Innovations in Healthcare

Improving the quality of care in your hospital isn’t just good for your hospital medicine group or your hospital; it’s good for the community. Each year, SHM leads some of the best quality improvement programs in healthcare, and you can get involved.

SHM is now accepting applications for the Glycemic Control Mentored Implementation Program. An informational webinar about the program will be available on Aug. 14. For details, visit www.hospitalmedicine.org/gcmi.

There is still time to apply for the Project BOOST fall cohort. For details, visit www.hospitalmedicine.org/boost.

Are you implementing Choosing Wisely in your hospital? You could win SHM’s Choosing Wisely competition and share your expertise with thousands of other hospitalists.

Visit www.hospitalmedicine.org/choosingwisely to learn more.

Improving the quality of care in your hospital isn’t just good for your hospital medicine group or your hospital; it’s good for the community. Each year, SHM leads some of the best quality improvement programs in healthcare, and you can get involved.

SHM is now accepting applications for the Glycemic Control Mentored Implementation Program. An informational webinar about the program will be available on Aug. 14. For details, visit www.hospitalmedicine.org/gcmi.

There is still time to apply for the Project BOOST fall cohort. For details, visit www.hospitalmedicine.org/boost.

Are you implementing Choosing Wisely in your hospital? You could win SHM’s Choosing Wisely competition and share your expertise with thousands of other hospitalists.

Visit www.hospitalmedicine.org/choosingwisely to learn more.

Improving the quality of care in your hospital isn’t just good for your hospital medicine group or your hospital; it’s good for the community. Each year, SHM leads some of the best quality improvement programs in healthcare, and you can get involved.

SHM is now accepting applications for the Glycemic Control Mentored Implementation Program. An informational webinar about the program will be available on Aug. 14. For details, visit www.hospitalmedicine.org/gcmi.

There is still time to apply for the Project BOOST fall cohort. For details, visit www.hospitalmedicine.org/boost.

Are you implementing Choosing Wisely in your hospital? You could win SHM’s Choosing Wisely competition and share your expertise with thousands of other hospitalists.

Visit www.hospitalmedicine.org/choosingwisely to learn more.

SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.

The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.

“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.

“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”

Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.

Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.

“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”

HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.

“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.

She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”

Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.

As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.

“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”

SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.

The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.

“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.

“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”

Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.

Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.

“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”

HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.

“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.

She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”

Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.

As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.

“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”

SHM’s Hospitalist Program Peak Performance, HP3 for short, will conclude at the end of 2014, but it will leave a legacy that will continue to improve HM groups everywhere for years to come.

The product of a unique collaboration among SHM, hospitalist consulting firm Nelson/Flores, and others, HP3 was designed as a key component of the Preventing Readmissions through Effective Partnerships (PREP) collaborative, sponsored by BlueCross BlueShield of Illinois in collaboration with the Illinois Hospital Association and Northwestern University Feinberg School of Medicine. The overall goal of the PREP collaborative is to help move Illinois from the bottom quartile to the upper quartile ranking on readmission rates by providing tools and approaches to improve transitions of care.

“HP3 was designed to be a little like getting a personal trainer at the gym,” says John Nelson, MD, MHM, who helped create the program. “Each hospitalist group was assigned an experienced hospitalist leader as a mentor, who in some ways acted like a personal trainer, guiding and encouraging efforts to complete projects to improve their practice.

“I think most groups were surprised and pleased that they were able to accomplish more than they realized. Our hope is that they will continue ‘working out’ to improve their practice even after their participation in HP3 concludes.”

Today, many of the lessons learned from HP3—including the idea that a healthy, high-functioning hospitalist practice is an important part of improving care—have been carried into other important SHM projects, like the recent “Key Principles and Characteristics of an Effective Hospital Medicine Group,” an assessment guide developed by SHM and published in the February 2014 Journal of Hospital Medicine.

Among the ideas presented in the “Key Principles and Characteristics” guide is the concept of hospitalist engagement, which is what Dr. Mark Williams thinks hospitals can also take away from HP3.

“Engaging hospitalists is key to improving care for hospitalized patients,” says Dr. Williams, who notes that engaging hospitalists means engaging much of the entire hospital. “Hospitalists are fully integrated into hospital care delivery for general medicine patients and many—if not most—specialty and surgical patients.”

HP3 faculty Leslie Flores, MHA, SFHM, saw a two-fold benefit from HP3: an outside perspective and an introduction to techniques that will continue beyond HP3.

“It caused them to look critically at their hospitalist program and assess its organization and performance against an objective benchmark. For many, it was the first time they had been challenged to think about their hospitalist program in this way,” Flores says.

She noticed that HP3 “also taught the participants how to use basic quality improvement and project management techniques to improve their own group’s performance—these are skills they can use again and again going forward.”

Flores thinks that HP3 also benefited from another core piece of SHM’s DNA: its award-winning Mentored Implementation (MI) model, which pairs hospital sites with national experts in hospital medicine. But, instead of being focused solely on quality improvement, it broadened the MI approach to operational improvement, opening up the possibility of improved quality outcomes.

As with many SHM educational programs, the learning went in both directions and may continue after the end of HP3, according to Flores.

“I think we [the faculty and mentors], in some cases, learned as much from our participants as they learned from us,” she says. “Some of them are doing some really great things that we can add to our fund of practice management ‘best practices’ and share with others!”

A recent article in the Journal of Internal Medicine draws a strong link between readmission rates and the degree to which patients are activated—possessing the knowledge, skills, and confidence to manage their own health post-discharge.² Co-author Judith Hibbard, DrPh, professor of health policy at the University of Oregon, is the lead inventor of the Patient Activation Measure (PAM), an eight-item tool that assigns patients to one of four levels of activation.

In a sample of 700 patients discharged from Boston Medical Center, those with the lowest levels of activation had 1.75 times the risk of 30-day readmissions, more ED visits, and greater utilization of health services, even after adjusting for severity of illness and demographics.

“Contrary to what some may assume, patients who demonstrate a lower level of activation do not fall into any specific racial, economic, or educational demographic,” Dr. Hibbard says, adding that providers should not expect to be able to reliably judge their patients’ ability to self-manage outside of the hospital. “We know that people who measure low tend to have little confidence in their ability to manage their own health. They feel overwhelmed, show poor problem-solving skills, don’t understand what professionals are telling them, and, as a result, may not pay close attention.”

Dr. Hibbard says higher activation scores reflect greater focus on personal health and the effort to monitor it—with more confidence.

The take-home message for hospitalists, she says, is to understand the importance of their patients’ activation level and to tailor interventions accordingly.

“Those with low activation may need more support,” such as post-discharge home visits instead of just a phone call. Low-activation patients should not be overwhelmed with information but should instead be given just a few prioritized key points, combined with the use of reinforcing communications techniques such as teach-back.

“Someone should sit with them and help negotiate their health behaviors,” she adds. “That’s how they get more activated. It doesn’t have to be a doctor going through these things. But just using the clinical lens to understand your patients is not enough.”

Larry Beresford is a freelance writer in Alameda, Calif.

A recent article in the Journal of Internal Medicine draws a strong link between readmission rates and the degree to which patients are activated—possessing the knowledge, skills, and confidence to manage their own health post-discharge.² Co-author Judith Hibbard, DrPh, professor of health policy at the University of Oregon, is the lead inventor of the Patient Activation Measure (PAM), an eight-item tool that assigns patients to one of four levels of activation.

In a sample of 700 patients discharged from Boston Medical Center, those with the lowest levels of activation had 1.75 times the risk of 30-day readmissions, more ED visits, and greater utilization of health services, even after adjusting for severity of illness and demographics.

“Contrary to what some may assume, patients who demonstrate a lower level of activation do not fall into any specific racial, economic, or educational demographic,” Dr. Hibbard says, adding that providers should not expect to be able to reliably judge their patients’ ability to self-manage outside of the hospital. “We know that people who measure low tend to have little confidence in their ability to manage their own health. They feel overwhelmed, show poor problem-solving skills, don’t understand what professionals are telling them, and, as a result, may not pay close attention.”

Dr. Hibbard says higher activation scores reflect greater focus on personal health and the effort to monitor it—with more confidence.

The take-home message for hospitalists, she says, is to understand the importance of their patients’ activation level and to tailor interventions accordingly.

“Those with low activation may need more support,” such as post-discharge home visits instead of just a phone call. Low-activation patients should not be overwhelmed with information but should instead be given just a few prioritized key points, combined with the use of reinforcing communications techniques such as teach-back.

“Someone should sit with them and help negotiate their health behaviors,” she adds. “That’s how they get more activated. It doesn’t have to be a doctor going through these things. But just using the clinical lens to understand your patients is not enough.”

Larry Beresford is a freelance writer in Alameda, Calif.

A recent article in the Journal of Internal Medicine draws a strong link between readmission rates and the degree to which patients are activated—possessing the knowledge, skills, and confidence to manage their own health post-discharge.² Co-author Judith Hibbard, DrPh, professor of health policy at the University of Oregon, is the lead inventor of the Patient Activation Measure (PAM), an eight-item tool that assigns patients to one of four levels of activation.

In a sample of 700 patients discharged from Boston Medical Center, those with the lowest levels of activation had 1.75 times the risk of 30-day readmissions, more ED visits, and greater utilization of health services, even after adjusting for severity of illness and demographics.

“Contrary to what some may assume, patients who demonstrate a lower level of activation do not fall into any specific racial, economic, or educational demographic,” Dr. Hibbard says, adding that providers should not expect to be able to reliably judge their patients’ ability to self-manage outside of the hospital. “We know that people who measure low tend to have little confidence in their ability to manage their own health. They feel overwhelmed, show poor problem-solving skills, don’t understand what professionals are telling them, and, as a result, may not pay close attention.”

Dr. Hibbard says higher activation scores reflect greater focus on personal health and the effort to monitor it—with more confidence.

The take-home message for hospitalists, she says, is to understand the importance of their patients’ activation level and to tailor interventions accordingly.

“Those with low activation may need more support,” such as post-discharge home visits instead of just a phone call. Low-activation patients should not be overwhelmed with information but should instead be given just a few prioritized key points, combined with the use of reinforcing communications techniques such as teach-back.

“Someone should sit with them and help negotiate their health behaviors,” she adds. “That’s how they get more activated. It doesn’t have to be a doctor going through these things. But just using the clinical lens to understand your patients is not enough.”

Larry Beresford is a freelance writer in Alameda, Calif.

Teaching trainees to identify and manage sepsis using an online game known as “Septris” earned hospitalists at Stanford University Medical Center in Palo Alto, Calif., a Research, Innovation, and Clinical Vignette category award at HM13.¹

“We took third-year medical students and residents in medicine, surgery, and emergency medicine—people who would be sepsis first responders on the floor—and gave them pre- and post-tests that documented improvements in both attitudes and knowledge,” says lead author Lisa Shieh, MD, PhD, Stanford’s medical director of quality in the department of medicine. All participants said they enjoyed playing the game, she reported.

Septris was developed by a multidisciplinary group of physicians, educational technology specialists, and programmers at Stanford. The game offers a case-based interactive learning environment drawn from evidence-based treatment algorithms. Players make treatment decisions and watch as the patient outcome rises or declines. The game’s rapid pace underscores the importance of early diagnosis and treatment.

“We tried to make our game as engaging and real-life as possible,” Dr. Shieh says.

The Stanford team is in touch with the Society of Critical Care Medicine’s Surviving Sepsis Campaign (www.survivingsepsis.org) and with other medical groups internationally. Thousands of players have accessed the game online for free (http://cme.stanford.edu/septris/game/SepsisTetris.html), with a nominal fee for CME credit. It is best played on an iPad or iPhone, Dr. Shieh says.

Larry Beresford is a freelance writer in Alameda, Calif.

Teaching trainees to identify and manage sepsis using an online game known as “Septris” earned hospitalists at Stanford University Medical Center in Palo Alto, Calif., a Research, Innovation, and Clinical Vignette category award at HM13.¹

“We took third-year medical students and residents in medicine, surgery, and emergency medicine—people who would be sepsis first responders on the floor—and gave them pre- and post-tests that documented improvements in both attitudes and knowledge,” says lead author Lisa Shieh, MD, PhD, Stanford’s medical director of quality in the department of medicine. All participants said they enjoyed playing the game, she reported.

Septris was developed by a multidisciplinary group of physicians, educational technology specialists, and programmers at Stanford. The game offers a case-based interactive learning environment drawn from evidence-based treatment algorithms. Players make treatment decisions and watch as the patient outcome rises or declines. The game’s rapid pace underscores the importance of early diagnosis and treatment.

“We tried to make our game as engaging and real-life as possible,” Dr. Shieh says.

The Stanford team is in touch with the Society of Critical Care Medicine’s Surviving Sepsis Campaign (www.survivingsepsis.org) and with other medical groups internationally. Thousands of players have accessed the game online for free (http://cme.stanford.edu/septris/game/SepsisTetris.html), with a nominal fee for CME credit. It is best played on an iPad or iPhone, Dr. Shieh says.

Larry Beresford is a freelance writer in Alameda, Calif.

Teaching trainees to identify and manage sepsis using an online game known as “Septris” earned hospitalists at Stanford University Medical Center in Palo Alto, Calif., a Research, Innovation, and Clinical Vignette category award at HM13.¹

“We took third-year medical students and residents in medicine, surgery, and emergency medicine—people who would be sepsis first responders on the floor—and gave them pre- and post-tests that documented improvements in both attitudes and knowledge,” says lead author Lisa Shieh, MD, PhD, Stanford’s medical director of quality in the department of medicine. All participants said they enjoyed playing the game, she reported.

Septris was developed by a multidisciplinary group of physicians, educational technology specialists, and programmers at Stanford. The game offers a case-based interactive learning environment drawn from evidence-based treatment algorithms. Players make treatment decisions and watch as the patient outcome rises or declines. The game’s rapid pace underscores the importance of early diagnosis and treatment.

“We tried to make our game as engaging and real-life as possible,” Dr. Shieh says.

The Stanford team is in touch with the Society of Critical Care Medicine’s Surviving Sepsis Campaign (www.survivingsepsis.org) and with other medical groups internationally. Thousands of players have accessed the game online for free (http://cme.stanford.edu/septris/game/SepsisTetris.html), with a nominal fee for CME credit. It is best played on an iPad or iPhone, Dr. Shieh says.

Larry Beresford is a freelance writer in Alameda, Calif.

The American Society for Parenteral and Enteral Nutrition (ASPEN), the Global Enteral Device Supplier Association (GEDSA) and a number of other quality-oriented groups, including the FDA, Centers for Medicare & Medicaid Services (CMS), and the Joint Commission, are working to address tubing misconnections for medical device small-bore connectors—used for enteral, luer, neuro-cranial, respiratory, and other medical tubing equipment.²

Misconnections, although rare, can be harmful or even fatal to patients. The task force conducted a panel discussion Oct. 22 in Washington, D.C., focused on redesign issues, and is collaborating with the International Standards Organization to develop new small-bore connector standards.

GEDSA’s “Stay Connected” is an education campaign to inform and prepare the healthcare community for impending changes in standards for small-bore connectors. For more information, visit www.stayconnected2014.org.

The American Society for Parenteral and Enteral Nutrition (ASPEN), the Global Enteral Device Supplier Association (GEDSA) and a number of other quality-oriented groups, including the FDA, Centers for Medicare & Medicaid Services (CMS), and the Joint Commission, are working to address tubing misconnections for medical device small-bore connectors—used for enteral, luer, neuro-cranial, respiratory, and other medical tubing equipment.²

Misconnections, although rare, can be harmful or even fatal to patients. The task force conducted a panel discussion Oct. 22 in Washington, D.C., focused on redesign issues, and is collaborating with the International Standards Organization to develop new small-bore connector standards.

GEDSA’s “Stay Connected” is an education campaign to inform and prepare the healthcare community for impending changes in standards for small-bore connectors. For more information, visit www.stayconnected2014.org.

The American Society for Parenteral and Enteral Nutrition (ASPEN), the Global Enteral Device Supplier Association (GEDSA) and a number of other quality-oriented groups, including the FDA, Centers for Medicare & Medicaid Services (CMS), and the Joint Commission, are working to address tubing misconnections for medical device small-bore connectors—used for enteral, luer, neuro-cranial, respiratory, and other medical tubing equipment.²

Misconnections, although rare, can be harmful or even fatal to patients. The task force conducted a panel discussion Oct. 22 in Washington, D.C., focused on redesign issues, and is collaborating with the International Standards Organization to develop new small-bore connector standards.

GEDSA’s “Stay Connected” is an education campaign to inform and prepare the healthcare community for impending changes in standards for small-bore connectors. For more information, visit www.stayconnected2014.org.

Mix the insights of a policy wonk and the accent of Sean Connery, and you have Ian Morrison, PhD, one of the keynote speakers at SHM’s annual meeting this spring.

A native of Scotland, Dr. Morrison is a well-known author, consultant, and futurist who often lectures on where healthcare is headed in this country. Appropriately, his address is titled, “The Future of the Healthcare Marketplace: Playing the New Game.”

A second-time annual meeting speaker, who last addressed HM attendees in 2008, Dr. Morrison is a founding partner in Strategic Health Perspectives (SHP), a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s Department of Health Policy and Management. Dr. Morrison is also president emeritus of the Institute for the Future (IFTF).

Dr. Morrison spoke at length with The Hospitalist about his speech next month in Las Vegas.

Question: What do you want a room full of hospitalists to know about what they should be doing?

Answer: What I’ve been urging groups to think about is to take the longer view. I think we all get caught up in the disaster of the moment, and it’s amplified by the ideological divide over healthcare and the politicization and partisanship over it. But I think what we’ve got to do is think about the one-, three-, and five-year time horizon, about the pace of change and what we’re trying to do here. Don’t conflate the future into a blur of simultaneous change. Some of these things are going to take time.

Q: How do you rise above that fray that is “the blur of simultaneous events?”

A: If you take the longer view, there are some things that are happening, no matter what, that will not be undone by even the politics of Washington, D.C. That is the massive consolidation in the delivery system—the fact that doctors are increasingly employed by hospital systems in the main. Now, this has always been true of hospitalists, but it’s increasingly true of cardiologists and everybody else. And those trends I don’t think are going to abate. The other “megatrend” that I think is over a longer time horizon is the increasing focus on reimbursement reform to reward quality and value, particularly on a population health basis. That, I think, has so much momentum that it’s unlikely to be undone. I urge people to think about the Wright Brothers as a metaphor, rather than the Indianapolis 500; let’s just get this sucker off the ground before we declare that flying is a bad idea.

Q: How do you tailor that message to hospitalists?

A: In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. They are trying to limit readmissions to hospitals where there are certainly financial incentives, and increasing senior management’s attention on that question. So I think hospitalists are in the center of all of those kinds of discussions, at the ground level.

“In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. ”

–Dr. Morrison

Q: Being at the eye of a storm isn’t always the best place to be. How do hospitalists navigate this landscape, both to address patient care challenges and to deal with the shift that’s going to take place over the next five to 10 years, regardless of how fumbled anything is politically?

A: The specialty may transform itself into more of a hospital-based care management specialty. In other words, just simply discharging patients and saying “My job is over” doesn’t seem to me to be the future of this particular discipline. I think they are going to be the hospital-based voice for redesigning care processes across the continuum of care. And they may find themselves reaching out, maybe not physically, but electronically and digitally, to patients as they leave the hospital and migrate back into their homes and into their other settings, like skilled nursing facilities and home care and long-term care. They’re having a more involved role in care coordination after the patient is gone, not necessarily on a routine basis, looking and seeing how they’re doing, but designing care processes across that system of care and monitoring their effectiveness.

Q: How does the healthcare system view hospital medicine?

A: Well, certainly among hospital CEOs and leaders, and I’m not just talking about ones that have medical training, I think they see [HM] as a critical asset. Hospitalists are actually in the vanguard of this transformation effect; they’re not the victims of it.

Richard Quinn is a freelance author in New Jersey.

Mix the insights of a policy wonk and the accent of Sean Connery, and you have Ian Morrison, PhD, one of the keynote speakers at SHM’s annual meeting this spring.

A native of Scotland, Dr. Morrison is a well-known author, consultant, and futurist who often lectures on where healthcare is headed in this country. Appropriately, his address is titled, “The Future of the Healthcare Marketplace: Playing the New Game.”

A second-time annual meeting speaker, who last addressed HM attendees in 2008, Dr. Morrison is a founding partner in Strategic Health Perspectives (SHP), a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s Department of Health Policy and Management. Dr. Morrison is also president emeritus of the Institute for the Future (IFTF).

Dr. Morrison spoke at length with The Hospitalist about his speech next month in Las Vegas.

Question: What do you want a room full of hospitalists to know about what they should be doing?

Answer: What I’ve been urging groups to think about is to take the longer view. I think we all get caught up in the disaster of the moment, and it’s amplified by the ideological divide over healthcare and the politicization and partisanship over it. But I think what we’ve got to do is think about the one-, three-, and five-year time horizon, about the pace of change and what we’re trying to do here. Don’t conflate the future into a blur of simultaneous change. Some of these things are going to take time.

Q: How do you rise above that fray that is “the blur of simultaneous events?”

A: If you take the longer view, there are some things that are happening, no matter what, that will not be undone by even the politics of Washington, D.C. That is the massive consolidation in the delivery system—the fact that doctors are increasingly employed by hospital systems in the main. Now, this has always been true of hospitalists, but it’s increasingly true of cardiologists and everybody else. And those trends I don’t think are going to abate. The other “megatrend” that I think is over a longer time horizon is the increasing focus on reimbursement reform to reward quality and value, particularly on a population health basis. That, I think, has so much momentum that it’s unlikely to be undone. I urge people to think about the Wright Brothers as a metaphor, rather than the Indianapolis 500; let’s just get this sucker off the ground before we declare that flying is a bad idea.

Q: How do you tailor that message to hospitalists?

A: In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. They are trying to limit readmissions to hospitals where there are certainly financial incentives, and increasing senior management’s attention on that question. So I think hospitalists are in the center of all of those kinds of discussions, at the ground level.

“In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. ”

–Dr. Morrison

Q: Being at the eye of a storm isn’t always the best place to be. How do hospitalists navigate this landscape, both to address patient care challenges and to deal with the shift that’s going to take place over the next five to 10 years, regardless of how fumbled anything is politically?

A: The specialty may transform itself into more of a hospital-based care management specialty. In other words, just simply discharging patients and saying “My job is over” doesn’t seem to me to be the future of this particular discipline. I think they are going to be the hospital-based voice for redesigning care processes across the continuum of care. And they may find themselves reaching out, maybe not physically, but electronically and digitally, to patients as they leave the hospital and migrate back into their homes and into their other settings, like skilled nursing facilities and home care and long-term care. They’re having a more involved role in care coordination after the patient is gone, not necessarily on a routine basis, looking and seeing how they’re doing, but designing care processes across that system of care and monitoring their effectiveness.

Q: How does the healthcare system view hospital medicine?

A: Well, certainly among hospital CEOs and leaders, and I’m not just talking about ones that have medical training, I think they see [HM] as a critical asset. Hospitalists are actually in the vanguard of this transformation effect; they’re not the victims of it.

Richard Quinn is a freelance author in New Jersey.

Mix the insights of a policy wonk and the accent of Sean Connery, and you have Ian Morrison, PhD, one of the keynote speakers at SHM’s annual meeting this spring.

A native of Scotland, Dr. Morrison is a well-known author, consultant, and futurist who often lectures on where healthcare is headed in this country. Appropriately, his address is titled, “The Future of the Healthcare Marketplace: Playing the New Game.”

A second-time annual meeting speaker, who last addressed HM attendees in 2008, Dr. Morrison is a founding partner in Strategic Health Perspectives (SHP), a forecasting service for the healthcare industry that includes joint venture partners Harris Interactive and the Harvard School of Public Health’s Department of Health Policy and Management. Dr. Morrison is also president emeritus of the Institute for the Future (IFTF).

Dr. Morrison spoke at length with The Hospitalist about his speech next month in Las Vegas.

Question: What do you want a room full of hospitalists to know about what they should be doing?

Answer: What I’ve been urging groups to think about is to take the longer view. I think we all get caught up in the disaster of the moment, and it’s amplified by the ideological divide over healthcare and the politicization and partisanship over it. But I think what we’ve got to do is think about the one-, three-, and five-year time horizon, about the pace of change and what we’re trying to do here. Don’t conflate the future into a blur of simultaneous change. Some of these things are going to take time.

Q: How do you rise above that fray that is “the blur of simultaneous events?”

A: If you take the longer view, there are some things that are happening, no matter what, that will not be undone by even the politics of Washington, D.C. That is the massive consolidation in the delivery system—the fact that doctors are increasingly employed by hospital systems in the main. Now, this has always been true of hospitalists, but it’s increasingly true of cardiologists and everybody else. And those trends I don’t think are going to abate. The other “megatrend” that I think is over a longer time horizon is the increasing focus on reimbursement reform to reward quality and value, particularly on a population health basis. That, I think, has so much momentum that it’s unlikely to be undone. I urge people to think about the Wright Brothers as a metaphor, rather than the Indianapolis 500; let’s just get this sucker off the ground before we declare that flying is a bad idea.

Q: How do you tailor that message to hospitalists?

A: In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. They are trying to limit readmissions to hospitals where there are certainly financial incentives, and increasing senior management’s attention on that question. So I think hospitalists are in the center of all of those kinds of discussions, at the ground level.

“In this new environment, hospitalists are seen as one of the specialties that have got it, in terms of patient safety, quality, and care coordination. In my rattling around the country, I see hospitalists playing a pretty critical role in things like care transitions and readmission redesign. ”

–Dr. Morrison

Q: Being at the eye of a storm isn’t always the best place to be. How do hospitalists navigate this landscape, both to address patient care challenges and to deal with the shift that’s going to take place over the next five to 10 years, regardless of how fumbled anything is politically?

A: The specialty may transform itself into more of a hospital-based care management specialty. In other words, just simply discharging patients and saying “My job is over” doesn’t seem to me to be the future of this particular discipline. I think they are going to be the hospital-based voice for redesigning care processes across the continuum of care. And they may find themselves reaching out, maybe not physically, but electronically and digitally, to patients as they leave the hospital and migrate back into their homes and into their other settings, like skilled nursing facilities and home care and long-term care. They’re having a more involved role in care coordination after the patient is gone, not necessarily on a routine basis, looking and seeing how they’re doing, but designing care processes across that system of care and monitoring their effectiveness.

Q: How does the healthcare system view hospital medicine?

A: Well, certainly among hospital CEOs and leaders, and I’m not just talking about ones that have medical training, I think they see [HM] as a critical asset. Hospitalists are actually in the vanguard of this transformation effect; they’re not the victims of it.

Richard Quinn is a freelance author in New Jersey.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

A new feature installed on HMX, LinkedIn Connect, makes it easier for you to fill out your member profile by pulling pieces of your LinkedIn profile into HMX. How does it work exactly?

Login at www.hmxchange.org and click “My Profile.” Midway down the page, you will see a section that reads, “Grab Profile Info from LinkedIn.” Click the link and follow the onscreen instructions. HMX will connect with your LinkedIn profile, pulling information like your photo, bio, education, and job history information.

It makes filling out your profile just a little bit easier.

At the Kaiser Permanente Medical Center in San Rafael, Calif., the 20 members of the hospitalist group were encouraged to study together in preparation for the October 2012 HPM boards. The group undertook weekly study sessions for the five months leading up to the exam. Sixteen hospitalists sat for the exam, along with oncologists, nephrologists, pulmonologists, and primary care physicians from the medical center.

All passed.

“For years, our hospitalist group has been doing actual rounding with the palliative care team on their own patients,” says Shideh Shadan, MD, the hospitalist group leader. “Everyone was on board with palliative care. It is now part of our daily care, and all we had to do was to sit down and study for the exam.”

Most of Kaiser’s HMO medical centers have designated interdisciplinary palliative care consultation teams. The one at San Rafael includes nurses, social workers, chaplains, and a part-time physician who is a hospitalist, Clay Angel, MD. Dr. Angel agrees that a cultural transformation has come about at Kaiser San Rafael through this collaboration. The two services are separate but closely connected.

“In hospital medicine, if you keep farming out what you do to specialists—if you’re not embracing palliative care as a hospitalist—you lose part of your practice,” he says.

Dr. Shadan says the study group “helped us to be more cohesive and more comfortable going to each other to ask for help. Palliative care is part of what we do—part of hospital medicine and of providing good care.”

Meanwhile, North Hollywood, Calif.-based IPC The Hospitalist Company, which is well-established in post-acute and long-term-care settings beyond the hospital walls, is now starting to explore palliative care approaches at the local level in a few of its 35 markets. Heather Zinzella-Cox, MD, who was part of a panel presentation on palliative care at HM13, is hospitalist practice group leader for IPC-Delaware. She also works part time as an associate medical director for a community hospice and helped to develop an inpatient palliative care team at a local community hospital.

“For me, as a post-acute hospitalist, every patient I see, I think about whether palliative care might benefit them,” says Dr. Zinzella-Cox, who is board certified in pain and in hospice and palliative medicine.

She says hospitalists need tools for identifying appropriate palliative care patients, along with training for how to communicate with them around goals of care, including simple language to help cue these conversations. She notes a “significant voltage drop” in information at the time of discharge, and the most careful discharge plans can fall apart in a hurry after the patient goes home.

IPC’s national practice group does not have a current policy or initiative for palliative care; however, there may be opportunities for further integrating palliative care with hospital medicine, says hospitalist Thomas Mathew, MD.

Larry Beresford is a freelance writer in San Francisco.

At the Kaiser Permanente Medical Center in San Rafael, Calif., the 20 members of the hospitalist group were encouraged to study together in preparation for the October 2012 HPM boards. The group undertook weekly study sessions for the five months leading up to the exam. Sixteen hospitalists sat for the exam, along with oncologists, nephrologists, pulmonologists, and primary care physicians from the medical center.

All passed.

“For years, our hospitalist group has been doing actual rounding with the palliative care team on their own patients,” says Shideh Shadan, MD, the hospitalist group leader. “Everyone was on board with palliative care. It is now part of our daily care, and all we had to do was to sit down and study for the exam.”

Most of Kaiser’s HMO medical centers have designated interdisciplinary palliative care consultation teams. The one at San Rafael includes nurses, social workers, chaplains, and a part-time physician who is a hospitalist, Clay Angel, MD. Dr. Angel agrees that a cultural transformation has come about at Kaiser San Rafael through this collaboration. The two services are separate but closely connected.

“In hospital medicine, if you keep farming out what you do to specialists—if you’re not embracing palliative care as a hospitalist—you lose part of your practice,” he says.

Dr. Shadan says the study group “helped us to be more cohesive and more comfortable going to each other to ask for help. Palliative care is part of what we do—part of hospital medicine and of providing good care.”

Meanwhile, North Hollywood, Calif.-based IPC The Hospitalist Company, which is well-established in post-acute and long-term-care settings beyond the hospital walls, is now starting to explore palliative care approaches at the local level in a few of its 35 markets. Heather Zinzella-Cox, MD, who was part of a panel presentation on palliative care at HM13, is hospitalist practice group leader for IPC-Delaware. She also works part time as an associate medical director for a community hospice and helped to develop an inpatient palliative care team at a local community hospital.

“For me, as a post-acute hospitalist, every patient I see, I think about whether palliative care might benefit them,” says Dr. Zinzella-Cox, who is board certified in pain and in hospice and palliative medicine.

She says hospitalists need tools for identifying appropriate palliative care patients, along with training for how to communicate with them around goals of care, including simple language to help cue these conversations. She notes a “significant voltage drop” in information at the time of discharge, and the most careful discharge plans can fall apart in a hurry after the patient goes home.

IPC’s national practice group does not have a current policy or initiative for palliative care; however, there may be opportunities for further integrating palliative care with hospital medicine, says hospitalist Thomas Mathew, MD.

Larry Beresford is a freelance writer in San Francisco.

At the Kaiser Permanente Medical Center in San Rafael, Calif., the 20 members of the hospitalist group were encouraged to study together in preparation for the October 2012 HPM boards. The group undertook weekly study sessions for the five months leading up to the exam. Sixteen hospitalists sat for the exam, along with oncologists, nephrologists, pulmonologists, and primary care physicians from the medical center.

All passed.

“For years, our hospitalist group has been doing actual rounding with the palliative care team on their own patients,” says Shideh Shadan, MD, the hospitalist group leader. “Everyone was on board with palliative care. It is now part of our daily care, and all we had to do was to sit down and study for the exam.”

Most of Kaiser’s HMO medical centers have designated interdisciplinary palliative care consultation teams. The one at San Rafael includes nurses, social workers, chaplains, and a part-time physician who is a hospitalist, Clay Angel, MD. Dr. Angel agrees that a cultural transformation has come about at Kaiser San Rafael through this collaboration. The two services are separate but closely connected.

“In hospital medicine, if you keep farming out what you do to specialists—if you’re not embracing palliative care as a hospitalist—you lose part of your practice,” he says.

Dr. Shadan says the study group “helped us to be more cohesive and more comfortable going to each other to ask for help. Palliative care is part of what we do—part of hospital medicine and of providing good care.”

Meanwhile, North Hollywood, Calif.-based IPC The Hospitalist Company, which is well-established in post-acute and long-term-care settings beyond the hospital walls, is now starting to explore palliative care approaches at the local level in a few of its 35 markets. Heather Zinzella-Cox, MD, who was part of a panel presentation on palliative care at HM13, is hospitalist practice group leader for IPC-Delaware. She also works part time as an associate medical director for a community hospice and helped to develop an inpatient palliative care team at a local community hospital.

“For me, as a post-acute hospitalist, every patient I see, I think about whether palliative care might benefit them,” says Dr. Zinzella-Cox, who is board certified in pain and in hospice and palliative medicine.

She says hospitalists need tools for identifying appropriate palliative care patients, along with training for how to communicate with them around goals of care, including simple language to help cue these conversations. She notes a “significant voltage drop” in information at the time of discharge, and the most careful discharge plans can fall apart in a hurry after the patient goes home.

IPC’s national practice group does not have a current policy or initiative for palliative care; however, there may be opportunities for further integrating palliative care with hospital medicine, says hospitalist Thomas Mathew, MD.

Larry Beresford is a freelance writer in San Francisco.

Hospitals nationwide face significant capacity constraints in emergency departments. High hospitalization rates can have a ripple effect, leading to long wait times, frequent diversion of patients to other hospitals, and higher patient-care expenses. However, a sizable number of inpatient admissions can be prevented through dedicated clinical observation units, or COUs. Such a strategy is likely to be more efficient, can result in shorter lengths of stay, and can decrease health-care costs.¹

Also known as clinical decision units, “obs” units, or short-stay observation units, these hospital-based units lend themselves as a feasible solution. Many of the COU success stories come from “chest pain” units, along with ED-based observation units. Over time, the COUs have been expanded to include many more conditions and have enjoyed success when dealing with asthma exacerbations, transient ischemic attacks, bronchiolitis in pediatric populations, and congestive-heart-failure exacerbation, to name a few.

Most COUs use a window of six to 24 hours to carry out triaging, diagnosing, treating, and monitoring the patient response. Anytime before the 24-hour mark, a decision is made whether to discharge or admit the patient. The success of dedicated COUs relies heavily on strong leadership, strict treatment protocols, and well-defined inclusion/exclusion criteria.

COU utilization has been well received by several professional bodies. Both emergency medicine physicians and hospitalists are natural key players in the widespread utilization of COUs. SHM, in a white paper, concluded: “Collaboration between hospitalists, emergency physicians, hospital administrators, and academicians will serve not only to promote outstanding observation care, but also to focus quality improvement and research efforts for the observation unit of the 21st century.”² The American College of Emergency Physicians (ACEP), in its position statement, said the “observation of appropriate ED patients in a dedicated ED observation area, instead of a general inpatient bed or an acute care ED bed, is a ‘best practice’ that requires a commitment of staff and hospital resources.”³

As promising as the COUs appear, it is estimated that only one-third of hospitals have them in place.⁴ And while much of the COU story is good, there are concerns with the patient-care model.

The Good

Instinctively, a COU is a win-win proposition for all stakeholders. Essentially, many see these units as a fine blend of clinical care, fiscal responsibility, and patient accountability. Among the benefits:

Reduced admissions. On average, the admission rates from ED to inpatient services are 13.3%.⁵ In contrast, in hospitals that have a robust COU in place, the admission rates are much lower. As an example, Cook County Hospital in Chicago in the mid-1990s saw a decline in the admission rates from the emergency room following implementation of a COU, along with an increase in bed capacity due to the efficient, protocol-driven approach that goes along with successful ED observation units.⁶ With well-structured and managed observation units, such a reduction in hospitalization rates has been shown, is reproducible, and is achievable.

Improved case-mix multiplier. Inpatient reimbursements from the Centers for Medicare and Medicaid Services (CMS) and private insurers frequently are tied to the acuity of care a hospital provides. Critical to making that determination is the case mix that a given hospital sees. Usually, the more complex patients a hospital admits, the higher the reimbursements are. With a successful COU, a hospital can expect a case-mix multiplier representing patients with greater complexity and higher acuity.

What a successful COU essentially does is lead to the admission of patients with greater comorbidities—those who are sicker than the average patient. In doing so, COUs also facilitate safe discharges of the patients who do not necessarily need to be admitted. As an average, the cohort of patients who are admitted as inpatients then consists of patients who are sick enough and absolutely need to be admitted.

Resource utilization. When a patient is admitted from the ED to an inpatient floor, a lot of resources are utilized. These include expenses related to transportation, housekeeping, nursing, and ancillary services. Each of these additional resources comes with an expense. The more resources that are put in motion, the greater the expense a hospital incurs. With effective COUs, it is generally expected that suitable patients will get the care in a specific geographic area by the same set of providers. COUs tend to reduce unnecessary hospitalizations, redundancy of manpower utilization, and duplication of documentation—therefore reducing the expenses incurred by the hospital.

Infection control. The COUs operate based on minimizing the stay of the patients who can be safely discharged after a brief observation period. Decreased duration of stay also means decreased movement and unique provider contact/exposure—thus decreasing the chances for acquiring health-care-related infections. Besides, most COUs are restricted to a certain geographic area within the hospital, which helps to restrict patients to a limited area. This again may be helpful in better overall infection-control practices. More research is necessary to establish this association of the infection-control advantages of COUs. The hypothesis, however, does appear very promising.

Prompt and standardized care. Most COUs use an evidence-based, standardized approach toward the patients seen in the ED. Several professional bodies have endorsed the use of protocol-driven care for the conditions seen in the COU. Most professional organizations that have a key role in COUs advocate this approach, and include the ACEP, AHA, and SHM. When a COU has established itself, it likely is to use specific, expedited, protocol-driven approaches. This allows for care to be focused and standardized. This also is an opportunity to avoid redundant imaging and lab testing.

Patient safety. In its landmark publication “To Err is Human: Building a Safer Health System,” the Institute of Medicine identified communication error as one of the factors that lead to mistakes in patient care.⁷ COUs often tend to provide bulk of care at a given geographical area; this minimizes the transfer of patients from one place to another, thereby decreasing communication errors.

By providing more time to make decisions, COUs afford a greater diagnostic certainty. In the long run, this also helps a hospital minimize costly lawsuits.

The Bad

Not everything about COUs is great. There are certain areas that dull the luster of an observation unit.

Overzealous approaches. COUs are designed to allow more time to make clinical decisions when the triaging is in a gray area: whether to admit or not. Also, COUs provide clinicians with more time to follow the response to the care the patients receive in an emergent fashion. It needs to be emphasized that COUs are designed neither to replace hospitalization, nor to act as urgent care. As a corollary, there is a chance clinicians may be overzealous in discharging patients from COUs close to the 24-hour mark—even though it might not be clear whether the patient needs to be admitted or discharged. Overzealous discharging of COU patients can damage the premise of these units: to determine the need for admission and ensure patient safety. Having strict inclusion and exclusion criteria and good management can prevent these problems.

Staffing. Introduction of a COU can strain an already short-staffed ED. No different from any other novel approach, COU staffers need to be afforded a learning curve. This requires training personnel and establishing a robust team to staff COUs. It can be a strenuous process, at least in the beginning. Strong leadership and support of hospital, physician, and nursing leadership all play a role in the successful implementation and ongoing utilization of COUs.

Logistics. Coordination of people, facilities, and supplies that go into instituting a COU might be a challenge. Also, there may be times where patient ownership may not be very clear. Logistical concerns can include:

• Who owns the patient?
• How much of a role does a consulting service have?
• Who oversees the follow-up plans?

Although a popular COU setup is to have a dedicated observation unit adjacent to the ED, it is not a standard.

Reimbursement. Unfortunately, there is some degree of negative incentive built into reimbursements for COU operations. To understand why this is a bad thing for a hospital, let’s examine how hospitals are paid for services provided in a COU.

Frequently, COU patients are treated as “outpatients.” The operating formula is based on the Hospital Outpatient Prospective Payment System (OPPS), which is based on Ambulatory Payment Classification, or APC.⁸ Reimbursement differences in these two approaches can be quite sizable. Depending on what condition is being treated, the hospital reimbursement can be as little as half to a quarter of the payment for inpatient treatment.⁹ Essentially, the patient would have received very similar care, diagnostic work-up, antibiotics, imaging, lab work, and equally qualified clinicians as caretakers in both the settings. The payments need to account for the care in the COUs, which is usually more acute than in the ambulatory setting and potentially more efficient than an inpatient setting. The payments, therefore, should be sensitive to these factors.

The Ugly

COUs are intended to address many of the challenges facing the healthcare system, and in large part, that is what they do. However, some hospitals could be penalized for providing care through COUs. An efficient COU means that the patients who are admitted are, in fact, sicker. Logically, these patients will have a higher chance of being readmitted. Because the “not so sick” patients were successfully intervened and discharged from COUs, the patients that did get admitted must be pretty sick and must have higher comorbidities.

According to CMS, a readmission occurs if a patient has “an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital.”¹⁰ The denominator here consists of all the patients who were discharged from the hospital inpatient stay. If a hospital does not have a robust COU, a large number of “not so sick” patients will be admitted as inpatients and will provide a larger denominator for calculating the readmission rates.

In contrast, a successful COU will allow for a large number of “not so sick” and “borderline” patients to be discharged, shrinking the denominator base, and “very sick” patients who are likely to be readmitted. This may erroneously cause the hospital to appear to have higher 30-day readmission rates. These hospitals may risk substantial readmission-related penalties.

This issue, along with a lopsided payment model, makes the COU landscape murky. With a greater share of pie being the “Il buono” in Il buono, il brutto, il cattivo, clinical observation units are certain to take a prominent position in addressing many of the issues that plague current healthcare facilities—capacity constraints, long ED wait times, limited inpatient beds, and soaring health-care expenditures.

Most important, COUs can lead to better and more efficient patient care.¹¹ It is, therefore, not surprising that the IOM, in its report “Hospital Based Emergency Care—At the Breaking Point,” has identified clinical decision units as a “particularly promising” technique to improve patient flow.¹²

Dr. Asudani is a hospitalist in the division of hospital medicine in the department of internal medicine at the University of California San Diego Health System. Dr. Tolia is director of observation medicine in the department of emergency medicine and internal medicine at UCSD Health System.

References

1. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
2. Society of Hospital Medicine. The observation unit white paper. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=21890. Accessed April 3, 2013.
3. American College of Emergency Physicians. Emergency department observation services. American College of Emergency Physicians website. Available at: http://www.acep.org/Clinical—Practice-Management/Emergency-Department-Observation-Services. Accessed April 10, 2013.
4. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Hyattsville, Md.: National Center for Health Statistics; 2010.
5. Centers for Disease Control and Prevention. Fast stats. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed April 9, 2013.
6. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001;110(4):274-277.
7. To err is human: building a safer health system. Institute of Medicine. Washington (DC): National Academies Press; 2000.
8. Centers for Medicare & Medicaid Services. Hospital outpatient prospective payment system. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospitaloutpaysysfctsht.pdf. Accessed April 2, 2013.
9. Runy L. Clinical observation units: Building a bridge between outpatient and inpatient services. Hospitals and Health Networks website. Available at: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/0603HHN_FEA_gatefold&domain=HHNMAG. Accessed April 9, 2013.
10. Centers for Medicare & Medicaid Services. Readmissions reduction program. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed May 6, 2013.
11. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation nits: a clinical and financial benefit for hospitals. Health Care Manage Rev. 2011;36(1):28-37.
12. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington: National Academies Press; 2007.

Hospitals nationwide face significant capacity constraints in emergency departments. High hospitalization rates can have a ripple effect, leading to long wait times, frequent diversion of patients to other hospitals, and higher patient-care expenses. However, a sizable number of inpatient admissions can be prevented through dedicated clinical observation units, or COUs. Such a strategy is likely to be more efficient, can result in shorter lengths of stay, and can decrease health-care costs.¹

Also known as clinical decision units, “obs” units, or short-stay observation units, these hospital-based units lend themselves as a feasible solution. Many of the COU success stories come from “chest pain” units, along with ED-based observation units. Over time, the COUs have been expanded to include many more conditions and have enjoyed success when dealing with asthma exacerbations, transient ischemic attacks, bronchiolitis in pediatric populations, and congestive-heart-failure exacerbation, to name a few.

Most COUs use a window of six to 24 hours to carry out triaging, diagnosing, treating, and monitoring the patient response. Anytime before the 24-hour mark, a decision is made whether to discharge or admit the patient. The success of dedicated COUs relies heavily on strong leadership, strict treatment protocols, and well-defined inclusion/exclusion criteria.

COU utilization has been well received by several professional bodies. Both emergency medicine physicians and hospitalists are natural key players in the widespread utilization of COUs. SHM, in a white paper, concluded: “Collaboration between hospitalists, emergency physicians, hospital administrators, and academicians will serve not only to promote outstanding observation care, but also to focus quality improvement and research efforts for the observation unit of the 21st century.”² The American College of Emergency Physicians (ACEP), in its position statement, said the “observation of appropriate ED patients in a dedicated ED observation area, instead of a general inpatient bed or an acute care ED bed, is a ‘best practice’ that requires a commitment of staff and hospital resources.”³

As promising as the COUs appear, it is estimated that only one-third of hospitals have them in place.⁴ And while much of the COU story is good, there are concerns with the patient-care model.

The Good

Instinctively, a COU is a win-win proposition for all stakeholders. Essentially, many see these units as a fine blend of clinical care, fiscal responsibility, and patient accountability. Among the benefits:

Reduced admissions. On average, the admission rates from ED to inpatient services are 13.3%.⁵ In contrast, in hospitals that have a robust COU in place, the admission rates are much lower. As an example, Cook County Hospital in Chicago in the mid-1990s saw a decline in the admission rates from the emergency room following implementation of a COU, along with an increase in bed capacity due to the efficient, protocol-driven approach that goes along with successful ED observation units.⁶ With well-structured and managed observation units, such a reduction in hospitalization rates has been shown, is reproducible, and is achievable.

Improved case-mix multiplier. Inpatient reimbursements from the Centers for Medicare and Medicaid Services (CMS) and private insurers frequently are tied to the acuity of care a hospital provides. Critical to making that determination is the case mix that a given hospital sees. Usually, the more complex patients a hospital admits, the higher the reimbursements are. With a successful COU, a hospital can expect a case-mix multiplier representing patients with greater complexity and higher acuity.

What a successful COU essentially does is lead to the admission of patients with greater comorbidities—those who are sicker than the average patient. In doing so, COUs also facilitate safe discharges of the patients who do not necessarily need to be admitted. As an average, the cohort of patients who are admitted as inpatients then consists of patients who are sick enough and absolutely need to be admitted.

Resource utilization. When a patient is admitted from the ED to an inpatient floor, a lot of resources are utilized. These include expenses related to transportation, housekeeping, nursing, and ancillary services. Each of these additional resources comes with an expense. The more resources that are put in motion, the greater the expense a hospital incurs. With effective COUs, it is generally expected that suitable patients will get the care in a specific geographic area by the same set of providers. COUs tend to reduce unnecessary hospitalizations, redundancy of manpower utilization, and duplication of documentation—therefore reducing the expenses incurred by the hospital.

Infection control. The COUs operate based on minimizing the stay of the patients who can be safely discharged after a brief observation period. Decreased duration of stay also means decreased movement and unique provider contact/exposure—thus decreasing the chances for acquiring health-care-related infections. Besides, most COUs are restricted to a certain geographic area within the hospital, which helps to restrict patients to a limited area. This again may be helpful in better overall infection-control practices. More research is necessary to establish this association of the infection-control advantages of COUs. The hypothesis, however, does appear very promising.

Prompt and standardized care. Most COUs use an evidence-based, standardized approach toward the patients seen in the ED. Several professional bodies have endorsed the use of protocol-driven care for the conditions seen in the COU. Most professional organizations that have a key role in COUs advocate this approach, and include the ACEP, AHA, and SHM. When a COU has established itself, it likely is to use specific, expedited, protocol-driven approaches. This allows for care to be focused and standardized. This also is an opportunity to avoid redundant imaging and lab testing.

Patient safety. In its landmark publication “To Err is Human: Building a Safer Health System,” the Institute of Medicine identified communication error as one of the factors that lead to mistakes in patient care.⁷ COUs often tend to provide bulk of care at a given geographical area; this minimizes the transfer of patients from one place to another, thereby decreasing communication errors.

By providing more time to make decisions, COUs afford a greater diagnostic certainty. In the long run, this also helps a hospital minimize costly lawsuits.

The Bad

Not everything about COUs is great. There are certain areas that dull the luster of an observation unit.

Overzealous approaches. COUs are designed to allow more time to make clinical decisions when the triaging is in a gray area: whether to admit or not. Also, COUs provide clinicians with more time to follow the response to the care the patients receive in an emergent fashion. It needs to be emphasized that COUs are designed neither to replace hospitalization, nor to act as urgent care. As a corollary, there is a chance clinicians may be overzealous in discharging patients from COUs close to the 24-hour mark—even though it might not be clear whether the patient needs to be admitted or discharged. Overzealous discharging of COU patients can damage the premise of these units: to determine the need for admission and ensure patient safety. Having strict inclusion and exclusion criteria and good management can prevent these problems.

Staffing. Introduction of a COU can strain an already short-staffed ED. No different from any other novel approach, COU staffers need to be afforded a learning curve. This requires training personnel and establishing a robust team to staff COUs. It can be a strenuous process, at least in the beginning. Strong leadership and support of hospital, physician, and nursing leadership all play a role in the successful implementation and ongoing utilization of COUs.

Logistics. Coordination of people, facilities, and supplies that go into instituting a COU might be a challenge. Also, there may be times where patient ownership may not be very clear. Logistical concerns can include:

• Who owns the patient?
• How much of a role does a consulting service have?
• Who oversees the follow-up plans?

Although a popular COU setup is to have a dedicated observation unit adjacent to the ED, it is not a standard.

Reimbursement. Unfortunately, there is some degree of negative incentive built into reimbursements for COU operations. To understand why this is a bad thing for a hospital, let’s examine how hospitals are paid for services provided in a COU.

Frequently, COU patients are treated as “outpatients.” The operating formula is based on the Hospital Outpatient Prospective Payment System (OPPS), which is based on Ambulatory Payment Classification, or APC.⁸ Reimbursement differences in these two approaches can be quite sizable. Depending on what condition is being treated, the hospital reimbursement can be as little as half to a quarter of the payment for inpatient treatment.⁹ Essentially, the patient would have received very similar care, diagnostic work-up, antibiotics, imaging, lab work, and equally qualified clinicians as caretakers in both the settings. The payments need to account for the care in the COUs, which is usually more acute than in the ambulatory setting and potentially more efficient than an inpatient setting. The payments, therefore, should be sensitive to these factors.

The Ugly

COUs are intended to address many of the challenges facing the healthcare system, and in large part, that is what they do. However, some hospitals could be penalized for providing care through COUs. An efficient COU means that the patients who are admitted are, in fact, sicker. Logically, these patients will have a higher chance of being readmitted. Because the “not so sick” patients were successfully intervened and discharged from COUs, the patients that did get admitted must be pretty sick and must have higher comorbidities.

According to CMS, a readmission occurs if a patient has “an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital.”¹⁰ The denominator here consists of all the patients who were discharged from the hospital inpatient stay. If a hospital does not have a robust COU, a large number of “not so sick” patients will be admitted as inpatients and will provide a larger denominator for calculating the readmission rates.

In contrast, a successful COU will allow for a large number of “not so sick” and “borderline” patients to be discharged, shrinking the denominator base, and “very sick” patients who are likely to be readmitted. This may erroneously cause the hospital to appear to have higher 30-day readmission rates. These hospitals may risk substantial readmission-related penalties.

This issue, along with a lopsided payment model, makes the COU landscape murky. With a greater share of pie being the “Il buono” in Il buono, il brutto, il cattivo, clinical observation units are certain to take a prominent position in addressing many of the issues that plague current healthcare facilities—capacity constraints, long ED wait times, limited inpatient beds, and soaring health-care expenditures.

Most important, COUs can lead to better and more efficient patient care.¹¹ It is, therefore, not surprising that the IOM, in its report “Hospital Based Emergency Care—At the Breaking Point,” has identified clinical decision units as a “particularly promising” technique to improve patient flow.¹²

Dr. Asudani is a hospitalist in the division of hospital medicine in the department of internal medicine at the University of California San Diego Health System. Dr. Tolia is director of observation medicine in the department of emergency medicine and internal medicine at UCSD Health System.

References

1. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
2. Society of Hospital Medicine. The observation unit white paper. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=21890. Accessed April 3, 2013.
3. American College of Emergency Physicians. Emergency department observation services. American College of Emergency Physicians website. Available at: http://www.acep.org/Clinical—Practice-Management/Emergency-Department-Observation-Services. Accessed April 10, 2013.
4. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Hyattsville, Md.: National Center for Health Statistics; 2010.
5. Centers for Disease Control and Prevention. Fast stats. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed April 9, 2013.
6. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001;110(4):274-277.
7. To err is human: building a safer health system. Institute of Medicine. Washington (DC): National Academies Press; 2000.
8. Centers for Medicare & Medicaid Services. Hospital outpatient prospective payment system. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospitaloutpaysysfctsht.pdf. Accessed April 2, 2013.
9. Runy L. Clinical observation units: Building a bridge between outpatient and inpatient services. Hospitals and Health Networks website. Available at: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/0603HHN_FEA_gatefold&domain=HHNMAG. Accessed April 9, 2013.
10. Centers for Medicare & Medicaid Services. Readmissions reduction program. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed May 6, 2013.
11. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation nits: a clinical and financial benefit for hospitals. Health Care Manage Rev. 2011;36(1):28-37.
12. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington: National Academies Press; 2007.

Hospitals nationwide face significant capacity constraints in emergency departments. High hospitalization rates can have a ripple effect, leading to long wait times, frequent diversion of patients to other hospitals, and higher patient-care expenses. However, a sizable number of inpatient admissions can be prevented through dedicated clinical observation units, or COUs. Such a strategy is likely to be more efficient, can result in shorter lengths of stay, and can decrease health-care costs.¹

Also known as clinical decision units, “obs” units, or short-stay observation units, these hospital-based units lend themselves as a feasible solution. Many of the COU success stories come from “chest pain” units, along with ED-based observation units. Over time, the COUs have been expanded to include many more conditions and have enjoyed success when dealing with asthma exacerbations, transient ischemic attacks, bronchiolitis in pediatric populations, and congestive-heart-failure exacerbation, to name a few.

Most COUs use a window of six to 24 hours to carry out triaging, diagnosing, treating, and monitoring the patient response. Anytime before the 24-hour mark, a decision is made whether to discharge or admit the patient. The success of dedicated COUs relies heavily on strong leadership, strict treatment protocols, and well-defined inclusion/exclusion criteria.

COU utilization has been well received by several professional bodies. Both emergency medicine physicians and hospitalists are natural key players in the widespread utilization of COUs. SHM, in a white paper, concluded: “Collaboration between hospitalists, emergency physicians, hospital administrators, and academicians will serve not only to promote outstanding observation care, but also to focus quality improvement and research efforts for the observation unit of the 21st century.”² The American College of Emergency Physicians (ACEP), in its position statement, said the “observation of appropriate ED patients in a dedicated ED observation area, instead of a general inpatient bed or an acute care ED bed, is a ‘best practice’ that requires a commitment of staff and hospital resources.”³

As promising as the COUs appear, it is estimated that only one-third of hospitals have them in place.⁴ And while much of the COU story is good, there are concerns with the patient-care model.

The Good

Instinctively, a COU is a win-win proposition for all stakeholders. Essentially, many see these units as a fine blend of clinical care, fiscal responsibility, and patient accountability. Among the benefits:

Reduced admissions. On average, the admission rates from ED to inpatient services are 13.3%.⁵ In contrast, in hospitals that have a robust COU in place, the admission rates are much lower. As an example, Cook County Hospital in Chicago in the mid-1990s saw a decline in the admission rates from the emergency room following implementation of a COU, along with an increase in bed capacity due to the efficient, protocol-driven approach that goes along with successful ED observation units.⁶ With well-structured and managed observation units, such a reduction in hospitalization rates has been shown, is reproducible, and is achievable.

Improved case-mix multiplier. Inpatient reimbursements from the Centers for Medicare and Medicaid Services (CMS) and private insurers frequently are tied to the acuity of care a hospital provides. Critical to making that determination is the case mix that a given hospital sees. Usually, the more complex patients a hospital admits, the higher the reimbursements are. With a successful COU, a hospital can expect a case-mix multiplier representing patients with greater complexity and higher acuity.

What a successful COU essentially does is lead to the admission of patients with greater comorbidities—those who are sicker than the average patient. In doing so, COUs also facilitate safe discharges of the patients who do not necessarily need to be admitted. As an average, the cohort of patients who are admitted as inpatients then consists of patients who are sick enough and absolutely need to be admitted.

Resource utilization. When a patient is admitted from the ED to an inpatient floor, a lot of resources are utilized. These include expenses related to transportation, housekeeping, nursing, and ancillary services. Each of these additional resources comes with an expense. The more resources that are put in motion, the greater the expense a hospital incurs. With effective COUs, it is generally expected that suitable patients will get the care in a specific geographic area by the same set of providers. COUs tend to reduce unnecessary hospitalizations, redundancy of manpower utilization, and duplication of documentation—therefore reducing the expenses incurred by the hospital.

Infection control. The COUs operate based on minimizing the stay of the patients who can be safely discharged after a brief observation period. Decreased duration of stay also means decreased movement and unique provider contact/exposure—thus decreasing the chances for acquiring health-care-related infections. Besides, most COUs are restricted to a certain geographic area within the hospital, which helps to restrict patients to a limited area. This again may be helpful in better overall infection-control practices. More research is necessary to establish this association of the infection-control advantages of COUs. The hypothesis, however, does appear very promising.

Prompt and standardized care. Most COUs use an evidence-based, standardized approach toward the patients seen in the ED. Several professional bodies have endorsed the use of protocol-driven care for the conditions seen in the COU. Most professional organizations that have a key role in COUs advocate this approach, and include the ACEP, AHA, and SHM. When a COU has established itself, it likely is to use specific, expedited, protocol-driven approaches. This allows for care to be focused and standardized. This also is an opportunity to avoid redundant imaging and lab testing.

Patient safety. In its landmark publication “To Err is Human: Building a Safer Health System,” the Institute of Medicine identified communication error as one of the factors that lead to mistakes in patient care.⁷ COUs often tend to provide bulk of care at a given geographical area; this minimizes the transfer of patients from one place to another, thereby decreasing communication errors.

By providing more time to make decisions, COUs afford a greater diagnostic certainty. In the long run, this also helps a hospital minimize costly lawsuits.

The Bad

Not everything about COUs is great. There are certain areas that dull the luster of an observation unit.

Overzealous approaches. COUs are designed to allow more time to make clinical decisions when the triaging is in a gray area: whether to admit or not. Also, COUs provide clinicians with more time to follow the response to the care the patients receive in an emergent fashion. It needs to be emphasized that COUs are designed neither to replace hospitalization, nor to act as urgent care. As a corollary, there is a chance clinicians may be overzealous in discharging patients from COUs close to the 24-hour mark—even though it might not be clear whether the patient needs to be admitted or discharged. Overzealous discharging of COU patients can damage the premise of these units: to determine the need for admission and ensure patient safety. Having strict inclusion and exclusion criteria and good management can prevent these problems.

Staffing. Introduction of a COU can strain an already short-staffed ED. No different from any other novel approach, COU staffers need to be afforded a learning curve. This requires training personnel and establishing a robust team to staff COUs. It can be a strenuous process, at least in the beginning. Strong leadership and support of hospital, physician, and nursing leadership all play a role in the successful implementation and ongoing utilization of COUs.

Logistics. Coordination of people, facilities, and supplies that go into instituting a COU might be a challenge. Also, there may be times where patient ownership may not be very clear. Logistical concerns can include:

• Who owns the patient?
• How much of a role does a consulting service have?
• Who oversees the follow-up plans?

Although a popular COU setup is to have a dedicated observation unit adjacent to the ED, it is not a standard.

Reimbursement. Unfortunately, there is some degree of negative incentive built into reimbursements for COU operations. To understand why this is a bad thing for a hospital, let’s examine how hospitals are paid for services provided in a COU.

Frequently, COU patients are treated as “outpatients.” The operating formula is based on the Hospital Outpatient Prospective Payment System (OPPS), which is based on Ambulatory Payment Classification, or APC.⁸ Reimbursement differences in these two approaches can be quite sizable. Depending on what condition is being treated, the hospital reimbursement can be as little as half to a quarter of the payment for inpatient treatment.⁹ Essentially, the patient would have received very similar care, diagnostic work-up, antibiotics, imaging, lab work, and equally qualified clinicians as caretakers in both the settings. The payments need to account for the care in the COUs, which is usually more acute than in the ambulatory setting and potentially more efficient than an inpatient setting. The payments, therefore, should be sensitive to these factors.

The Ugly

COUs are intended to address many of the challenges facing the healthcare system, and in large part, that is what they do. However, some hospitals could be penalized for providing care through COUs. An efficient COU means that the patients who are admitted are, in fact, sicker. Logically, these patients will have a higher chance of being readmitted. Because the “not so sick” patients were successfully intervened and discharged from COUs, the patients that did get admitted must be pretty sick and must have higher comorbidities.

According to CMS, a readmission occurs if a patient has “an admission to a subsection hospital within 30 days of a discharge from the same or another subsection hospital.”¹⁰ The denominator here consists of all the patients who were discharged from the hospital inpatient stay. If a hospital does not have a robust COU, a large number of “not so sick” patients will be admitted as inpatients and will provide a larger denominator for calculating the readmission rates.

In contrast, a successful COU will allow for a large number of “not so sick” and “borderline” patients to be discharged, shrinking the denominator base, and “very sick” patients who are likely to be readmitted. This may erroneously cause the hospital to appear to have higher 30-day readmission rates. These hospitals may risk substantial readmission-related penalties.

This issue, along with a lopsided payment model, makes the COU landscape murky. With a greater share of pie being the “Il buono” in Il buono, il brutto, il cattivo, clinical observation units are certain to take a prominent position in addressing many of the issues that plague current healthcare facilities—capacity constraints, long ED wait times, limited inpatient beds, and soaring health-care expenditures.

Most important, COUs can lead to better and more efficient patient care.¹¹ It is, therefore, not surprising that the IOM, in its report “Hospital Based Emergency Care—At the Breaking Point,” has identified clinical decision units as a “particularly promising” technique to improve patient flow.¹²

Dr. Asudani is a hospitalist in the division of hospital medicine in the department of internal medicine at the University of California San Diego Health System. Dr. Tolia is director of observation medicine in the department of emergency medicine and internal medicine at UCSD Health System.

References

1. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur JD, Bohan JS. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Aff (Millwood). 2012;31(10):2314-2323.
2. Society of Hospital Medicine. The observation unit white paper. Society of Hospital Medicine website. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=White_Papers&Template=/CM/ContentDisplay.cfm&ContentID=21890. Accessed April 3, 2013.
3. American College of Emergency Physicians. Emergency department observation services. American College of Emergency Physicians website. Available at: http://www.acep.org/Clinical—Practice-Management/Emergency-Department-Observation-Services. Accessed April 10, 2013.
4. Niska R, Bhuiya F, Xu J. National Hospital Ambulatory Medical Care Survey: 2007 emergency department summary. Hyattsville, Md.: National Center for Health Statistics; 2010.
5. Centers for Disease Control and Prevention. Fast stats. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed April 9, 2013.
6. Martinez E, Reilly BM, Evans AT, Roberts RR. The observation unit: a new interface between inpatient and outpatient care. Am J Med. 2001;110(4):274-277.
7. To err is human: building a safer health system. Institute of Medicine. Washington (DC): National Academies Press; 2000.
8. Centers for Medicare & Medicaid Services. Hospital outpatient prospective payment system. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/hospitaloutpaysysfctsht.pdf. Accessed April 2, 2013.
9. Runy L. Clinical observation units: Building a bridge between outpatient and inpatient services. Hospitals and Health Networks website. Available at: http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006March/0603HHN_FEA_gatefold&domain=HHNMAG. Accessed April 9, 2013.
10. Centers for Medicare & Medicaid Services. Readmissions reduction program. Centers for Medicare & Medicaid Services website. Available at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed May 6, 2013.
11. Baugh CW, Venkatesh AK, Bohan JS. Emergency department observation nits: a clinical and financial benefit for hospitals. Health Care Manage Rev. 2011;36(1):28-37.
12. Institute of Medicine. Hospital-based emergency care: at the breaking point. Washington: National Academies Press; 2007.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.

Today marks the end of the second week of a three-month experiment we are embarking on to improve team-based care. The main elements of our experiment are two early career hospitalists dedicated to a single nursing unit who are present on the unit throughout the day, structured multidisciplinary rounds, pharmacists doing medication histories to help with medical reconciliation, and a veteran hospitalist serving as a coach, broadly overseeing care coordination and throughput on the unit. (I’m going to focus on multidisciplinary care and leave the coaching part for another day.)

Many have written about and many more have tried to establish unit-based hospitalist models, where a hospitalist is assigned to a single nursing unit. These models often incorporate multidisciplinary rounds, where the hospitalist, case management, social services, physical therapy, and perhaps pharmacy meet each day and review each patient’s progress through the hospitalization. The underlying premise for establishing a unit-based model is that all, or nearly all, of the hospitalist’s patients are located on the nursing unit.

It Can’t Be That Hard

Dedicated units and multidisciplinary rounds are designed to achieve better coordination between the hospitalists and the other members of the hospital team. Most healthcare professionals intuitively support this model; however, many hospitalists have concerns.

To provide the best care for their patients while maintaining career satisfaction, these hospitalists may feel the need for flexibility—the ability to be independent and roam unrestricted through the hallways and departments of the hospital. This goal can be at odds with being limited to a single nursing unit.

For these hospitalists to support the unit-based model, there had better be good reasons for doing so.

Measuring the Effects of Teamwork

Jody Hoffer Gittell, PhD, a professor of management at Brandeis University in Waltham, Mass., has studied relational coordination extensively in healthcare and other service industries. Relational coordination can be defined as “coordinating work through relationships of shared goals, shared knowledge and mutual respect, supported by frequent, timely, accurate, problem-solving communication.”¹

Dr. Gittell has developed a validated questionnaire to be completed by each member of the healthcare team, quantifying their perspective on these dimensions for others on the team. I think of relational coordination as a rigorous way of quantifying teamwork.

In 2008, Dr. Gittell published an observational study with SHM senior vice president Joe Miller and hospitalist leader Adrienne L. Bennett, MD, PhD, conducted at a suburban Boston hospital.² The study looked at relational coordination between members of the hospital team under hospitalist care compared to traditional, PCP-based hospital care. They measured relational coordination by asking the attending physician (hospitalist or PCP providing hospital care), medical resident, floor nurse, case manager, social worker, and therapist (occupational, physical, respiratory, speech) to complete questionnaires about the other team members for a cohort of patients.

The study concluded that relational coordination between other members of the team and the physician was significantly higher for patients treated by hospitalists than for patients treated by traditional PCPs. Further, they found that as relational coordination increased, for patients treated either by hospitalists or PCPs, length of stay, cost, and 30-day readmission rates decreased. I will add that the hospitalists were not unit-based in this study, but were assumed to be more available to the care team than traditional PCPs.

Subsequent studies of multidisciplinary rounds on a “hospitalist unit” conducted by Kevin O’Leary, MD, and colleagues at Northwestern University in Chicago have demonstrated a favorable effect on nurses’ ratings of teamwork and collaboration, as well as the rate of adverse events.^3,4 The former study did not, however, find decreased costs or length of stay.

Keys to Success

Before our current experiment, I’ve had the privilege to witness, both at my home institution and at a number of outside ones, many permutations of multidisciplinary rounds and unit-based hospitalists. I’ve seen failures, some mixed results, and occasional success stories. In all cases, participants seem to agree that it takes extra effort to execute on this model, especially once the initial enthusiasm wanes. So, for these arrangements to succeed over time, including our current experiment, I see the following four factors as critical:

1. Multidisciplinary rounds must be tightly organized, with case manager, nurse, and hospitalist providing input concisely. Average time per patient should not exceed about three minutes. The total time for rounds, no matter how many patients are under discussion, should not exceed one hour.
2. Each team member must be prepared to provide critical information for rounds. For example, hospitalists and nurses should have seen/reviewed their patients, case managers should know expected length of stay and key disposition information, and pharmacists should know medical histories and other pertinent information.
3. The fundamental concern of multidisciplinary rounds—that someone’s time is being wasted (when not talking about that team member’s patient at that moment)—must be mitigated one way or another. Solutions include rotating nurses or hospitalists in and out of rounds, and allowing hospitalists to enter orders and do other discreet multitasking during rounds. Careful attention to showing up for the rounds on time and on cue is crucial.
4. Hospitalist autonomy and need to roam has to be programmed in by allowing them time to get off the unit, see the broader world, and interact with colleagues.

At the conclusion of three months, as a QI project (as opposed to rigorous research), we will measure a number of things, including cost, throughput, patient satisfaction, and team member satisfaction with the model. If you have predictions, please e-mail me. I’ll report our results in a subsequent column.

Dr. Whitcomb is medical director of healthcare quality at Baystate Medical Center in Springfield, Mass. He is co-founder and past president of SHM. E-mail him at [email protected].

References

1. Relational Coordination Research Collaborative. Brandeis University website. Available at: http://rcrc.brandeis.edu/about-rc/What%20is%20Relational%20Coordination.html. Accessed September 23, 2013.
2. Gittell JH, Weinberg DB, Bennett AL, Miller JA. Is the doctor in? A relational approach to job design and the coordination of work. Hum Resource Manag J. 2008;47(4):729-755.
3. O’Leary KJ, Haviley C, Slade ME, Shah HM, Lee J, Williams MV. Improving teamwork: impact of structured interdisciplinary rounds on a hospitalist unit. J Hosp Med. 2011;6(2):88-93.
4. O’Leary KJ, Buck R, Fligiel HM, et al. Structured interdisciplinary rounds in a medical teaching unit: improving patient safety. Arch Intern Med. 2011;171(7):678-684.