road, past a cemetery.

On this side of the world, to see her, you would never have thought that my grandmother had led such an epic life. She never worked again after immigrating with us in 1975. She lived on Social Security checks, gardened, said Buddhist prayers, and was nanny to her grandchildren. She watched soap operas religiously, and could report their full plot lines while sitting and knitting. She bundled her many sadnesses in a contented, 4‐foot 9‐inch frame.

Having no home of her own, she would move from one child's house to another every few months so as not to wear out her welcome. But her children lived in Pennsylvania, New Jersey, Florida, Texas, and Maryland. And in most of these cities, she had a different primary care physician. She has 21 grandchildren; 8 of us are physicians. Yet the aunts and uncles told us very little about her medical care. She preferred older‐generation Vietnamese physicians and I'm not sure that they were all competent, but her children did not want to argue with an octogenarian war survivor, and we deferred to their judgment. So we would find out only incidentally, for example, that a doctor prescribed her tuberculosis drugs for a visit to Vietnam.

For many years, Ba ngoai had no major medical problems. She was hypothyroid and hypertensive but on medication and generally high functioning. She had a lumpectomy for early‐stage breast cancer. Then, a year or so after she told me the story of my grandfather's death, Alzheimer's set in. It became harder for her to report symptoms reliably, and she became mildly depressed. Her grandchildren were now birthing our own babies, and we offered these as a distraction, trying to surround her with celebrations of these new fruits of her life labors.

Ba ngoai's decline worsened 3 years ago. She became more easily fatigued, depressed, and confused. A few months before she died, she started to get dyspneic, and couldn't go for short walks any more. In retrospect, I think that her prescription for thyroid replacement somehow fell through the cracks, probably in the transfer of care from one city to another, although there remains a great deal of confusion in the family about exactly what happened. Her thyroxine levels dwindled. One evening in October of that year, at my uncle's house in Maryland, she became severely short of breath and nearly unconscious. They called her Maryland PCP, who sent her to an emergency room at a local hospital. She was admitted in severe congestive heart failure. When the hospitalist spoke with my mother and uncle, he explained that he could take some fluid off her lungs, but that she might need to be intubated and admitted to intensive care. Looking back, I guessed that she probably needed pressors and invasive monitoring. He asked them, Is this what you want? My uncle said, No, it's not. And the hospitalist and the huddle of relatives decided she should come home.

The question was, into whose care would she be discharged? My elders were wary of contacting her PCP, partly because some blamed him for not catching and addressing her symptoms sooner, partly because to even confront him with this perception would cause him, and hence them, to lose face. This seemed too excruciating a scenario to them.

So at last, my uncle called my brother, the oldest grandchild and a very talented clinician. My brother is a pulmonologist, the kind of physician who once did a history and physical on a patient complaining only of Really feeling bad, Doc, and confidently started a steroid infusion before returning the next day with test results confirming his suspicion of Wegener's granulomatosis. He took my grandmother's physical by phone, and told my uncle to increase her furosemide dose. Then he said, I'm on call, but I'll be down there tomorrow. Call everyone together. Most of my relatives were already in town; they had come at news of her decline. She became alert enough for a couple of days to see and recognize most of the faces around her, like so many markers on a long journey. And then she died, slipped away.

I find it hard to define good coordination of care. My instinct as a researcher is to list measurable elements, but the tools we currently have generate metrics that are either reductionistsuch as how rapidly a physician returns a patient's callor so global that they no longer seem actionablesuch as patient satisfaction. But if such metrics set the goal in the distance, it seems useful to also define its counterpartdiscoordinationas a marker of the reality we would like to leave behind us as far as possible. Discoordination includes elements of discontinuity (lost patient history), fragmentation (actions by multiple players), overuse and/or inappropriate use of services, and ultimately, ineffective care (that is, the patient's needs go unmet).

My experience of discoordination was that of a Rube Goldberg contraption. It's composed of innumerable subtasks, each cleverly designed as the easiest solution to a seemingly short‐term problem, as quick fixes, but that in aggregate generate such chaos that the ultimate purpose is lost. They include acts of denial, lies to avoid embarrassment or conflict, and choices of convenience. My mother and her siblings accommodated my grandmother's choice of physicians by (secretly) not always adhering to care recommendations they didn't agree with, instead of challenging her. They took her to different physicians in different cities rather than risk embarrassing (due to an exaggerated sense of the smallness of the Vietnamese community) any one physician by dropping him. Her grandchildren, despite our medical training, found it culturally easier to defer to our elders than to intervene in substandard care. And none of her physicians aggressively followed up to ensure that a frail Alzheimer's patient was getting the care she needed. This is not to suggest that coordination is a simple task because Rube Goldberg machines make simple tasks complicated. Rather, it is a depiction of how indirectly we tend to address the problem.

I imagine a different course of events for my grandmother in the absence of discoordination. What if her children and physicians had understood and acknowledged to one another that her care was fragmented and therefore suboptimal? What if we grandchildren had confronted both Ba Ngoai and our parents sooner about their choice of physicians and offered to take on more of the burden of helping with her care decisions? Would we, as physicians, have been better able to ensure that her providers made rational clinical decisions? And what if she and her family had consistently recognized a single physician as her medical home? Snowbirding is hardly a rare phenomenon among Medicare patients; we could have designated one physician as primarily responsible for coordinating her care even without limiting her travel.

Care coordination is an inherently human activity. Supportive elements such as efficient transfer of medical information, resources for patient education and self‐care, and adequate reimbursement can take us to the brink of, but not actually bridge, the chasm that we want to cross. Traversing that divide sometimes requires settling turf issues over undesirable responsibilities between different physicians and between physicians and other providers; clarifying who has primary responsibility for different types of decisions (I lead on cardiac issues and her son leads on health maintenance); and the violation of cultural norms of patients, families, and/or providers. These can be uncomfortable, unpleasant conversations that at times seem beside the point. But in aggregate, they are the work of coordination, because they force us to align our expectations of one another. No level of information technology could have dismantled the Rube Goldberg machine that trapped my grandmother. Her last of many lessons for me was that emotional courage, honesty, and perseverance offer a much more direct path through the muck.

Hospitalists recognize the importance of the care transition from the inpatient setting to the outpatient setting, despite being described as causing a divorce between inpatient and outpatient care.1 If you do not believe this, just glance at the table of contents for this issue of the Journal of Hospital Medicine, which has 5 reports on research about various aspects of the hospital discharge transition complemented by an eloquent story of how a hospitalist facilitated the care coordination of one family's matriarch.2 An accompanying editorial proposes that hospitalists embrace the need of patients and their caregivers for care coordination.3 Thankfully, a growing number of academic hospitalists are focusing their efforts on identifying problems in the process and evaluating potential interventions to optimize it.

The hospital discharge process commonly has been an afterthought, concluding a typically intense experience for patients, some of whom may have begun the episode of hospitalization near death. After diagnostic evaluations and treatments, a patient has achieved stable enough status to be discharged home, and the inpatient physician has signed off with a simple may go in the written orders. The physician may feel absolved of responsibility as he expects the nurses to take care of instructions and to find transportation home for the patient. Unfortunately, this experience often is consistent with Webster's definition of discharge: to relieve of a charge, load, or burden unload release from an obligation. Some patients may feel like a Nolan Ryan fastball flying out of the hospital, but with no one to catch them.

Recognizing how the hospital discharge transition to home can be a perilous process fraught with failure,4 we laid out a research agenda for transitions of care. We are gratified to see the robust response from researchers published in this issue of the Journal of Hospital Medicine. The studies range from the description of a new tool to assess patients' mobility before discharge5 to evidence that the length of stay is prolonged (ie, delayed discharge) when the discharge diagnosis differs from that made on admission.6 Chen and colleagues analyzed the timing of discharge during the day and found that the duration of the discharge process was influenced by the need for consultation or a procedure prior to discharge; this finding is not surprising to practicing hospitalists. We agree with their conclusion that broad institutional efforts will be needed to facilitate the process. Hospitalists are part of a system and must engage the entire team to improve efficiency.

O'Leary and fellow hospitalists7 at Northwestern Memorial Hospital focused on creating a better discharge summary within their electronic health record with the aim of improved overall quality of the summaries and, just as important, timely completion. Despite some research indicating that absence of adequate communication between primary care providers and inpatient medical teams is not associated with adverse clinical outcomes,8 other research has demonstrated that it does affect outcomes and probably affects rehospitalization rates.9, 10 Moreover, another article in this issue describes a project undertaken at Baylor Health Care System (Dallas, TX) that demonstrated a reduction in emergency department visits and readmissions within 30 days post‐discharge among high‐risk elderly medical patients when a targeted care bundle was used.11 The results from this intervention, which consisted of medication counseling/reconciliation by a clinical pharmacist, condition‐specific enhanced discharge planning by a care coordinator, and phone follow‐up, confirm recent results from 2 similar studies.12, 13 These studies provide support for the idea that straightforward changes in the discharge process can improve patient outcomes.

Today in the United States, hospitalists likely care for the majority of hospitalized older patients.14 We strongly encourage them to use evidence‐based approaches to optimize the discharge process in their hospitals, and fortunately, clear guidance is available. Because of generous funding from the John A. Hartford Foundation, Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) is mentoring 30 hospitals in an effort to implement the BOOST toolkit and improve their discharge transition processes.15 Another cost‐effective method involves the use of transition coaches to help the most vulnerable older patients with complex care needs.16 This approach is now being implemented by more than 100 healthcare organizations worldwide.17

Heartened by these exciting initiatives, we applaud the Society of Hospital Medicine's collaboration with the American College of Physicians, the Society of General Internal Medicine, the American Geriatrics Society, and the Society of Academic Emergency Medicine to produce a consensus policy statement on transitions of care that provides guiding principles for transitions both into and out of the hospital.18 Soon, all hospitalized patients and their caregivers may receive robust education prior to discharge, confirmation of their understanding with the teach‐back approach, medication reconciliation, and clear instructions for follow‐up, and the patient's primary care provider will be aware of all that has happened. Patients should expect nothing less than hospitalists ensuring their seamless transition from hospital to home.

Hospitalists recognize the importance of the care transition from the inpatient setting to the outpatient setting, despite being described as causing a divorce between inpatient and outpatient care.1 If you do not believe this, just glance at the table of contents for this issue of the Journal of Hospital Medicine, which has 5 reports on research about various aspects of the hospital discharge transition complemented by an eloquent story of how a hospitalist facilitated the care coordination of one family's matriarch.2 An accompanying editorial proposes that hospitalists embrace the need of patients and their caregivers for care coordination.3 Thankfully, a growing number of academic hospitalists are focusing their efforts on identifying problems in the process and evaluating potential interventions to optimize it.

The hospital discharge process commonly has been an afterthought, concluding a typically intense experience for patients, some of whom may have begun the episode of hospitalization near death. After diagnostic evaluations and treatments, a patient has achieved stable enough status to be discharged home, and the inpatient physician has signed off with a simple may go in the written orders. The physician may feel absolved of responsibility as he expects the nurses to take care of instructions and to find transportation home for the patient. Unfortunately, this experience often is consistent with Webster's definition of discharge: to relieve of a charge, load, or burden unload release from an obligation. Some patients may feel like a Nolan Ryan fastball flying out of the hospital, but with no one to catch them.

Recognizing how the hospital discharge transition to home can be a perilous process fraught with failure,4 we laid out a research agenda for transitions of care. We are gratified to see the robust response from researchers published in this issue of the Journal of Hospital Medicine. The studies range from the description of a new tool to assess patients' mobility before discharge5 to evidence that the length of stay is prolonged (ie, delayed discharge) when the discharge diagnosis differs from that made on admission.6 Chen and colleagues analyzed the timing of discharge during the day and found that the duration of the discharge process was influenced by the need for consultation or a procedure prior to discharge; this finding is not surprising to practicing hospitalists. We agree with their conclusion that broad institutional efforts will be needed to facilitate the process. Hospitalists are part of a system and must engage the entire team to improve efficiency.

O'Leary and fellow hospitalists7 at Northwestern Memorial Hospital focused on creating a better discharge summary within their electronic health record with the aim of improved overall quality of the summaries and, just as important, timely completion. Despite some research indicating that absence of adequate communication between primary care providers and inpatient medical teams is not associated with adverse clinical outcomes,8 other research has demonstrated that it does affect outcomes and probably affects rehospitalization rates.9, 10 Moreover, another article in this issue describes a project undertaken at Baylor Health Care System (Dallas, TX) that demonstrated a reduction in emergency department visits and readmissions within 30 days post‐discharge among high‐risk elderly medical patients when a targeted care bundle was used.11 The results from this intervention, which consisted of medication counseling/reconciliation by a clinical pharmacist, condition‐specific enhanced discharge planning by a care coordinator, and phone follow‐up, confirm recent results from 2 similar studies.12, 13 These studies provide support for the idea that straightforward changes in the discharge process can improve patient outcomes.

Today in the United States, hospitalists likely care for the majority of hospitalized older patients.14 We strongly encourage them to use evidence‐based approaches to optimize the discharge process in their hospitals, and fortunately, clear guidance is available. Because of generous funding from the John A. Hartford Foundation, Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) is mentoring 30 hospitals in an effort to implement the BOOST toolkit and improve their discharge transition processes.15 Another cost‐effective method involves the use of transition coaches to help the most vulnerable older patients with complex care needs.16 This approach is now being implemented by more than 100 healthcare organizations worldwide.17

Heartened by these exciting initiatives, we applaud the Society of Hospital Medicine's collaboration with the American College of Physicians, the Society of General Internal Medicine, the American Geriatrics Society, and the Society of Academic Emergency Medicine to produce a consensus policy statement on transitions of care that provides guiding principles for transitions both into and out of the hospital.18 Soon, all hospitalized patients and their caregivers may receive robust education prior to discharge, confirmation of their understanding with the teach‐back approach, medication reconciliation, and clear instructions for follow‐up, and the patient's primary care provider will be aware of all that has happened. Patients should expect nothing less than hospitalists ensuring their seamless transition from hospital to home.

Hospitalists recognize the importance of the care transition from the inpatient setting to the outpatient setting, despite being described as causing a divorce between inpatient and outpatient care.1 If you do not believe this, just glance at the table of contents for this issue of the Journal of Hospital Medicine, which has 5 reports on research about various aspects of the hospital discharge transition complemented by an eloquent story of how a hospitalist facilitated the care coordination of one family's matriarch.2 An accompanying editorial proposes that hospitalists embrace the need of patients and their caregivers for care coordination.3 Thankfully, a growing number of academic hospitalists are focusing their efforts on identifying problems in the process and evaluating potential interventions to optimize it.

The hospital discharge process commonly has been an afterthought, concluding a typically intense experience for patients, some of whom may have begun the episode of hospitalization near death. After diagnostic evaluations and treatments, a patient has achieved stable enough status to be discharged home, and the inpatient physician has signed off with a simple may go in the written orders. The physician may feel absolved of responsibility as he expects the nurses to take care of instructions and to find transportation home for the patient. Unfortunately, this experience often is consistent with Webster's definition of discharge: to relieve of a charge, load, or burden unload release from an obligation. Some patients may feel like a Nolan Ryan fastball flying out of the hospital, but with no one to catch them.

Recognizing how the hospital discharge transition to home can be a perilous process fraught with failure,4 we laid out a research agenda for transitions of care. We are gratified to see the robust response from researchers published in this issue of the Journal of Hospital Medicine. The studies range from the description of a new tool to assess patients' mobility before discharge5 to evidence that the length of stay is prolonged (ie, delayed discharge) when the discharge diagnosis differs from that made on admission.6 Chen and colleagues analyzed the timing of discharge during the day and found that the duration of the discharge process was influenced by the need for consultation or a procedure prior to discharge; this finding is not surprising to practicing hospitalists. We agree with their conclusion that broad institutional efforts will be needed to facilitate the process. Hospitalists are part of a system and must engage the entire team to improve efficiency.

O'Leary and fellow hospitalists7 at Northwestern Memorial Hospital focused on creating a better discharge summary within their electronic health record with the aim of improved overall quality of the summaries and, just as important, timely completion. Despite some research indicating that absence of adequate communication between primary care providers and inpatient medical teams is not associated with adverse clinical outcomes,8 other research has demonstrated that it does affect outcomes and probably affects rehospitalization rates.9, 10 Moreover, another article in this issue describes a project undertaken at Baylor Health Care System (Dallas, TX) that demonstrated a reduction in emergency department visits and readmissions within 30 days post‐discharge among high‐risk elderly medical patients when a targeted care bundle was used.11 The results from this intervention, which consisted of medication counseling/reconciliation by a clinical pharmacist, condition‐specific enhanced discharge planning by a care coordinator, and phone follow‐up, confirm recent results from 2 similar studies.12, 13 These studies provide support for the idea that straightforward changes in the discharge process can improve patient outcomes.

Today in the United States, hospitalists likely care for the majority of hospitalized older patients.14 We strongly encourage them to use evidence‐based approaches to optimize the discharge process in their hospitals, and fortunately, clear guidance is available. Because of generous funding from the John A. Hartford Foundation, Project BOOST (Better Outcomes for Older Adults Through Safe Transitions) is mentoring 30 hospitals in an effort to implement the BOOST toolkit and improve their discharge transition processes.15 Another cost‐effective method involves the use of transition coaches to help the most vulnerable older patients with complex care needs.16 This approach is now being implemented by more than 100 healthcare organizations worldwide.17

Heartened by these exciting initiatives, we applaud the Society of Hospital Medicine's collaboration with the American College of Physicians, the Society of General Internal Medicine, the American Geriatrics Society, and the Society of Academic Emergency Medicine to produce a consensus policy statement on transitions of care that provides guiding principles for transitions both into and out of the hospital.18 Soon, all hospitalized patients and their caregivers may receive robust education prior to discharge, confirmation of their understanding with the teach‐back approach, medication reconciliation, and clear instructions for follow‐up, and the patient's primary care provider will be aware of all that has happened. Patients should expect nothing less than hospitalists ensuring their seamless transition from hospital to home.

The hospitalist is not typically the hero in contemporary narratives about medical practice. More often, the hospitalist is portrayed as an interloper, a doctor who works for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care. Elsewhere in this issue, Mai Pham1 offers an updated story in which a hospitalist organizes the loose ends of a patient's medical history and contributes significantly to healthcare coordination.

Hospitalists acknowledge that an admission to the hospital disrupts established outpatient continuity and that discharge can be a perilous event, with potential for medical errors. The Society of Hospital Medicine has recognized discontinuity as enough of a concern that care transitions are considered a core competency for hospital physicians.2 This competency requires hospitalists to be able to move a patient safely from the outpatient setting through the hospital wards and back home again.

As our specialty approaches two decades of practice experience, the work that we do in coordinating medical care and ensuring continuity has evolved and deepened. Initial efforts to coordinate care from the inpatient setting focused on how key hospital events could be best communicated to the patient's primary physician.3, 4 Communication at admission and at critical junctures was encouraged, and research demonstrated that a timely discharge summary sent to the primary care office could decrease hospital readmission.5

Experienced hospitalists recognize, however, that not every inpatient can identify a primary care doctor; sometimes, it is this very lack of established outpatient care that triggers a patient's admission. Reasons for discontinuous prehospital care include disrupted outpatient relationships, particularly as provider networks and insurance status are re‐evaluated, as well as cultural and social barriers. Complex, overcrowded outpatient health systems can be challenging to navigate even for the savviest of patients.

These concerns have helped us to focus on the hospital as a critical setting for delivering continuity of care. The mechanisms for ensuring continuity include, harnessing the inpatient capability for real‐time diagnosis and treatment synthesis, which, in Mai Pham's case,1 enabled decision‐making and timely care coordination for her dying grandmother. Hospitals typically offer an array of tools needed to assist physicians in coordinating a patient's care, including rapid diagnostic testing and simultaneous multidisciplinary evaluation with consulting physicians; nurses; case managers; physical, occupational, and speech therapists; pharmacists; nutritionists; social workers; and palliative care teams. The patient's family members and friends are frequently present in the inpatient setting and can provide additional data points that are not always available in a timely manner in the ambulatory setting. Each of these inpatient interactions can help patients to develop routes of access to healthcare after they are discharged from the hospital.

Despite the advantages of the hospital setting, however, the knock on hospitalists is that we are just on the clock. Frequent handoffs, both when physician shifts change and when a fresh hospitalist rotates on service, present a significant concern to seamless care.6 Increasing fragmentation in hospital staffing may correlate with lengthened hospital stay and increased difficulty in receiving follow‐up outpatient care.7 A new narrative for hospitalists, one focused on enhancing continuity, requires mindfulness toward schedule fragmentation and balances personal desires with the need to maintain a continued presence and availability for patients.

Enhancing continuity and care coordination in the hospital also means continually working to improve provider‐to‐provider communications. Solutions may include well‐executed chart documentation, with active concerns flagged for the oncoming physician, and an electronic medical record that is easy to access from various locations. Computerized templates may enable more thorough handoffs in certain settings.8 As the use of systems and checklists gains traction for their ability to reduce iatrogenic complications and save money,9 hospitalists may come to rely more widely on systems that improve continuity, especially for aspects of inpatient care such as medication reconciliation.10

We believe that the most critical way in which hospitalists can ensure continuous care involves increasing physician efforts to engage with patients during their hospitalization. Hospitalists meet patients at particularly intense and vulnerable times of life, and we have all observed how patients can lose autonomy simply by being hospitalized. In the hospital, things happen to patients, sometimes because of the sheer size and force of the inpatient team and the momentum of a hospital stay.

Yet hospitalists can quickly develop a rapport with their patients through the number and intensity of their patient interactions. The free‐form structure of the inpatient schedule means a flexibility to be present with patients on short notice, to respond to acute events in real time, and to be available to talk with family members and other caregivers at their convenience. Hospitalists can take part in multiple bedside interactions in a single day and on consecutive days. Because of this flexibility, hospitalists can bond with their patients in a short time frame11 as they access critical social and clinical contexts, often more efficiently than possible elsewhere. As one primary care physician wrote when she gave up caring for her hospitalized patients, I know what happened to my patient, but I didn't really experience it with my patient.12 Hospitalists do get to share in this drama.

The medical community has been slow to recognize that hospitalists, as much as any generalist physician, can and do engage patients actively in their medical care. The hospital can be an ideal setting to ensure continuity through real‐time diagnostics and therapeutics and even more so through the intense bonding that can happen between physicians and patients on the wards. The old story of an outpatient provider single‐handedly managing a patient's care is rapidly disappearing in many locales. However, the story of the hospitalist is more than that of the hero in waiting. The story is a cautionary tale, one in which the relationship between the hospitalist and his or her patients is still under development, a tale for which much work remains. As hospitalists, we must continue to refine our skills and systems to deliver continuous care for patients in transition. We must also continue to focus on experiences with our patients and their families and, when called upon, to engage in those challenging conversations that Mai Pham1 says force us to align our expectations of one another. Forging this human connection will always be part of seamless healthcare for every physician, not least for the hospitalist.

The hospitalist is not typically the hero in contemporary narratives about medical practice. More often, the hospitalist is portrayed as an interloper, a doctor who works for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care. Elsewhere in this issue, Mai Pham1 offers an updated story in which a hospitalist organizes the loose ends of a patient's medical history and contributes significantly to healthcare coordination.

Hospitalists acknowledge that an admission to the hospital disrupts established outpatient continuity and that discharge can be a perilous event, with potential for medical errors. The Society of Hospital Medicine has recognized discontinuity as enough of a concern that care transitions are considered a core competency for hospital physicians.2 This competency requires hospitalists to be able to move a patient safely from the outpatient setting through the hospital wards and back home again.

As our specialty approaches two decades of practice experience, the work that we do in coordinating medical care and ensuring continuity has evolved and deepened. Initial efforts to coordinate care from the inpatient setting focused on how key hospital events could be best communicated to the patient's primary physician.3, 4 Communication at admission and at critical junctures was encouraged, and research demonstrated that a timely discharge summary sent to the primary care office could decrease hospital readmission.5

Experienced hospitalists recognize, however, that not every inpatient can identify a primary care doctor; sometimes, it is this very lack of established outpatient care that triggers a patient's admission. Reasons for discontinuous prehospital care include disrupted outpatient relationships, particularly as provider networks and insurance status are re‐evaluated, as well as cultural and social barriers. Complex, overcrowded outpatient health systems can be challenging to navigate even for the savviest of patients.

These concerns have helped us to focus on the hospital as a critical setting for delivering continuity of care. The mechanisms for ensuring continuity include, harnessing the inpatient capability for real‐time diagnosis and treatment synthesis, which, in Mai Pham's case,1 enabled decision‐making and timely care coordination for her dying grandmother. Hospitals typically offer an array of tools needed to assist physicians in coordinating a patient's care, including rapid diagnostic testing and simultaneous multidisciplinary evaluation with consulting physicians; nurses; case managers; physical, occupational, and speech therapists; pharmacists; nutritionists; social workers; and palliative care teams. The patient's family members and friends are frequently present in the inpatient setting and can provide additional data points that are not always available in a timely manner in the ambulatory setting. Each of these inpatient interactions can help patients to develop routes of access to healthcare after they are discharged from the hospital.

Despite the advantages of the hospital setting, however, the knock on hospitalists is that we are just on the clock. Frequent handoffs, both when physician shifts change and when a fresh hospitalist rotates on service, present a significant concern to seamless care.6 Increasing fragmentation in hospital staffing may correlate with lengthened hospital stay and increased difficulty in receiving follow‐up outpatient care.7 A new narrative for hospitalists, one focused on enhancing continuity, requires mindfulness toward schedule fragmentation and balances personal desires with the need to maintain a continued presence and availability for patients.

Enhancing continuity and care coordination in the hospital also means continually working to improve provider‐to‐provider communications. Solutions may include well‐executed chart documentation, with active concerns flagged for the oncoming physician, and an electronic medical record that is easy to access from various locations. Computerized templates may enable more thorough handoffs in certain settings.8 As the use of systems and checklists gains traction for their ability to reduce iatrogenic complications and save money,9 hospitalists may come to rely more widely on systems that improve continuity, especially for aspects of inpatient care such as medication reconciliation.10

We believe that the most critical way in which hospitalists can ensure continuous care involves increasing physician efforts to engage with patients during their hospitalization. Hospitalists meet patients at particularly intense and vulnerable times of life, and we have all observed how patients can lose autonomy simply by being hospitalized. In the hospital, things happen to patients, sometimes because of the sheer size and force of the inpatient team and the momentum of a hospital stay.

Yet hospitalists can quickly develop a rapport with their patients through the number and intensity of their patient interactions. The free‐form structure of the inpatient schedule means a flexibility to be present with patients on short notice, to respond to acute events in real time, and to be available to talk with family members and other caregivers at their convenience. Hospitalists can take part in multiple bedside interactions in a single day and on consecutive days. Because of this flexibility, hospitalists can bond with their patients in a short time frame11 as they access critical social and clinical contexts, often more efficiently than possible elsewhere. As one primary care physician wrote when she gave up caring for her hospitalized patients, I know what happened to my patient, but I didn't really experience it with my patient.12 Hospitalists do get to share in this drama.

The medical community has been slow to recognize that hospitalists, as much as any generalist physician, can and do engage patients actively in their medical care. The hospital can be an ideal setting to ensure continuity through real‐time diagnostics and therapeutics and even more so through the intense bonding that can happen between physicians and patients on the wards. The old story of an outpatient provider single‐handedly managing a patient's care is rapidly disappearing in many locales. However, the story of the hospitalist is more than that of the hero in waiting. The story is a cautionary tale, one in which the relationship between the hospitalist and his or her patients is still under development, a tale for which much work remains. As hospitalists, we must continue to refine our skills and systems to deliver continuous care for patients in transition. We must also continue to focus on experiences with our patients and their families and, when called upon, to engage in those challenging conversations that Mai Pham1 says force us to align our expectations of one another. Forging this human connection will always be part of seamless healthcare for every physician, not least for the hospitalist.

The hospitalist is not typically the hero in contemporary narratives about medical practice. More often, the hospitalist is portrayed as an interloper, a doctor who works for the hospital and not the patient, an employee focused on efficiency and rapid discharge rather than continuous medical care. Elsewhere in this issue, Mai Pham1 offers an updated story in which a hospitalist organizes the loose ends of a patient's medical history and contributes significantly to healthcare coordination.

Hospitalists acknowledge that an admission to the hospital disrupts established outpatient continuity and that discharge can be a perilous event, with potential for medical errors. The Society of Hospital Medicine has recognized discontinuity as enough of a concern that care transitions are considered a core competency for hospital physicians.2 This competency requires hospitalists to be able to move a patient safely from the outpatient setting through the hospital wards and back home again.

As our specialty approaches two decades of practice experience, the work that we do in coordinating medical care and ensuring continuity has evolved and deepened. Initial efforts to coordinate care from the inpatient setting focused on how key hospital events could be best communicated to the patient's primary physician.3, 4 Communication at admission and at critical junctures was encouraged, and research demonstrated that a timely discharge summary sent to the primary care office could decrease hospital readmission.5

Experienced hospitalists recognize, however, that not every inpatient can identify a primary care doctor; sometimes, it is this very lack of established outpatient care that triggers a patient's admission. Reasons for discontinuous prehospital care include disrupted outpatient relationships, particularly as provider networks and insurance status are re‐evaluated, as well as cultural and social barriers. Complex, overcrowded outpatient health systems can be challenging to navigate even for the savviest of patients.

These concerns have helped us to focus on the hospital as a critical setting for delivering continuity of care. The mechanisms for ensuring continuity include, harnessing the inpatient capability for real‐time diagnosis and treatment synthesis, which, in Mai Pham's case,1 enabled decision‐making and timely care coordination for her dying grandmother. Hospitals typically offer an array of tools needed to assist physicians in coordinating a patient's care, including rapid diagnostic testing and simultaneous multidisciplinary evaluation with consulting physicians; nurses; case managers; physical, occupational, and speech therapists; pharmacists; nutritionists; social workers; and palliative care teams. The patient's family members and friends are frequently present in the inpatient setting and can provide additional data points that are not always available in a timely manner in the ambulatory setting. Each of these inpatient interactions can help patients to develop routes of access to healthcare after they are discharged from the hospital.

Despite the advantages of the hospital setting, however, the knock on hospitalists is that we are just on the clock. Frequent handoffs, both when physician shifts change and when a fresh hospitalist rotates on service, present a significant concern to seamless care.6 Increasing fragmentation in hospital staffing may correlate with lengthened hospital stay and increased difficulty in receiving follow‐up outpatient care.7 A new narrative for hospitalists, one focused on enhancing continuity, requires mindfulness toward schedule fragmentation and balances personal desires with the need to maintain a continued presence and availability for patients.

Enhancing continuity and care coordination in the hospital also means continually working to improve provider‐to‐provider communications. Solutions may include well‐executed chart documentation, with active concerns flagged for the oncoming physician, and an electronic medical record that is easy to access from various locations. Computerized templates may enable more thorough handoffs in certain settings.8 As the use of systems and checklists gains traction for their ability to reduce iatrogenic complications and save money,9 hospitalists may come to rely more widely on systems that improve continuity, especially for aspects of inpatient care such as medication reconciliation.10

We believe that the most critical way in which hospitalists can ensure continuous care involves increasing physician efforts to engage with patients during their hospitalization. Hospitalists meet patients at particularly intense and vulnerable times of life, and we have all observed how patients can lose autonomy simply by being hospitalized. In the hospital, things happen to patients, sometimes because of the sheer size and force of the inpatient team and the momentum of a hospital stay.

Yet hospitalists can quickly develop a rapport with their patients through the number and intensity of their patient interactions. The free‐form structure of the inpatient schedule means a flexibility to be present with patients on short notice, to respond to acute events in real time, and to be available to talk with family members and other caregivers at their convenience. Hospitalists can take part in multiple bedside interactions in a single day and on consecutive days. Because of this flexibility, hospitalists can bond with their patients in a short time frame11 as they access critical social and clinical contexts, often more efficiently than possible elsewhere. As one primary care physician wrote when she gave up caring for her hospitalized patients, I know what happened to my patient, but I didn't really experience it with my patient.12 Hospitalists do get to share in this drama.

The medical community has been slow to recognize that hospitalists, as much as any generalist physician, can and do engage patients actively in their medical care. The hospital can be an ideal setting to ensure continuity through real‐time diagnostics and therapeutics and even more so through the intense bonding that can happen between physicians and patients on the wards. The old story of an outpatient provider single‐handedly managing a patient's care is rapidly disappearing in many locales. However, the story of the hospitalist is more than that of the hero in waiting. The story is a cautionary tale, one in which the relationship between the hospitalist and his or her patients is still under development, a tale for which much work remains. As hospitalists, we must continue to refine our skills and systems to deliver continuous care for patients in transition. We must also continue to focus on experiences with our patients and their families and, when called upon, to engage in those challenging conversations that Mai Pham1 says force us to align our expectations of one another. Forging this human connection will always be part of seamless healthcare for every physician, not least for the hospitalist.

He looked upon the earth so filled with misery and pox

On Cro‐Magnon Neurosurgeons taking tumors out with rocks

With the blood banks run by leeches and their pterodactyl nursing

And observed This can't be healthcare these mere creatures are rehearsing

What shall we do when their lifespan will exceed eleven years?

When they no longer drink from toilet pits or make hearts from used pig ears?

There will need to be a better way to care for newer ills

A time when broadband wireless will be cheaper than their pills

He came up with a brilliant plan to revolutionize the health

To advance all medical outcomes and thereby spread the wealth

But for some strange combination of wisdom, luck, and quirk

He devised sufficient stakeholders to ensure this could not work

So a King might hire a knight to wipe out enemies with his lance

Then buy a plan to pay the cost of repairing his chain mail pants

Then along will come men with crosses of Blue who can manage that so much smarter

By inventing rules that convert poor fools from heroic docs to martyrs

He made tiny things that hide in meat and cause nasty cramps and rashes

That leave only the fittest alive to run in the royal 50 yard dashes

He made plants with spikes and purple leaves that can make one very sick

Then companies who turn green goop to gold that can flow thru a needle stick

He made medical schools to teach more tools, taking 10 years from students' lives

Then ruined careers with malpractice fears if they forget to wash their knives.

He made men whose pockets are filled with stuff from frivolous medical suits

When the experts forget the proper dosing of Peruvian medicinal fruits

He made routine birth a hazardous game between midwife, mom, and fetus

He made people who dress in masks and gloves to bravely retrieve and greet us

Then if anything goes wrong because one more time he throws snake eyes on the dice

He made lawyers to ensure that at least someone benefits while everyone else paid the price

Then along came the buildings with gadgets and learning, to find things we can't hope to fix

And those who get paid to know how NOT to pay the providers of care to the sick

He made organized giants that make tablets and gizmos from the minds of the cream of the crop

And made multiple races with all different faces whose subjective complaints will not stop

But alas came the gadgets, the photons and diodes, the software, the web and the data

Then the standards, the knowledge bases, multiuser interfaces, all in perpetual BETA

To automate the arcane, declare real what is feigned, and make INPUT like losing a toe

Then the last fatal strawhe made privacy laws to ensure they can't share what they know

Oh what have I done, this is really no fun, they now live to one hundred and thirty

But there's no more MDs and the few with degrees refuse to get their hands dirty

Next time when I try to take research to practice I'll start with a real I.O.M.

Evidence galore, so when we screw up once more I can put all the blame right on them

He looked upon the earth so filled with misery and pox

On Cro‐Magnon Neurosurgeons taking tumors out with rocks

With the blood banks run by leeches and their pterodactyl nursing

And observed This can't be healthcare these mere creatures are rehearsing

What shall we do when their lifespan will exceed eleven years?

When they no longer drink from toilet pits or make hearts from used pig ears?

There will need to be a better way to care for newer ills

A time when broadband wireless will be cheaper than their pills

He came up with a brilliant plan to revolutionize the health

To advance all medical outcomes and thereby spread the wealth

But for some strange combination of wisdom, luck, and quirk

He devised sufficient stakeholders to ensure this could not work

So a King might hire a knight to wipe out enemies with his lance

Then buy a plan to pay the cost of repairing his chain mail pants

Then along will come men with crosses of Blue who can manage that so much smarter

By inventing rules that convert poor fools from heroic docs to martyrs

He made tiny things that hide in meat and cause nasty cramps and rashes

That leave only the fittest alive to run in the royal 50 yard dashes

He made plants with spikes and purple leaves that can make one very sick

Then companies who turn green goop to gold that can flow thru a needle stick

He made medical schools to teach more tools, taking 10 years from students' lives

Then ruined careers with malpractice fears if they forget to wash their knives.

He made men whose pockets are filled with stuff from frivolous medical suits

When the experts forget the proper dosing of Peruvian medicinal fruits

He made routine birth a hazardous game between midwife, mom, and fetus

He made people who dress in masks and gloves to bravely retrieve and greet us

Then if anything goes wrong because one more time he throws snake eyes on the dice

He made lawyers to ensure that at least someone benefits while everyone else paid the price

Then along came the buildings with gadgets and learning, to find things we can't hope to fix

And those who get paid to know how NOT to pay the providers of care to the sick

He made organized giants that make tablets and gizmos from the minds of the cream of the crop

And made multiple races with all different faces whose subjective complaints will not stop

But alas came the gadgets, the photons and diodes, the software, the web and the data

Then the standards, the knowledge bases, multiuser interfaces, all in perpetual BETA

To automate the arcane, declare real what is feigned, and make INPUT like losing a toe

Then the last fatal strawhe made privacy laws to ensure they can't share what they know

Oh what have I done, this is really no fun, they now live to one hundred and thirty

But there's no more MDs and the few with degrees refuse to get their hands dirty

Next time when I try to take research to practice I'll start with a real I.O.M.

Evidence galore, so when we screw up once more I can put all the blame right on them

He looked upon the earth so filled with misery and pox

On Cro‐Magnon Neurosurgeons taking tumors out with rocks

With the blood banks run by leeches and their pterodactyl nursing

And observed This can't be healthcare these mere creatures are rehearsing

What shall we do when their lifespan will exceed eleven years?

When they no longer drink from toilet pits or make hearts from used pig ears?

There will need to be a better way to care for newer ills

A time when broadband wireless will be cheaper than their pills

He came up with a brilliant plan to revolutionize the health

To advance all medical outcomes and thereby spread the wealth

But for some strange combination of wisdom, luck, and quirk

He devised sufficient stakeholders to ensure this could not work

So a King might hire a knight to wipe out enemies with his lance

Then buy a plan to pay the cost of repairing his chain mail pants

Then along will come men with crosses of Blue who can manage that so much smarter

By inventing rules that convert poor fools from heroic docs to martyrs

He made tiny things that hide in meat and cause nasty cramps and rashes

That leave only the fittest alive to run in the royal 50 yard dashes

He made plants with spikes and purple leaves that can make one very sick

Then companies who turn green goop to gold that can flow thru a needle stick

He made medical schools to teach more tools, taking 10 years from students' lives

Then ruined careers with malpractice fears if they forget to wash their knives.

He made men whose pockets are filled with stuff from frivolous medical suits

When the experts forget the proper dosing of Peruvian medicinal fruits

He made routine birth a hazardous game between midwife, mom, and fetus

He made people who dress in masks and gloves to bravely retrieve and greet us

Then if anything goes wrong because one more time he throws snake eyes on the dice

He made lawyers to ensure that at least someone benefits while everyone else paid the price

Then along came the buildings with gadgets and learning, to find things we can't hope to fix

And those who get paid to know how NOT to pay the providers of care to the sick

He made organized giants that make tablets and gizmos from the minds of the cream of the crop

And made multiple races with all different faces whose subjective complaints will not stop

But alas came the gadgets, the photons and diodes, the software, the web and the data

Then the standards, the knowledge bases, multiuser interfaces, all in perpetual BETA

To automate the arcane, declare real what is feigned, and make INPUT like losing a toe

Then the last fatal strawhe made privacy laws to ensure they can't share what they know

Oh what have I done, this is really no fun, they now live to one hundred and thirty

But there's no more MDs and the few with degrees refuse to get their hands dirty

Next time when I try to take research to practice I'll start with a real I.O.M.

Evidence galore, so when we screw up once more I can put all the blame right on them

The March issue of the Journal of Hospital Medicine represents a landmark for pediatric hospital medicine (PHM), with 100% of the original research content devoted to pediatrics. Since the days of the National Association of Inpatient Physicians, pediatric hospitalists have consistently constituted 8% to 10% of the membership of the Society of Hospital Medicine (SHM). SHM has always welcomed pediatrics and pediatricians into the community of hospital medicine. A pediatrician has sat on the board since the founding of the National Association of Inpatient Physicians, and for the past 3 years, there has been a formal pediatric board seat. The Hospitalist has consistently included pediatric content with program descriptions and literature reviews. This past July, more than 325 pediatric hospitalists gathered in Denver for the largest PHM meeting ever, a 4‐day event trisponsored by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA).

As pediatric hospitalists, we have prospered by following the successes of adult hospitalists. We have flattered/emmitated our adult colleagues with pediatric voluntary referral policies, core competencies, salary surveys, fellowship programs, and quality improvement projects. In other areas, pediatrics has set trends for (adult) hospital medicine. Pediatrics developed the medical home concept. We zealously advocate for family‐centered rounds. (Imagine actually rounding in the room with the patient, family, nurse, and physician. It certainly beats flipping cards in the conference room)! Pediatricians have developed global fee codes for evaluation and management services (albeit limited to neonatal and pediatric critical care). As evidenced by the trisponsored meeting mentioned previously and the Pediatric Research in Inpatient Settings Network, we have created collaborative relationships among the pediatric academic (APA), professional (AAP), and hospitalist organizations (SHM) that serve as models for other disciplines and their respective sandboxes.

Research and publications are where we most lag behind our adult colleagues and where the most work needs to be done for us to achieve legitimacy as practitioners and as a discipline. This issue of the Journal of Hospital Medicine is a harbinger of more pediatric content to come, with topics that run the gamut of PHM. Woolford et al.1 highlight clinical, public health, and public policy issues with their analysis of the increased costs and morbidity associated with obesity and inpatient hospitalizations. Wilkes et al.2 explore the logistic issues surrounding influenza testing. As is frequently true for hospitalists, our expertise is not purely clinical: Is oseltamvir effective and, if so, in what age groups? That question is probably best left to the infectious disease community. Rather, Wilkes et al. highlight both the provider and system issues involved in reliably and expeditiously obtaining, reporting, and communicating flu antigen test results so that clinicians and families have the opportunity to consider oseltamvir use within the first 48 hours of disease. Odetola et al.'s3 analysis of a Michigan administrative data set suggests that morbidity, length of stay, and resource utilization are decreased for patients who ultimately require pediatric critical care when these patients are directly transferred from the emergency room to a facility with a pediatric intensive care unit (PICU) in comparison with the morbidity, length of stay, and resource utilization of patients who are initially admitted to the ward from the emergency room and then transferred to a facility with a PICU. This study lacks the rigor of prospectively collected physiological data and would probably never receive institutional review board approval for randomization, but it certainly raises key questions about appropriate transfer criteria for patients cared for in hospitals without a PICU. This is a key quality concern for pediatric hospitalists practicing in smaller, community hospital settings.

The 2 most controversial articles in this pediatric inpatient potpourri are the studies conducted by Freed and Kelly examining pediatric hospitalist training, practice, and career goals4 and PHM fellowship programs.5 These studies are part of a 6‐perspective analysis of pediatric hospitalists/PHM requested by the American Board of Pediatrics (ABP) to provide background to the ABP as it begins to grapple with its role in certifying pediatricians whose primary practice is inpatient pediatrics. A previously published study analyzed the perspective of PHM group leaders.6 The remaining studies assess the perspectives of residency program directors, department chairs, and hospital leaders.

Not surprisingly, these 3 articles46 tend to be more critical of the PHM movement and its current state than are articles and commentaries written by those of us who are practicing hospitalists. As a hospitalist, my initial reaction was to focus on the studies' shortcomings. The methods seemed flawed, the criticisms seemed unwarranted, and the study limitations seemed underappreciated. Aside from the fellowship study, which surveyed the entire n = 8 universe of PHM fellowship programs, the group leader and hospitalist surveys suffer from a selection bias. Sampling for these studies was based on hospital size and type. Although this sampling strategy is appropriate for comparing programs across hospitals, it fails to account for programs of different sizes in different settings. It is not the best sampling strategy for a denominator of all pediatric hospitalists. For example, community hospital programs without residents are often much bigger than academic programs with residents. Community pediatric hospitalists are likely underrepresented in Freed's survey.4 From a study design standpoint, it does not appear that specific a priori hypotheses were generated when subgroups were compared. Rather, one suspects that every possible comparison was analyzed. Thus, the percent differences from one group to another are best considered descriptive rather than rigorously statistically significant at a p < 0.05 level. Some criticisms addressed to hospitalists apply to all pediatricians. Given the current emphasis on quality assessment, wouldn't most office‐based pediatricians (and particularly group leaders) believe that they need extra training in this field? When less than 50% of hospitals require practitioners in established subboarded specialties to be board‐certified to maintain hospital privileges,7 is it surprising to see that privileging standards vary for pediatric hospitalists?

However, nitpicking these studies is a defensive response that does a disservice both to the reports and more importantly to the PHM community as a whole and to the children, parents, and colleagues that we serve. There is no denying that we are a young, evolving field with significant inter‐institutional and at times intra‐institutional variability. All of us in the PHM community, leaders and lurkers, need to rise to the challenges offered by comprehensive analysis. Freed's sample of 431 hospitalists4 is significantly larger than the sample of 265 hospitalist participants in the latest Pediatric Research in Inpatient Settings survey.8 The perceptions of external observers are crucial; it would be a mistake to dismiss their findings or to ignore their interpretations and criticisms.

Certainly none would challenge the variability of practice revealed in Freed's analyses.46 Remember, if you've seen one pediatric hospital medicine program, you've seen ONE pediatric hospital medicine program. Some may see this variability as a weakness; others may see it as a strength. We must be equally receptive to other less‐flattering observations, data, and conclusions included in these reports to the ABP. All programs target seamless communication with referring physicians, but hospitalists and referring physicians alike agree that we do not achieve it, as evidenced by the work of Harlan et al.9 in this issue. SHM is taking the lead in developing performance standards for transitions of care and has created best discharge practices for the geriatric population.10 Similarly, we in the PHM community would do well to ramp up our self‐assessment and quality improvement activities. Our recusal from Centers for Medicare and Medicaid Services reporting requirements for (adult) inpatient quality metrics does not excuse us from pursuing voluntary, rigorous, transparent, public reporting on pediatric quality indicators. As Freed et al.6 clearly implied, the public and payers expect this of us. No doubt, if we do not first propose and implement our own standards, external standards will be imposed upon us.

Aside from the question of mandatory fellowship training for hospitalists, does the vision implied in the studies commissioned by the ABP vary significantly from the challenges to PHM that Sandy Melzer11 presented at his keynote address at the Denver meeting? Melzer used strategic planning principles to outline a future vision for PHM, including the following:

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

  Hospital care is highly coordinated, especially for children with chronic conditions.

• 4

  A robust research agenda supports all aspects of inpatient care.

Is not the work done by the SHM and APA to develop core competencies for PHM an effort to define our field and identify (uniform) expectations? Do not the criteria for designation as a fellow of hospital medicine (5 years as a practicing hospitalist; 2 national meetings; and a minimum combination of leadership, teamwork, and quality improvement activities)12 serve to recognize the commitment and accomplishments that distinguish a true hospitalist practicing systems‐based hospital medicine from a physician who simply works in the hospital?

There is no need for pediatric hospitalists to respond defensively to the hospitalist studies commissioned by the ABP. In fact, Freed46 has done us a favor by adding dimension and texture to the preliminary outlines of what it means for PHM to be ultimately successful. Both Freed and Melzer11 are describing the same path. As hospitalists, we tend to take pride in how far we have already come along this adventure. External observers such as Freed remind of us of how far we still need to go. Either way, Dorothy Gale, MD, pediatric hospitalist, has a relatively well‐identified yellow brick road to follow with specific challenges and charges to meet. What is unclear is whether formal acknowledgment will be awarded at the end of this journey and, if so, what form it will take. Options include (1) recognition of focused practice in hospital medicine with maintenance of certification, (2) SHM fellowship, (3) a traditionally boarded subspecialty, or (4) all of the above.

Any formal designation will be of secondary importance. Remember, the wizard did not change anything when he bestowed the diploma, the heart‐shaped testimonial, and the medal of valor. Like the scarecrow, tin man, and lion, all the qualities that we need for success as pediatric hospitalists are already within us. No wizard's pronouncements will help us provide better care to our patients. Change will come from working together on shared goals with mutual support along our common path. Look to the Journal of Hospital Medicine for frequent updates on the journey. See you in the Emerald City.

The March issue of the Journal of Hospital Medicine represents a landmark for pediatric hospital medicine (PHM), with 100% of the original research content devoted to pediatrics. Since the days of the National Association of Inpatient Physicians, pediatric hospitalists have consistently constituted 8% to 10% of the membership of the Society of Hospital Medicine (SHM). SHM has always welcomed pediatrics and pediatricians into the community of hospital medicine. A pediatrician has sat on the board since the founding of the National Association of Inpatient Physicians, and for the past 3 years, there has been a formal pediatric board seat. The Hospitalist has consistently included pediatric content with program descriptions and literature reviews. This past July, more than 325 pediatric hospitalists gathered in Denver for the largest PHM meeting ever, a 4‐day event trisponsored by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA).

As pediatric hospitalists, we have prospered by following the successes of adult hospitalists. We have flattered/emmitated our adult colleagues with pediatric voluntary referral policies, core competencies, salary surveys, fellowship programs, and quality improvement projects. In other areas, pediatrics has set trends for (adult) hospital medicine. Pediatrics developed the medical home concept. We zealously advocate for family‐centered rounds. (Imagine actually rounding in the room with the patient, family, nurse, and physician. It certainly beats flipping cards in the conference room)! Pediatricians have developed global fee codes for evaluation and management services (albeit limited to neonatal and pediatric critical care). As evidenced by the trisponsored meeting mentioned previously and the Pediatric Research in Inpatient Settings Network, we have created collaborative relationships among the pediatric academic (APA), professional (AAP), and hospitalist organizations (SHM) that serve as models for other disciplines and their respective sandboxes.

Research and publications are where we most lag behind our adult colleagues and where the most work needs to be done for us to achieve legitimacy as practitioners and as a discipline. This issue of the Journal of Hospital Medicine is a harbinger of more pediatric content to come, with topics that run the gamut of PHM. Woolford et al.1 highlight clinical, public health, and public policy issues with their analysis of the increased costs and morbidity associated with obesity and inpatient hospitalizations. Wilkes et al.2 explore the logistic issues surrounding influenza testing. As is frequently true for hospitalists, our expertise is not purely clinical: Is oseltamvir effective and, if so, in what age groups? That question is probably best left to the infectious disease community. Rather, Wilkes et al. highlight both the provider and system issues involved in reliably and expeditiously obtaining, reporting, and communicating flu antigen test results so that clinicians and families have the opportunity to consider oseltamvir use within the first 48 hours of disease. Odetola et al.'s3 analysis of a Michigan administrative data set suggests that morbidity, length of stay, and resource utilization are decreased for patients who ultimately require pediatric critical care when these patients are directly transferred from the emergency room to a facility with a pediatric intensive care unit (PICU) in comparison with the morbidity, length of stay, and resource utilization of patients who are initially admitted to the ward from the emergency room and then transferred to a facility with a PICU. This study lacks the rigor of prospectively collected physiological data and would probably never receive institutional review board approval for randomization, but it certainly raises key questions about appropriate transfer criteria for patients cared for in hospitals without a PICU. This is a key quality concern for pediatric hospitalists practicing in smaller, community hospital settings.

The 2 most controversial articles in this pediatric inpatient potpourri are the studies conducted by Freed and Kelly examining pediatric hospitalist training, practice, and career goals4 and PHM fellowship programs.5 These studies are part of a 6‐perspective analysis of pediatric hospitalists/PHM requested by the American Board of Pediatrics (ABP) to provide background to the ABP as it begins to grapple with its role in certifying pediatricians whose primary practice is inpatient pediatrics. A previously published study analyzed the perspective of PHM group leaders.6 The remaining studies assess the perspectives of residency program directors, department chairs, and hospital leaders.

Not surprisingly, these 3 articles46 tend to be more critical of the PHM movement and its current state than are articles and commentaries written by those of us who are practicing hospitalists. As a hospitalist, my initial reaction was to focus on the studies' shortcomings. The methods seemed flawed, the criticisms seemed unwarranted, and the study limitations seemed underappreciated. Aside from the fellowship study, which surveyed the entire n = 8 universe of PHM fellowship programs, the group leader and hospitalist surveys suffer from a selection bias. Sampling for these studies was based on hospital size and type. Although this sampling strategy is appropriate for comparing programs across hospitals, it fails to account for programs of different sizes in different settings. It is not the best sampling strategy for a denominator of all pediatric hospitalists. For example, community hospital programs without residents are often much bigger than academic programs with residents. Community pediatric hospitalists are likely underrepresented in Freed's survey.4 From a study design standpoint, it does not appear that specific a priori hypotheses were generated when subgroups were compared. Rather, one suspects that every possible comparison was analyzed. Thus, the percent differences from one group to another are best considered descriptive rather than rigorously statistically significant at a p < 0.05 level. Some criticisms addressed to hospitalists apply to all pediatricians. Given the current emphasis on quality assessment, wouldn't most office‐based pediatricians (and particularly group leaders) believe that they need extra training in this field? When less than 50% of hospitals require practitioners in established subboarded specialties to be board‐certified to maintain hospital privileges,7 is it surprising to see that privileging standards vary for pediatric hospitalists?

However, nitpicking these studies is a defensive response that does a disservice both to the reports and more importantly to the PHM community as a whole and to the children, parents, and colleagues that we serve. There is no denying that we are a young, evolving field with significant inter‐institutional and at times intra‐institutional variability. All of us in the PHM community, leaders and lurkers, need to rise to the challenges offered by comprehensive analysis. Freed's sample of 431 hospitalists4 is significantly larger than the sample of 265 hospitalist participants in the latest Pediatric Research in Inpatient Settings survey.8 The perceptions of external observers are crucial; it would be a mistake to dismiss their findings or to ignore their interpretations and criticisms.

Certainly none would challenge the variability of practice revealed in Freed's analyses.46 Remember, if you've seen one pediatric hospital medicine program, you've seen ONE pediatric hospital medicine program. Some may see this variability as a weakness; others may see it as a strength. We must be equally receptive to other less‐flattering observations, data, and conclusions included in these reports to the ABP. All programs target seamless communication with referring physicians, but hospitalists and referring physicians alike agree that we do not achieve it, as evidenced by the work of Harlan et al.9 in this issue. SHM is taking the lead in developing performance standards for transitions of care and has created best discharge practices for the geriatric population.10 Similarly, we in the PHM community would do well to ramp up our self‐assessment and quality improvement activities. Our recusal from Centers for Medicare and Medicaid Services reporting requirements for (adult) inpatient quality metrics does not excuse us from pursuing voluntary, rigorous, transparent, public reporting on pediatric quality indicators. As Freed et al.6 clearly implied, the public and payers expect this of us. No doubt, if we do not first propose and implement our own standards, external standards will be imposed upon us.

Aside from the question of mandatory fellowship training for hospitalists, does the vision implied in the studies commissioned by the ABP vary significantly from the challenges to PHM that Sandy Melzer11 presented at his keynote address at the Denver meeting? Melzer used strategic planning principles to outline a future vision for PHM, including the following:

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

  Hospital care is highly coordinated, especially for children with chronic conditions.

• 4

  A robust research agenda supports all aspects of inpatient care.

Is not the work done by the SHM and APA to develop core competencies for PHM an effort to define our field and identify (uniform) expectations? Do not the criteria for designation as a fellow of hospital medicine (5 years as a practicing hospitalist; 2 national meetings; and a minimum combination of leadership, teamwork, and quality improvement activities)12 serve to recognize the commitment and accomplishments that distinguish a true hospitalist practicing systems‐based hospital medicine from a physician who simply works in the hospital?

There is no need for pediatric hospitalists to respond defensively to the hospitalist studies commissioned by the ABP. In fact, Freed46 has done us a favor by adding dimension and texture to the preliminary outlines of what it means for PHM to be ultimately successful. Both Freed and Melzer11 are describing the same path. As hospitalists, we tend to take pride in how far we have already come along this adventure. External observers such as Freed remind of us of how far we still need to go. Either way, Dorothy Gale, MD, pediatric hospitalist, has a relatively well‐identified yellow brick road to follow with specific challenges and charges to meet. What is unclear is whether formal acknowledgment will be awarded at the end of this journey and, if so, what form it will take. Options include (1) recognition of focused practice in hospital medicine with maintenance of certification, (2) SHM fellowship, (3) a traditionally boarded subspecialty, or (4) all of the above.

Any formal designation will be of secondary importance. Remember, the wizard did not change anything when he bestowed the diploma, the heart‐shaped testimonial, and the medal of valor. Like the scarecrow, tin man, and lion, all the qualities that we need for success as pediatric hospitalists are already within us. No wizard's pronouncements will help us provide better care to our patients. Change will come from working together on shared goals with mutual support along our common path. Look to the Journal of Hospital Medicine for frequent updates on the journey. See you in the Emerald City.

The March issue of the Journal of Hospital Medicine represents a landmark for pediatric hospital medicine (PHM), with 100% of the original research content devoted to pediatrics. Since the days of the National Association of Inpatient Physicians, pediatric hospitalists have consistently constituted 8% to 10% of the membership of the Society of Hospital Medicine (SHM). SHM has always welcomed pediatrics and pediatricians into the community of hospital medicine. A pediatrician has sat on the board since the founding of the National Association of Inpatient Physicians, and for the past 3 years, there has been a formal pediatric board seat. The Hospitalist has consistently included pediatric content with program descriptions and literature reviews. This past July, more than 325 pediatric hospitalists gathered in Denver for the largest PHM meeting ever, a 4‐day event trisponsored by SHM, the American Academy of Pediatrics (AAP), and the Academic Pediatric Association (APA).

As pediatric hospitalists, we have prospered by following the successes of adult hospitalists. We have flattered/emmitated our adult colleagues with pediatric voluntary referral policies, core competencies, salary surveys, fellowship programs, and quality improvement projects. In other areas, pediatrics has set trends for (adult) hospital medicine. Pediatrics developed the medical home concept. We zealously advocate for family‐centered rounds. (Imagine actually rounding in the room with the patient, family, nurse, and physician. It certainly beats flipping cards in the conference room)! Pediatricians have developed global fee codes for evaluation and management services (albeit limited to neonatal and pediatric critical care). As evidenced by the trisponsored meeting mentioned previously and the Pediatric Research in Inpatient Settings Network, we have created collaborative relationships among the pediatric academic (APA), professional (AAP), and hospitalist organizations (SHM) that serve as models for other disciplines and their respective sandboxes.

Research and publications are where we most lag behind our adult colleagues and where the most work needs to be done for us to achieve legitimacy as practitioners and as a discipline. This issue of the Journal of Hospital Medicine is a harbinger of more pediatric content to come, with topics that run the gamut of PHM. Woolford et al.1 highlight clinical, public health, and public policy issues with their analysis of the increased costs and morbidity associated with obesity and inpatient hospitalizations. Wilkes et al.2 explore the logistic issues surrounding influenza testing. As is frequently true for hospitalists, our expertise is not purely clinical: Is oseltamvir effective and, if so, in what age groups? That question is probably best left to the infectious disease community. Rather, Wilkes et al. highlight both the provider and system issues involved in reliably and expeditiously obtaining, reporting, and communicating flu antigen test results so that clinicians and families have the opportunity to consider oseltamvir use within the first 48 hours of disease. Odetola et al.'s3 analysis of a Michigan administrative data set suggests that morbidity, length of stay, and resource utilization are decreased for patients who ultimately require pediatric critical care when these patients are directly transferred from the emergency room to a facility with a pediatric intensive care unit (PICU) in comparison with the morbidity, length of stay, and resource utilization of patients who are initially admitted to the ward from the emergency room and then transferred to a facility with a PICU. This study lacks the rigor of prospectively collected physiological data and would probably never receive institutional review board approval for randomization, but it certainly raises key questions about appropriate transfer criteria for patients cared for in hospitals without a PICU. This is a key quality concern for pediatric hospitalists practicing in smaller, community hospital settings.

The 2 most controversial articles in this pediatric inpatient potpourri are the studies conducted by Freed and Kelly examining pediatric hospitalist training, practice, and career goals4 and PHM fellowship programs.5 These studies are part of a 6‐perspective analysis of pediatric hospitalists/PHM requested by the American Board of Pediatrics (ABP) to provide background to the ABP as it begins to grapple with its role in certifying pediatricians whose primary practice is inpatient pediatrics. A previously published study analyzed the perspective of PHM group leaders.6 The remaining studies assess the perspectives of residency program directors, department chairs, and hospital leaders.

Not surprisingly, these 3 articles46 tend to be more critical of the PHM movement and its current state than are articles and commentaries written by those of us who are practicing hospitalists. As a hospitalist, my initial reaction was to focus on the studies' shortcomings. The methods seemed flawed, the criticisms seemed unwarranted, and the study limitations seemed underappreciated. Aside from the fellowship study, which surveyed the entire n = 8 universe of PHM fellowship programs, the group leader and hospitalist surveys suffer from a selection bias. Sampling for these studies was based on hospital size and type. Although this sampling strategy is appropriate for comparing programs across hospitals, it fails to account for programs of different sizes in different settings. It is not the best sampling strategy for a denominator of all pediatric hospitalists. For example, community hospital programs without residents are often much bigger than academic programs with residents. Community pediatric hospitalists are likely underrepresented in Freed's survey.4 From a study design standpoint, it does not appear that specific a priori hypotheses were generated when subgroups were compared. Rather, one suspects that every possible comparison was analyzed. Thus, the percent differences from one group to another are best considered descriptive rather than rigorously statistically significant at a p < 0.05 level. Some criticisms addressed to hospitalists apply to all pediatricians. Given the current emphasis on quality assessment, wouldn't most office‐based pediatricians (and particularly group leaders) believe that they need extra training in this field? When less than 50% of hospitals require practitioners in established subboarded specialties to be board‐certified to maintain hospital privileges,7 is it surprising to see that privileging standards vary for pediatric hospitalists?

However, nitpicking these studies is a defensive response that does a disservice both to the reports and more importantly to the PHM community as a whole and to the children, parents, and colleagues that we serve. There is no denying that we are a young, evolving field with significant inter‐institutional and at times intra‐institutional variability. All of us in the PHM community, leaders and lurkers, need to rise to the challenges offered by comprehensive analysis. Freed's sample of 431 hospitalists4 is significantly larger than the sample of 265 hospitalist participants in the latest Pediatric Research in Inpatient Settings survey.8 The perceptions of external observers are crucial; it would be a mistake to dismiss their findings or to ignore their interpretations and criticisms.

Certainly none would challenge the variability of practice revealed in Freed's analyses.46 Remember, if you've seen one pediatric hospital medicine program, you've seen ONE pediatric hospital medicine program. Some may see this variability as a weakness; others may see it as a strength. We must be equally receptive to other less‐flattering observations, data, and conclusions included in these reports to the ABP. All programs target seamless communication with referring physicians, but hospitalists and referring physicians alike agree that we do not achieve it, as evidenced by the work of Harlan et al.9 in this issue. SHM is taking the lead in developing performance standards for transitions of care and has created best discharge practices for the geriatric population.10 Similarly, we in the PHM community would do well to ramp up our self‐assessment and quality improvement activities. Our recusal from Centers for Medicare and Medicaid Services reporting requirements for (adult) inpatient quality metrics does not excuse us from pursuing voluntary, rigorous, transparent, public reporting on pediatric quality indicators. As Freed et al.6 clearly implied, the public and payers expect this of us. No doubt, if we do not first propose and implement our own standards, external standards will be imposed upon us.

Aside from the question of mandatory fellowship training for hospitalists, does the vision implied in the studies commissioned by the ABP vary significantly from the challenges to PHM that Sandy Melzer11 presented at his keynote address at the Denver meeting? Melzer used strategic planning principles to outline a future vision for PHM, including the following:

• 1

  Harm is eliminated from the inpatient setting.

• 2

  Inpatient care is evidence‐based for all conditions treated.

• 3

  Hospital care is highly coordinated, especially for children with chronic conditions.

• 4

  A robust research agenda supports all aspects of inpatient care.

Is not the work done by the SHM and APA to develop core competencies for PHM an effort to define our field and identify (uniform) expectations? Do not the criteria for designation as a fellow of hospital medicine (5 years as a practicing hospitalist; 2 national meetings; and a minimum combination of leadership, teamwork, and quality improvement activities)12 serve to recognize the commitment and accomplishments that distinguish a true hospitalist practicing systems‐based hospital medicine from a physician who simply works in the hospital?

There is no need for pediatric hospitalists to respond defensively to the hospitalist studies commissioned by the ABP. In fact, Freed46 has done us a favor by adding dimension and texture to the preliminary outlines of what it means for PHM to be ultimately successful. Both Freed and Melzer11 are describing the same path. As hospitalists, we tend to take pride in how far we have already come along this adventure. External observers such as Freed remind of us of how far we still need to go. Either way, Dorothy Gale, MD, pediatric hospitalist, has a relatively well‐identified yellow brick road to follow with specific challenges and charges to meet. What is unclear is whether formal acknowledgment will be awarded at the end of this journey and, if so, what form it will take. Options include (1) recognition of focused practice in hospital medicine with maintenance of certification, (2) SHM fellowship, (3) a traditionally boarded subspecialty, or (4) all of the above.

Any formal designation will be of secondary importance. Remember, the wizard did not change anything when he bestowed the diploma, the heart‐shaped testimonial, and the medal of valor. Like the scarecrow, tin man, and lion, all the qualities that we need for success as pediatric hospitalists are already within us. No wizard's pronouncements will help us provide better care to our patients. Change will come from working together on shared goals with mutual support along our common path. Look to the Journal of Hospital Medicine for frequent updates on the journey. See you in the Emerald City.

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

I knew that he was going to die. I do not remember when it became evident to me, and I was not sure how to tell the family. I thought that I could arrange a family meeting and inform them of the sad reality in a calm, sympathetic manner. The patient had chronic lymphocytic leukemia, and his case was advanced. The only medication available to him was chlorambucil. As the days passed, I could not bring myself to call the family meeting because they had so much hope. Every day as we got results and I shared them, I would sandwich the bad news with some optimism to ease their pain. Well, his white blood cell count has come down, but his platelet count and red blood cell counts are very low, and this puts him in danger of bleeding. The medicine is bringing the white cell count down but has not yet brought the other cell counts up. What we can do is give him some blood. I tried not to allow despair to creep into my thoughts or my voice. I knew that the blood bank had no platelets or packed red blood cells. He was not eating or drinking, and we had placed a nasogastric tube through which his family fed him wheat or millet porridge (manufactured tube feeds are not widely available in Uganda). I tried not to think about the time that he had almost died a few weeks before.

I had been called to the bedside because the patient was in respiratory distress. The doctor on call was in his office when I arrived, and I wondered why he was not at the bedside. I took one look at the patient and had to step away for a moment to compose myself. I felt the tears threatening to come, but I had to stop them. This was not the time for emotions. I had to assess the patient and make some quick decisions. The doctor on call seemed to have given up. He was a young trainee in a system in which you treat when you can and, if the situation is hopeless, you move on to the next patient. There are no resources for perpetuating hope. This is so different from my practice in the United States, where if a patient wants everything done, we will do it. We are not taught when to give up hope, and futility does not figure into the allocation of resources. I looked at the patient struggling to breathe and felt that I had to do all that I could for him. I asked the doctor on call to place the patient on oxygen and hoped that the tanks were not empty. I was worried about a lot of things, such as pulmonary embolus, myocardial infarction, and pneumonia. Diagnosing any of these would not be easy (the hospital did not have a computed tomography scanner, and obtaining cardiac enzymes was not as simple as clicking a button on a computer). First things first: the chest X‐ray. I thanked God that we were in a private hospital, one of the best in the city of Kampala, so we were able to get a chest X‐ray right away. As we transported the patient (portable X‐rays are nonexistent), the resident told me that he had called the consultant (the equivalent of an attending physician in the United States), who happened to be out of town. The consultant instructed us to transfer the patient to Mulago Hospital (the largest tertiary center in Uganda with well over 1000 beds and some of the equipment that you might find in an American hospital). I wondered how an attending physician could be out of town and leave a resident in charge. The thought was disturbing, but I had no time to ponder it. I later learned that physicians are so poorly paid that many have their own private clinics. My patient got the X‐ray, and I reviewed it with the resident. Tuberculosis, he said. Tuberculosis was this resident's reality. Many patients who need chest X‐rays in Uganda have tuberculosis. As I reviewed the X‐ray, though, I was certain that this was congestive heart failure. However, in Uganda, congestive heart failure is rarely diagnosed in the hospital. Patients with an ejection fraction low enough to cause congestion generally die before they get to a hospital. I knew that some furosemide would work for this patient, but I could not get the resident to listen to me. He had orders from the consultant to transfer the patient immediately, and the ambulance was ready. I tried to convince the resident to administer furosemide before transferring the patient, but he feared administering a drug not approved by his superior. As the patient was loaded onto the ambulance, I reflected for a second on how different things would be if we were in the United States. We arrived at Mulago in record time, and I tried to get the intake doctors to understand what the problem was; however, they did not want to hear from the US doctor. I stared in frustration as they wasted valuable time. I wondered how long the patient would survive in respiratory distress with nothing being done. I called the patient's son and asked him to come to Mulago immediately. Miraculously, he had already been on his way. As I held the patient's hand, sure that he would die right then and there in a waiting area as nobody did anything, I saw the patient's son. I knew that he was a pharmacist, and I asked him to go to the pharmacy and buy furosemide and some syringes. In Uganda, one can buy any medication without a prescription. Luckily, the hospital pharmacy had the drug. We treated the patient, and in no time, his breathing had returned to normal.

I was jolted back to reality. He was dying, and I knew it. He had had many close calls. There was the time that he got the wrong blood during a blood transfusion. I informed the doctor on call as the blood was being administered that I thought the patient was getting a transfusion reaction because he had rigors. The physician on call suggested covering him in blankets, and I suggested stopping the infusion and administering steroids. The pack of blood showed that he was getting his blood type. The patient was typed and crossed again, and to our surprise, we got a different result. I went to the laboratory to perform a third, tie‐breaking cross match and was surprised to note that the reagents had passed their expiration date. However, I knew that these were small battles we were winning and that there was no winning the war.

I recognized that the challenges of practicing medicine in the developing world were many. I wondered how the patients of families with fewer resources survived. The answer was obvious: they didn't. I personally picked up blood when it was available from the blood bank and vividly remember walking from the blood bank at night to the private hospital with units of blood in each hand. Once we arrived at the hospital, I had to warm the blood to room temperature by holding it close to my own skin. Many tests that we perform routinely on a hospitalized patient in the United States are not available.

There was still the problem of breaking the news to the family. Despite everything that had been done and the many near misses that the patient had survived, he was still going to die. It turns out that the family was more intuitive than I thought. One day, the son came to me and asked how long his dad had. Not long, I said quietly. I thought about all that I could potentially do if I had the patient in the hospital at which I worked in the United States. Would it have made a difference? I do not know. It was impossible doctoring this patient, and I suspect doing it in a resource‐rich environment would not have made it any easier. You see this patient, perhaps the most important patient of my life, certainly a patient that I will never forget, was my father.

It had been 15 years since I had traveled to the United States for an education. I knew that my father was so incredibly proud of me. I think that he was the happiest I had ever seen him when he attended my graduation from medical school in Minnesota. I had been looking forward to this visit back home because it had been 3 years since I had last seen my family. I was somewhat concerned because my father had told me a week before I traveled that he was not feeling well. When I arrived, there seemed to be relief on my brother's face when he met me at the airport. We drove straight to the hospital, and along with the joy of seeing me, I could sense that my father was glad that I was home at this particular point in time. They had just received the diagnosis. He had leukemia, and they were glad that their doctor was home. They had particular faith in the daughter (sister) sent abroad for an education. Things would now be okay. Initially, I never got to choose the role of doctor that I played in the final chapter of my father's life. The decision was made for me out of my family's desperation to make sure that they had left no stone unturned to help my father, and I accepted it out of necessity. As my father became my father when I entered this world, I became his doctor when he was leaving it; there was never any question in my mind, as there never was in his. As it became clear that my father would not survive, I chose to continue the role of doctor. I have watched many patients die as a physician and have done my best to make sure that their passing is comfortable, peaceful, and dignified. The doctor could help this patient die, but the daughter could not watch her father go. When it was evident that he had only days to live and did not need this doctor or know his daughter, I flew back to the United States. Three days later my father died. I was not physically at his bedside, but my spirit was. I have no regrets. Although the head knows that he passed on, in my mind's eye, he is laughing and has a twinkle in his eye. I could not bear to see him without life. A piece of my heart is buried with him, and for this reason, I will never be out of Africa.

In this issue of JHM, O'Connor et al.1 examine the impact of paper‐based admission order sets on several quality measures relevant to medical inpatients in a large community medical center, focusing the most attention on the use of venous thromboembolism (VTE) prophylaxis. Randomly selected medical admissions from 4 time periods were examined by chart review for use of the order set, and for the use of VTE prophylaxis (defined as either unfractionated heparin [UFH] 5,000 units subcutaneous [sc] twice daily [BID] or compression stockings). VTE prophylaxis was ordered in an abysmally low 10.9% of inpatients in the baseline period. In spite of the limitations inherent in a before and after study design and a failure to assess the appropriateness of VTE prophylaxis, VTE rates, or side effects, the authors present convincing evidence that improvement in VTE prophylaxis did occur. However, it was a very limited and suboptimal improvement. By the fourteenth and fifteenth month after order set introduction, only about one‐half of admissions used the order set, and even when the order set was used, only 44% had VTE prophylaxis ordered. The percent of patient‐days with pharmacologic VTE prophylaxis in medical inpatients improved after order set implementation, but remained very low, at 26%. Therefore, the key lessons to be learned from this study are likely derived from what went wrong, rather than what went right.

Why did VTE prophylaxis rates stay so low in the face of a multiyear effort? An examination of more successful efforts,25 recent reviews in the VTE and quality improvement literature,610 and the Society of Hospital Medicine VTE Prevention Collaborative experience reveals several principles for effective improvement that were not followed in this study.

A VTE PREVENTION ORDER SET SHOULD PROVIDE DECISION SUPPORT (NOT JUST A PROMPT)

A simple prompt for mechanical prophylaxis or for UFH 5,000 units sc BID was embedded into a voluntary order set in this effort. Mechanical prophylaxis, pharmacologic prophylaxis, and no prophylaxis were treated as equal options, even though most medical inpatients have significant VTE risk factors,11, 12 and in spite of strong evidence‐based recommendations12 relegating mechanical prophylaxis to an adjunctive role for pharmacologic prophylaxis (unless there are contraindications to pharmacologic prophylaxis). The authors point out that the way order sets are structured or introduced is important to ensure they achieve the desired changes in practice. I could not agree more, but, unfortunately, the structure of their order set only secured the desired change in 44% of patients, even if you count compression stockings as adequate prophylaxis. This relatively poor result should have sparked a redesign of the VTE prevention component of the order set.

A more effective order set would reflect an institutional VTE prevention protocol.6, 7, 9, 13 A VTE prevention protocol consists of a standardized VTE risk assessment and contraindications to pharmacologic or heparin prophylaxis, linked to a menu of appropriate VTE prophylaxis options for each level of risk.13 The best protocols provide decision support at the point of care,9, 13 and yet preserve the ability to customize care for special patient situations or circumstances.

Ease of use issues and the lack of prospectively validated models have hindered widespread adoption of VTE risk assessment protocols (especially the point‐based models),14 but a simpler and more streamlined approach has been validated by the UCSD Medical Center experience,2 and by the general success of similar protocols in diverse medical centers taking part in the Society of Hospital Medicine (SHM) VTE Prevention Collaborative. This simpler method generally places patients into 1 of 3 levels of VTE risk, can be completed in seconds, and has excellent interobserver agreement. Reinforcing the expectation that pharmacologic prophylaxis is desirable for most ill inpatients (unless there is a contraindication to it) is likely more important than the finer details of the risk assessment model.

PROTOCOLS AND ORDER SETS MUST REACH THE GREAT MAJORITY OF PATIENTS

Protocols and order sets that sit on the shelf do not benefit patients. An order set that is used for one‐half of the targeted population has no chance of promoting excellent adherence to a protocol, and protocols/order sets must be widely adapted to be effective.13 Institutional mandates for the use of preprinted (or computerized) orders can be a very effective strategy. If the order set is constructed properly, it is easy to use and can actually save clinician time, thereby promoting widespread use, in some cases even without such a mandate. The SHM VTE Prevention Collaborative generally endorses an institution‐wide protocol and order set module that covers a variety of patient populations. A plug and play modular order set design allows the VTE prevention order set to be incorporated into all appropriate admission and transfer orders, and lends itself well to paper or computerized order formats.

LAYER ON ADDITIONAL INTERVENTIONS TO ENHANCE THE POWER OF THE PROTOCOL

Skillful introduction of a good order set that reaches most patients has often yielded observed VTE prophylaxis rates of 75% to 80% in the SHM VTE Prevention Collaborative. To reach higher levels, a multifaceted approach using a variety of techniques has been an effective strategy in the literature24, 6, 7, 10, 13, 15 and in the Collaborative. Educational programs alone,4, 16, 17 while not generally sufficient to bring about reliable VTE prophylaxis, remain an important intervention that can foster a more enthusiastic and appropriate use of order sets and protocols. Periodic audit and feedback and computerized decision support can also be very effective,3, 1822 particularly when there is an institutional protocol to hold up as the defining standard for adequate prophylaxis. We favor a method that involves real‐time identification of outliers (i.e., patients without prophylaxis who have some VTE risk and no obvious contraindication to prophylaxis). This identification can be done manually, but automated reports are generally feasible and effective. A simple templated note or page from a nurse or pharmacist to the provider of an outlier patient can bolster VTE prevention rates to well over 95%.5 Fatigue from alerts is minimized if this strategy is deployed after substantial improvement in VTE prophylaxis rates has been achieved via a well‐implemented and uniformly‐utilized order set. Trending and discussing cases of hospital‐acquired VTE can also motivate medical staff and reduce resistance to standardization.2, 3

THE FOUNDATION FOR IMPROVEMENT MUST BE IN PLACE

To explain why they did not implement educational programs, guidelines, or provide feedback to providers on their performance, the authors cite a lack of resources common to community medical centers. Yet, they were able to achieve the most resource‐intensive and challenging component of a VTE prevention effort, data collection and analysis. While resources for quality improvement are indeed insufficient in many academic and community hospitals, suboptimal levels of improvement tend to reflect, as in this study, fundamental failures in approach or execution. In this case, the order set design and implementation issues outlined above do not require extensive resources. Moreover, the foundation for effective improvement must be in place to address these issues effectively. This foundation includes administrative buy‐in that VTE prevention is an institutional priority, a commitment to support standardization (even in the face of occasional medical staff resistance), and a willingness to examine and redesign processes.13 It is unclear whether the administration was convinced that the effort should be a priority or whether this improvement team reported results through appropriate medical staff committees. The key point, of course, is that a culture of shared purpose, cooperation, and high expectations between the medical staff and the administration is more important than extensive resources. The right foundational elements put most improvement resources within the grasp of most medical centers.

The authors present work that is praiseworthy in many respects, but their suboptimal levels of improvement should serve as a cautionary tale rather than a model for other centers. Core improvement principles are of key importance. A mere prompt to order VTE prophylaxis within voluntarily‐used order sets, without supporting strategies to enhance VTE prophylaxis, is a recipe for mediocre improvement. Far superior results have been demonstrated in both community and academic centers, even in environments with limited resources. A multifaceted approach, including order sets that promote VTE prophylaxis and provide decision support for the majority of the targeted population, proactive intervention applied to outliers who are not on appropriate prophylaxis, educational programs, and an institutional commitment to standardization, are the ingredients for excellent results.

In this issue of JHM, O'Connor et al.1 examine the impact of paper‐based admission order sets on several quality measures relevant to medical inpatients in a large community medical center, focusing the most attention on the use of venous thromboembolism (VTE) prophylaxis. Randomly selected medical admissions from 4 time periods were examined by chart review for use of the order set, and for the use of VTE prophylaxis (defined as either unfractionated heparin [UFH] 5,000 units subcutaneous [sc] twice daily [BID] or compression stockings). VTE prophylaxis was ordered in an abysmally low 10.9% of inpatients in the baseline period. In spite of the limitations inherent in a before and after study design and a failure to assess the appropriateness of VTE prophylaxis, VTE rates, or side effects, the authors present convincing evidence that improvement in VTE prophylaxis did occur. However, it was a very limited and suboptimal improvement. By the fourteenth and fifteenth month after order set introduction, only about one‐half of admissions used the order set, and even when the order set was used, only 44% had VTE prophylaxis ordered. The percent of patient‐days with pharmacologic VTE prophylaxis in medical inpatients improved after order set implementation, but remained very low, at 26%. Therefore, the key lessons to be learned from this study are likely derived from what went wrong, rather than what went right.

Why did VTE prophylaxis rates stay so low in the face of a multiyear effort? An examination of more successful efforts,25 recent reviews in the VTE and quality improvement literature,610 and the Society of Hospital Medicine VTE Prevention Collaborative experience reveals several principles for effective improvement that were not followed in this study.

A VTE PREVENTION ORDER SET SHOULD PROVIDE DECISION SUPPORT (NOT JUST A PROMPT)

A simple prompt for mechanical prophylaxis or for UFH 5,000 units sc BID was embedded into a voluntary order set in this effort. Mechanical prophylaxis, pharmacologic prophylaxis, and no prophylaxis were treated as equal options, even though most medical inpatients have significant VTE risk factors,11, 12 and in spite of strong evidence‐based recommendations12 relegating mechanical prophylaxis to an adjunctive role for pharmacologic prophylaxis (unless there are contraindications to pharmacologic prophylaxis). The authors point out that the way order sets are structured or introduced is important to ensure they achieve the desired changes in practice. I could not agree more, but, unfortunately, the structure of their order set only secured the desired change in 44% of patients, even if you count compression stockings as adequate prophylaxis. This relatively poor result should have sparked a redesign of the VTE prevention component of the order set.

A more effective order set would reflect an institutional VTE prevention protocol.6, 7, 9, 13 A VTE prevention protocol consists of a standardized VTE risk assessment and contraindications to pharmacologic or heparin prophylaxis, linked to a menu of appropriate VTE prophylaxis options for each level of risk.13 The best protocols provide decision support at the point of care,9, 13 and yet preserve the ability to customize care for special patient situations or circumstances.

Ease of use issues and the lack of prospectively validated models have hindered widespread adoption of VTE risk assessment protocols (especially the point‐based models),14 but a simpler and more streamlined approach has been validated by the UCSD Medical Center experience,2 and by the general success of similar protocols in diverse medical centers taking part in the Society of Hospital Medicine (SHM) VTE Prevention Collaborative. This simpler method generally places patients into 1 of 3 levels of VTE risk, can be completed in seconds, and has excellent interobserver agreement. Reinforcing the expectation that pharmacologic prophylaxis is desirable for most ill inpatients (unless there is a contraindication to it) is likely more important than the finer details of the risk assessment model.

PROTOCOLS AND ORDER SETS MUST REACH THE GREAT MAJORITY OF PATIENTS

Protocols and order sets that sit on the shelf do not benefit patients. An order set that is used for one‐half of the targeted population has no chance of promoting excellent adherence to a protocol, and protocols/order sets must be widely adapted to be effective.13 Institutional mandates for the use of preprinted (or computerized) orders can be a very effective strategy. If the order set is constructed properly, it is easy to use and can actually save clinician time, thereby promoting widespread use, in some cases even without such a mandate. The SHM VTE Prevention Collaborative generally endorses an institution‐wide protocol and order set module that covers a variety of patient populations. A plug and play modular order set design allows the VTE prevention order set to be incorporated into all appropriate admission and transfer orders, and lends itself well to paper or computerized order formats.

LAYER ON ADDITIONAL INTERVENTIONS TO ENHANCE THE POWER OF THE PROTOCOL

Skillful introduction of a good order set that reaches most patients has often yielded observed VTE prophylaxis rates of 75% to 80% in the SHM VTE Prevention Collaborative. To reach higher levels, a multifaceted approach using a variety of techniques has been an effective strategy in the literature24, 6, 7, 10, 13, 15 and in the Collaborative. Educational programs alone,4, 16, 17 while not generally sufficient to bring about reliable VTE prophylaxis, remain an important intervention that can foster a more enthusiastic and appropriate use of order sets and protocols. Periodic audit and feedback and computerized decision support can also be very effective,3, 1822 particularly when there is an institutional protocol to hold up as the defining standard for adequate prophylaxis. We favor a method that involves real‐time identification of outliers (i.e., patients without prophylaxis who have some VTE risk and no obvious contraindication to prophylaxis). This identification can be done manually, but automated reports are generally feasible and effective. A simple templated note or page from a nurse or pharmacist to the provider of an outlier patient can bolster VTE prevention rates to well over 95%.5 Fatigue from alerts is minimized if this strategy is deployed after substantial improvement in VTE prophylaxis rates has been achieved via a well‐implemented and uniformly‐utilized order set. Trending and discussing cases of hospital‐acquired VTE can also motivate medical staff and reduce resistance to standardization.2, 3

THE FOUNDATION FOR IMPROVEMENT MUST BE IN PLACE

To explain why they did not implement educational programs, guidelines, or provide feedback to providers on their performance, the authors cite a lack of resources common to community medical centers. Yet, they were able to achieve the most resource‐intensive and challenging component of a VTE prevention effort, data collection and analysis. While resources for quality improvement are indeed insufficient in many academic and community hospitals, suboptimal levels of improvement tend to reflect, as in this study, fundamental failures in approach or execution. In this case, the order set design and implementation issues outlined above do not require extensive resources. Moreover, the foundation for effective improvement must be in place to address these issues effectively. This foundation includes administrative buy‐in that VTE prevention is an institutional priority, a commitment to support standardization (even in the face of occasional medical staff resistance), and a willingness to examine and redesign processes.13 It is unclear whether the administration was convinced that the effort should be a priority or whether this improvement team reported results through appropriate medical staff committees. The key point, of course, is that a culture of shared purpose, cooperation, and high expectations between the medical staff and the administration is more important than extensive resources. The right foundational elements put most improvement resources within the grasp of most medical centers.

The authors present work that is praiseworthy in many respects, but their suboptimal levels of improvement should serve as a cautionary tale rather than a model for other centers. Core improvement principles are of key importance. A mere prompt to order VTE prophylaxis within voluntarily‐used order sets, without supporting strategies to enhance VTE prophylaxis, is a recipe for mediocre improvement. Far superior results have been demonstrated in both community and academic centers, even in environments with limited resources. A multifaceted approach, including order sets that promote VTE prophylaxis and provide decision support for the majority of the targeted population, proactive intervention applied to outliers who are not on appropriate prophylaxis, educational programs, and an institutional commitment to standardization, are the ingredients for excellent results.

In this issue of JHM, O'Connor et al.1 examine the impact of paper‐based admission order sets on several quality measures relevant to medical inpatients in a large community medical center, focusing the most attention on the use of venous thromboembolism (VTE) prophylaxis. Randomly selected medical admissions from 4 time periods were examined by chart review for use of the order set, and for the use of VTE prophylaxis (defined as either unfractionated heparin [UFH] 5,000 units subcutaneous [sc] twice daily [BID] or compression stockings). VTE prophylaxis was ordered in an abysmally low 10.9% of inpatients in the baseline period. In spite of the limitations inherent in a before and after study design and a failure to assess the appropriateness of VTE prophylaxis, VTE rates, or side effects, the authors present convincing evidence that improvement in VTE prophylaxis did occur. However, it was a very limited and suboptimal improvement. By the fourteenth and fifteenth month after order set introduction, only about one‐half of admissions used the order set, and even when the order set was used, only 44% had VTE prophylaxis ordered. The percent of patient‐days with pharmacologic VTE prophylaxis in medical inpatients improved after order set implementation, but remained very low, at 26%. Therefore, the key lessons to be learned from this study are likely derived from what went wrong, rather than what went right.

Why did VTE prophylaxis rates stay so low in the face of a multiyear effort? An examination of more successful efforts,25 recent reviews in the VTE and quality improvement literature,610 and the Society of Hospital Medicine VTE Prevention Collaborative experience reveals several principles for effective improvement that were not followed in this study.

A VTE PREVENTION ORDER SET SHOULD PROVIDE DECISION SUPPORT (NOT JUST A PROMPT)

A simple prompt for mechanical prophylaxis or for UFH 5,000 units sc BID was embedded into a voluntary order set in this effort. Mechanical prophylaxis, pharmacologic prophylaxis, and no prophylaxis were treated as equal options, even though most medical inpatients have significant VTE risk factors,11, 12 and in spite of strong evidence‐based recommendations12 relegating mechanical prophylaxis to an adjunctive role for pharmacologic prophylaxis (unless there are contraindications to pharmacologic prophylaxis). The authors point out that the way order sets are structured or introduced is important to ensure they achieve the desired changes in practice. I could not agree more, but, unfortunately, the structure of their order set only secured the desired change in 44% of patients, even if you count compression stockings as adequate prophylaxis. This relatively poor result should have sparked a redesign of the VTE prevention component of the order set.

A more effective order set would reflect an institutional VTE prevention protocol.6, 7, 9, 13 A VTE prevention protocol consists of a standardized VTE risk assessment and contraindications to pharmacologic or heparin prophylaxis, linked to a menu of appropriate VTE prophylaxis options for each level of risk.13 The best protocols provide decision support at the point of care,9, 13 and yet preserve the ability to customize care for special patient situations or circumstances.

Ease of use issues and the lack of prospectively validated models have hindered widespread adoption of VTE risk assessment protocols (especially the point‐based models),14 but a simpler and more streamlined approach has been validated by the UCSD Medical Center experience,2 and by the general success of similar protocols in diverse medical centers taking part in the Society of Hospital Medicine (SHM) VTE Prevention Collaborative. This simpler method generally places patients into 1 of 3 levels of VTE risk, can be completed in seconds, and has excellent interobserver agreement. Reinforcing the expectation that pharmacologic prophylaxis is desirable for most ill inpatients (unless there is a contraindication to it) is likely more important than the finer details of the risk assessment model.

PROTOCOLS AND ORDER SETS MUST REACH THE GREAT MAJORITY OF PATIENTS

Protocols and order sets that sit on the shelf do not benefit patients. An order set that is used for one‐half of the targeted population has no chance of promoting excellent adherence to a protocol, and protocols/order sets must be widely adapted to be effective.13 Institutional mandates for the use of preprinted (or computerized) orders can be a very effective strategy. If the order set is constructed properly, it is easy to use and can actually save clinician time, thereby promoting widespread use, in some cases even without such a mandate. The SHM VTE Prevention Collaborative generally endorses an institution‐wide protocol and order set module that covers a variety of patient populations. A plug and play modular order set design allows the VTE prevention order set to be incorporated into all appropriate admission and transfer orders, and lends itself well to paper or computerized order formats.

LAYER ON ADDITIONAL INTERVENTIONS TO ENHANCE THE POWER OF THE PROTOCOL

Skillful introduction of a good order set that reaches most patients has often yielded observed VTE prophylaxis rates of 75% to 80% in the SHM VTE Prevention Collaborative. To reach higher levels, a multifaceted approach using a variety of techniques has been an effective strategy in the literature24, 6, 7, 10, 13, 15 and in the Collaborative. Educational programs alone,4, 16, 17 while not generally sufficient to bring about reliable VTE prophylaxis, remain an important intervention that can foster a more enthusiastic and appropriate use of order sets and protocols. Periodic audit and feedback and computerized decision support can also be very effective,3, 1822 particularly when there is an institutional protocol to hold up as the defining standard for adequate prophylaxis. We favor a method that involves real‐time identification of outliers (i.e., patients without prophylaxis who have some VTE risk and no obvious contraindication to prophylaxis). This identification can be done manually, but automated reports are generally feasible and effective. A simple templated note or page from a nurse or pharmacist to the provider of an outlier patient can bolster VTE prevention rates to well over 95%.5 Fatigue from alerts is minimized if this strategy is deployed after substantial improvement in VTE prophylaxis rates has been achieved via a well‐implemented and uniformly‐utilized order set. Trending and discussing cases of hospital‐acquired VTE can also motivate medical staff and reduce resistance to standardization.2, 3

THE FOUNDATION FOR IMPROVEMENT MUST BE IN PLACE

To explain why they did not implement educational programs, guidelines, or provide feedback to providers on their performance, the authors cite a lack of resources common to community medical centers. Yet, they were able to achieve the most resource‐intensive and challenging component of a VTE prevention effort, data collection and analysis. While resources for quality improvement are indeed insufficient in many academic and community hospitals, suboptimal levels of improvement tend to reflect, as in this study, fundamental failures in approach or execution. In this case, the order set design and implementation issues outlined above do not require extensive resources. Moreover, the foundation for effective improvement must be in place to address these issues effectively. This foundation includes administrative buy‐in that VTE prevention is an institutional priority, a commitment to support standardization (even in the face of occasional medical staff resistance), and a willingness to examine and redesign processes.13 It is unclear whether the administration was convinced that the effort should be a priority or whether this improvement team reported results through appropriate medical staff committees. The key point, of course, is that a culture of shared purpose, cooperation, and high expectations between the medical staff and the administration is more important than extensive resources. The right foundational elements put most improvement resources within the grasp of most medical centers.

The authors present work that is praiseworthy in many respects, but their suboptimal levels of improvement should serve as a cautionary tale rather than a model for other centers. Core improvement principles are of key importance. A mere prompt to order VTE prophylaxis within voluntarily‐used order sets, without supporting strategies to enhance VTE prophylaxis, is a recipe for mediocre improvement. Far superior results have been demonstrated in both community and academic centers, even in environments with limited resources. A multifaceted approach, including order sets that promote VTE prophylaxis and provide decision support for the majority of the targeted population, proactive intervention applied to outliers who are not on appropriate prophylaxis, educational programs, and an institutional commitment to standardization, are the ingredients for excellent results.